A randomized, noninferiority, controlled trial of two doses of intravenous subdissociative ketamine for analgesia in the emergency department.
Lovett S, Reed T, Riggs R, Lew G, Koch E, Durazo-Arvizu RA, Rech MA. | Acad Emerg Med. 2021 Jun;28(6):647-654
DOI: https://doi.org/10.1111/acem.14200
Keywords: analgesia; emergency department; subdissociative ketamine.

ORIGINAL CONTRIBUTION

Introduction : This study aimed to determine if 0.15 mg/kg intravenous (IV) subdissociative ketamine is noninferior to 0.3 mg/kg in emergency department (ED) patients with acute pain.

Méthode : This randomized, prospective, double-blinded, noninferiority trial included patients' age 18 to 59 years presenting to the ED with acute moderate to severe pain. Subjects were randomized to IV subdissociative ketamine, 0.15 mg/kg ("low" dose) or 0.30 mg/kg ("high" dose), over 15 minutes. The primary endpoint was the 11-point numeric rating scale (NRS) pain score between groups at 30 minutes. Secondary endpoints included NRS pain scores at 15 and 60 minutes; change in NRS at 15, 30, and 60 minutes; rescue analgesia; and adverse effects. The noninferiority limit, δ0 , was set to 1.3.

Résultats : Forty-nine patients were included in each group. After the differences in the baseline NRS score were adjusted for, the mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low-dose group and 5.0 (95% CI = 4.2 to 5.8) in the high-dose group (mean difference = 0.4, 95% CI = -0.8 to 1.5), indicating that the low-dose subdissociative ketamine was noninferior to the high dose (lower limit of 95% CI = -0.8 to ≥1.3 = -δ0 ). Adverse effects were similar at 30 minutes. At 15 minutes, the high-dose group experienced greater change in NRS; however, more adverse effects occurred.

Conclusion : Our data did not detect a large difference in analgesia or adverse effect profile between 0.15 mg/kg IV ketamine and 0.30 mg/kg in the short-term treatment of acute pain in the ED.

Conclusion (proposition de traduction) : Nos données n'ont pas identifié une grande différence dans l'analgésie ou le profil d'effets indésirables entre 0,15 mg/kg de kétamine IV et 0,30 mg/kg dans le traitement à court terme de la douleur aiguë aux urgences.

Does Intravenous Acetaminophen Reduce Opioid Requirement in Pediatric Emergency Department Patients With Acute Sickle Cell Crises?.
Dhebaria T, Sivitz A, Tejani C. | Acad Emerg Med. 2021 Jun;28(6):639-646
DOI: https://doi.org/10.1111/acem.14149  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : We evaluated the ability of intravenous (IV) acetaminophen to reduce the amount of opioid medication administered in pediatric patients with sickle cell disease (SCD) having vasoocclusive crisis (VOC) in an emergency department (ED) setting.

Méthode : This was a prospective, randomized, double-blind placebo-controlled trial at an academic urban pediatric ED. Participants included patients with SCD, aged 4 to 16 years, with VOC pain. All patients received a 0.1 mg/kg dose of IV morphine, 0.5 mg/kg ketorolac, or both. Patients were randomized to receive either 15 mg/kg IV acetaminophen or placebo. Patients were reassessed every 30 minutes to see whether additional opioid doses were indicated to a maximum of three doses. The total morphine given, pain scores, rates of admissions, 72-hour return visits, and adverse events were assessed for each group.

Résultats : Of 71 subjects randomized, 35 patients in the acetaminophen group and 36 patients in the control group were analyzed. Baseline characteristics and initial pain scores were similar in both groups. The mean total amount of morphine given was 8.6 mg (95% confidence interval [CI] = 6.5 to 10.8) in the acetaminophen group and 8.0 mg (95% CI = 5.9 to 10.2) in the placebo group. The mean total cumulative morphine dosing was 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the acetaminophen group and 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the control group. The mean pain score at time of disposition was 5.5 (95% CI = 4.3 to 6.6) in the acetaminophen group and 5.2 (95% CI = 4.2 to 6.3) in the placebo group. There were no clinical or statistically significant differences between the rates of admission, 72-hour return visits, or adverse events.

Conclusion : In this study, patients who received IV acetaminophen did not receive less morphine than patients in the placebo group. Disposition pain scores for the two groups were also equivalent. We conclude that IV acetaminophen, when used in addition to morphine for pediatric sickle cell VOC pain, does not provide an opioid-sparing effect. Further searches for adjunctive nonaddictive pain medicines are indicated.

Conclusion (proposition de traduction) : Dans cette étude, les patients ayant reçu du paracétamol IV n'ont pas reçu moins de morphine que les patients du groupe placebo. Les scores de douleur à l'arrêt pour les deux groupes étaient également équivalents. Nous concluons que le paracétamol IV, lorsqu'il est utilisé en plus de la morphine dans la douleur liée à une crise aigüe drépanocytaire, n'a pas d'effet d'épargne des morphiniques. D'autres recherches sur les analgésiques adjuvants non opiacés sont indiquées.

Comparative Effectiveness of Protective Ventilation Strategies for Moderate and Severe Acute Respiratory Distress Syndrome. A Network Meta-Analysis.
Sud S, Friedrich JO, Adhikari NKJ, Fan E, Ferguson ND, Guyatt G, Meade MO. | Am J Respir Crit Care Med. 2021 Jun 1;203(11):1366-1377
DOI: https://doi.org/10.1164/rccm.202008-3039oc
Keywords: adult; extracorporeal membrane oxygenation; mechanical ventilation; prone position; respiratory distress syndrome.

Cortical care

Introduction : Choosing the best ventilation strategy for acute respiratory distress syndrome (ARDS) is complex, yet it is highly relevant to clinicians during a respiratory pandemic.
Objectives: To compare the effects of low Vt, high Vt, high positive end-expiratory pressure (PEEP), prone ventilation, high-frequency oscillation, and venovenous extracorporeal membrane oxygenation (VV ECMO) on mortality in ARDS.

Méthode : We performed a network meta-analysis of randomized trials. We applied the Grading of Recommendations Assessment, Development and Evaluation methodology to discern the relative effect of interventions on mortality

Résultats : We analyzed 34 trials including 9,085 adults with primarily moderate-to-severe ARDS (median baseline PaO2/FiO2, 118; interquartile range, 110-143). Prone positioning combined with low Vt was the best strategy (risk ratio [RR], 0.74 [95% confidence interval (CI), 0.60-0.92] vs. low Vt; high certainty). VV ECMO was also rated among the best (RR, 0.78 [95% CI, 0.58-1.05] vs. low Vt; RR, 0.66; [95% CI, 0.49-0.88] vs. high Vt) but was rated with lower certainty because VV ECMO was restricted to very severe ARDS (mean baseline PaO2/FiO2<75). High PEEP combined with low Vt was rated intermediately (RR, 0.91 [95% CI, 0.81-1.03] vs. low Vt; low certainty; RR, 0.77 [95% CI, 0.65-0.91] vs. high Vt; moderate certainty). High Vt was rated worst (RR, 1.19 [95% CI, 1.02-1.37] vs. low Vt; moderate certainty), and we found no support for high-frequency oscillation or high Vt with prone ventilation.

Conclusion : These findings suggest that combining low Vt with prone ventilation is associated with the greatest reduction in mortality for critically ill adults with moderate-to-severe ARDS.

Conclusion (proposition de traduction) : Ces résultats suggèrent que la combinaison d'un faible volume courant (Vt) et d'une ventilation en décubitus ventral est associée à la plus grande réduction de la mortalité chez les adultes gravement malades atteints de SDRA modéré à sévère.

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial.
Reuben A, Appelboam A, Stevens KN, Vickery J, Ewings P, Ingram W, Jeffery AN, Body R, Hilton M, Coppell J, Wainman B, Barton A. | Ann Emerg Med. 2021 Jun;77(6):631-640
DOI: https://doi.org/10.1016/j.annemergmed.2020.12.013
Keywords: Aucun

General Medicine

Introduction : Epistaxis is a common emergency department (ED) presentation and, if simple first aid measures fail, can lead to a need for anterior nasal packing. Tranexamic acid is an agent that contributes to blood clot stability. The aim of this study is to investigate the effectiveness of topical intranasal tranexamic acid in adult patients presenting to the ED with persistent epistaxis, and whether it reduces the need for anterior nasal packing.

Méthode : From May 5, 2017, to March 31, 2019, a double-blind, placebo-controlled, multicenter, 1:1, randomized controlled trial was conducted across 26 EDs in the United Kingdom. Participants with spontaneous epistaxis, persisting after simple first aid and the application of a topical vasoconstrictor, were randomly allocated to receive topical tranexamic acid or placebo. The primary outcome was the need for anterior nasal packing of any kind during the index ED attendance. Secondary outcome measures included hospital admission, need for blood transfusion, recurrent epistaxis, and any thrombotic events requiring any hospital reattendance within 1 week.

Résultats : The study sample consisted of 496 participants with spontaneous epistaxis, persisting after simple first aid and application of a topical vasoconstrictor. In total, 211 participants (42.5%) received anterior nasal packing during the index ED attendance, including 111 of 254 (43.7%) in the tranexamic acid group versus 100 of 242 (41.3%) in the placebo group. The difference was not statistically significant (odds ratio 1.107; 95% confidence interval 0.769 to 1.594; P=.59). Furthermore, there were no statistically significant differences between tranexamic acid and placebo for any of the secondary outcome measures.

Conclusion : In patients presenting to an ED with atraumatic epistaxis that is uncontrolled with simple first aid measures, topical tranexamic acid applied in the bleeding nostril on a cotton wool dental roll is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing.

Conclusion (proposition de traduction) : Chez les patients se présentant aux urgences avec une épistaxis atraumatique qui n'est pas contrôlée par de simples mesures de premiers soins, l'acide tranexamique topique appliqué dans la narine qui saigne sur un rouleau de coton n'est pas plus efficace que le placebo pour contrôler le saignement et réduire le besoin d'un tamponnement nasal antérieur.

Target arterial PO2 according to the underlying pathology: a mini-review of the available data in mechanically ventilated patients.
Demiselle J, Calzia E, Hartmann C, Messerer DAC, Asfar P, Radermacher P, Datzmann T. | Ann Intensive Care. 2021 Jun 2;11(1):88
DOI: https://doi.org/10.1186/s13613-021-00872-y  | Télécharger l'article au format  
Keywords: Acute subarachnoidal haemorrhage; Cardiopulmonary resuscitation; Hyperox(aem)ia; Intracerebral bleeding; Ischaemic brain injury; Septic shock; Surgical site infection; Traumatic brain injury; Traumatic–haemorrhagic shock.

Review

Editorial : There is an ongoing discussion whether hyperoxia, i.e. ventilation with high inspiratory O2 concentrations (FIO2), and the consecutive hyperoxaemia, i.e. supraphysiological arterial O2 tensions (PaO2), have a place during the acute management of circulatory shock. This concept is based on experimental evidence that hyperoxaemia may contribute to the compensation of the imbalance between O2 supply and requirements. However, despite still being common practice, its use is limited due to possible oxygen toxicity resulting from the increased formation of reactive oxygen species (ROS) limits, especially under conditions of ischaemia/reperfusion. Several studies have reported that there is a U-shaped relation between PaO2 and mortality/morbidity in ICU patients. Interestingly, these mostly retrospective studies found that the lowest mortality coincided with PaO2 ~ 150 mmHg during the first 24 h of ICU stay, i.e. supraphysiological PaO2 levels. Most of the recent large-scale retrospective analyses studied general ICU populations, but there are major differences according to the underlying pathology studied as well as whether medical or surgical patients are concerned. Therefore, as far as possible from the data reported, we focus on the need of mechanical ventilation as well as the distinction between the absence or presence of circulatory shock. There seems to be no ideal target PaO2 except for avoiding prolonged exposure (> 24 h) to either hypoxaemia (PaO2 < 55-60 mmHg) or supraphysiological (PaO2 > 100 mmHg). Moreover, the need for mechanical ventilation, absence or presence of circulatory shock and/or the aetiology of tissue dysoxia, i.e. whether it is mainly due to impaired macro- and/or microcirculatory O2 transport and/or disturbed cellular O2 utilization, may determine whether any degree of hyperoxaemia causes deleterious side effects.

Conclusion : Several authors reported that in ICU patients there is a U-shaped relation between PaO2 and mortality/morbid- ity. Interestingly, these mostly retrospective studies found that the lowest mortality was present at PaO2 ~ 150 mm Hg. Nevertheless, such supraphysiological PaO2 values cannot be recommended in general, since the absence or presence of circulatory shock and/or the aetiology of tissue dysoxia, i.e. whether it is mainly due to impaired (macro- and/or microcirculatory) O2 transport and/or disturbed cellular O2 utilization may determine whether any supraphysiological PaO2 level is really beneficial and/ or even causes deleterious side effects.

Conclusion (proposition de traduction) : Plusieurs auteurs ont signalé que chez les patients en soins intensifs, il existe une relation en forme de U entre la PaO₂ et la mortalité/morbidité. Fait intéressant, ces études principalement rétrospectives ont révélé que la mortalité la plus faible était présente à PaO₂ ~ 150 mmHg. Néanmoins, de telles valeurs de PaO₂ supraphysiologiques ne peuvent être recommandées en général, car l'absence ou la présence de choc circulatoire et/ou l'étiologie d'une dysoxie tissulaire, c'est-à-dire qu'elle soit principalement due à une altération (macro- et/ou microcirculatoire) du transport de l'O₂ et/ou une utilisation cellulaire perturbée de l'O₂ peut déterminer si un niveau de PaO₂ supraphysiologique est vraiment bénéfique et/ou provoque même des effets secondaires délétères.

The Role of Cardiac Arrest Sonographic Exam (CASE) in Predicting the Outcome of Cardiopulmonary Resuscitation; a Cross-sectional Study.
Masoumi B, Azizkhani R, Heydari F, Zamani M, Nasr Isfahani M. | Arch Acad Emerg Med. 2021 Jun 28;9(1):e48
DOI: https://doi.org/10.22037/aaem.v9i1.1272  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Heart arrest; Return of Spontaneous Circulation; Ultrasonography.

Original/Research Article

Introduction : Ultrasonography (US) has been suggested as an integral part of resuscitation to identify potentially reversible causes of cardiac arrest (CA). This study aimed to evaluate the association between cardiac activity on ultrasonography during resuscitation and outcome of patients with non-shockable rhythms.

Méthode : We conducted a prospective, observational study on adult patients presenting with CA or experiencing CA in the emergency department (ED), and initial non-shockable rhythm. US examination of the sub-xiphoid region was performed during the 10-second interval of rhythm and pulse check and the association of US findings and patients' outcomes was evaluated.

Résultats : 151 patients with the mean age of 65.32 ± 11.68 years were evaluated (76.2% male). 43 patients (28.5%) demonstrated cardiac activity on the initial US. The rate of asystole in initial rhythm was 58.9% (n=89). Return of spontaneous circulation (ROSC) was achieved in 36 (23.8%) patients, twenty (13.2%) survived to hospital admission and seven (4.6%) survived to hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge. Potentially reversible causes were detected in 15 cases (9.9%), and four of them survived to hospital discharge. Cardiac activity on first scan was associated with ROSC (OR: 6.86, 95%CI: 2.92-16.09; p < 0.001), survival to hospital admission (OR: 17.80, 95%CI: 3.95-80.17; p < 0.001), and survival to hospital discharge (OR: 17.35, 95%CI: 2.02-148.92; p = 0.001).

Conclusion : In non-traumatic cardiac arrest patients with non-shockable rhythms, bedside US is of great importance in predicting ROSC. The presence of pulseless electrical activity (PEA) rhythm and cardiac activity on initial US were associated with ROSC, survival to hospital admission, and hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque non traumatique avec des rythmes non choquables, l'échographie au chevet est d'une grande importance pour prédire le RACS. La présence d'une activité électrique sans pouls et d'une activité cardiaque lors de l'échographie initiale était associée au RACS, à la survie à l'admission à l'hôpital et à la sortie de l'hôpital. Lorsque la durée de l'arrêt cardiaque est passée à six minutes, aucun patient n'a survécu à la sortie de l'hôpital.

Incidence rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries: a retrospective cohort study.
Abboud AE, Boudabbous S, Andereggen E, de Foy M, Ansorge A, Gamulin A. | BMC Emerg Med. 2021 Jun 30;21(1):75
DOI: https://doi.org/10.1186/s12873-021-00470-y  | Télécharger l'article au format  
Keywords: High-energy blunt trauma; High-energy pelvic ring injury; Incidence; Intra-pelvic arterial lesion; Topography.

Research

Introduction : The aim of this study was to determine the rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries (PRI).

Méthode : This retrospective cohort study was conducted in a level I trauma center serving 500,000 inhabitants. A total of 127 consecutive patients with high-energy blunt PRI were included between January 1st, 2014 and December 31st, 2017. Every patient had a total body or thoraco-abdominal computed tomography scan including contrast enhanced arterial sequences. A board-certified radiologist reviewed all the vascular images and precisely described every intra-pelvic arterial lesion in terms of localization. Complete pelvic series (standard radiographs and fine cut computed tomography images) were reviewed by three board-certified orthopedic surgeons experienced in PRI management, and Young and Burgess and AO/OTA classifications were determined. Demographic, clinical, therapeutic and outcome data were extracted from the institutional severely injured patients' registry.

Résultats : Patients' mean age was 45.3 years and 58.3% were males. Fifteen (11.8%) had a total of 21 intra-pelvic arterial lesions: seven lesions of the obturator artery, four of the superior gluteal artery, three of the inferior gluteal artery, two of the vesical artery, and one of each of the following arteries: internal iliac, internal pudendal, fifth lumbar, lateral sacral, ilio-lumbar. These lesions occurred in 8.6% of lateral compression injuries, 33.3% of anteroposterior compression injuries and 23.5% of vertical shear and combined mechanism injuries (Young and Burgess classification, p = 0.003); and in 0% of type A injuries, 9.9% of type B injuries and 35% of type C injuries (AO/OTA classification, p = 0.001). Patients with an intra-pelvic arterial lesion were more likely to present with pre-hospital hemodynamic instability (p = 0.046) and to need packed red blood cells transfusion within the first 24 h (p = 0.023; they needed a mean of 7.53 units vs. 1.88, p = 0.0016); however, they did not have a worst outcome in terms of complications or mortality.

Conclusion : This systematic study found an 11.8% rate of intra-pelvic arterial lesion related to high-energy blunt PRI. The obturator, superior gluteal and inferior gluteal arteries were most often injured. These findings are important for the aggressive management of high-energy blunt PRI.

Conclusion (proposition de traduction) : Cette étude systématique a trouvé un taux de 11,8 % de lésions artérielles intra-pelviennes liées à des lésions de l'anneau pelvien contondant à haute énergie. Les artères obturatrice, fessière supérieure et fessière inférieure étaient le plus souvent lésées. Ces résultats sont importants pour la prise en charge agressive des lésions de l'anneau pelvien contondant à haute énergie.

Commentaire :  Topographie des lésions artérielles intra-pelviennes trouvées dans l'étude.
Toutes les lésions sont signalées arbitrairement sur le côté droit du bassin pour des raisons de clarté. Chaque cercle correspond à un emplacement de lésion artérielle ; la taille de chaque cercle est proportionnelle au nombre de lésions artérielles trouvées à l'emplacement particulier, et le nombre à l'intérieur de chaque cercle fait référence au nombre de cas trouvés à l'emplacement particulier. Les noms des artères sont indiqués sur le côté gauche du bassin. Cette figure est le travail des auteurs.

P2Y12 inhibitor monotherapy or dual antiplatelet therapy after coronary revascularisation: individual patient level meta-analysis of randomised controlled trials.
Valgimigli M, Gragnano F, Branca M, Franzone A, Baber U, Jang Y, Kimura T, Hahn JY, Zhao Q, Windecker S, Gibson CM, Kim BK, Watanabe H, Song YB, Zhu Y, Vranckx P, Mehta S, Hong SJ, Ando K, Gwon HC, Serruys PW, Dangas GD, McFadden EP, Angiolillo DJ, Heg D, Jüni P, Mehran R. | BMJ. 2021 Jun 16;373:n1332
DOI: https://doi.org/10.1136/bmj.n1332  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To assess the risks and benefits of P2Y12 inhibitor monotherapy compared with dual antiplatelet therapy (DAPT) and whether these associations are modified by patients' characteristics.
Design: Individual patient level meta-analysis of randomised controlled trials.

Méthode : Searches were conducted in Ovid Medline, Embase, and three websites (www.tctmd.com, www.escardio.org, www.acc.org/cardiosourceplus) from inception to 16 July 2020. The primary authors provided individual participant data.
Eligibility criteria: Randomised controlled trials comparing effects of oral P2Y12 monotherapy and DAPT on centrally adjudicated endpoints after coronary revascularisation in patients without an indication for oral anticoagulation.
Main outcome measures: The primary outcome was a composite of all cause death, myocardial infarction, and stroke, tested for non-inferiority against a margin of 1.15 for the hazard ratio. The key safety endpoint was Bleeding Academic Research Consortium (BARC) type 3 or type 5 bleeding.

Résultats : The meta-analysis included data from six trials, including 24 096 patients. The primary outcome occurred in 283 (2.95%) patients with P2Y₁₂ inhibitor monotherapy and 315 (3.27%) with DAPT in the per protocol population (hazard ratio 0.93, 95% confidence interval 0.79 to 1.09; P=0.005 for non-inferiority; P=0.38 for superiority; τ²=0.00) and in 303 (2.94%) with P2Y₁₂ inhibitor monotherapy and 338 (3.36%) with DAPT in the intention to treat population (0.90, 0.77 to 1.05; P=0.18 for superiority; τ²=0.00). The treatment effect was consistent across all subgroups, except for sex (P for interaction=0.02), suggesting that P2Y₁₂ inhibitor monotherapy lowers the risk of the primary ischaemic endpoint in women (hazard ratio 0.64, 0.46 to 0.89) but not in men (1.00, 0.83 to 1.19). The risk of bleeding was lower with P2Y₁₂ inhibitor monotherapy than with DAPT (97 (0.89%) v 197 (1.83%); hazard ratio 0.49, 0.39 to 0.63; P<0.001; τ²=0.03), which was consistent across subgroups, except for type of P2Y₁₂ inhibitor (P for interaction=0.02), suggesting greater benefit when a newer P2Y₁₂ inhibitor rather than clopidogrel was part of the DAPT regimen.

Conclusion : P2Y₁₂ inhibitor monotherapy was associated with a similar risk of death, myocardial infarction, or stroke, with evidence that this association may be modified by sex, and a lower bleeding risk compared with dual antiplatelet therapy.

Conclusion (proposition de traduction) : La monothérapie par inhibiteur P2Y₁₂ était associée à un risque similaire de décès, d'infarctus du myocarde ou d'accident vasculaire cérébral, avec des preuves que cette association peut être modifiée par le sexe, et un risque hémorragique plus faible par rapport à la bithérapie antiplaquettaire.

Role of C reactive protein and procalcitonin in the diagnosis of lower respiratory tract infection in children in the outpatient setting.
Pérez-López A, Irwin A, Rodrigo C, Prat-Aymerich C. | BMJ. 2021 Jun 11;373:n1409.
DOI: https://doi.org/10.1136/bmj.n1409  | Télécharger l'article au format  
Keywords: Aucun

Education

Editorial : A previously healthy and fully vaccinated (including 13-valent pneumococcal conjugate vaccine) 22 month old boy is brought to the emergency department because of a 12 hour history of high fever (up to 40°C). He had had low grade fever, runny nose, cough, and decreased oral intake for the past two days. On examination, he did not look severely ill but was febrile (38.3°C). His respiratory rate was 45 breaths/minute (normal range 25-40 breaths/min at 18-24 months old), heart rate was 140 beats/minute (normal range 98-135 beats/min at 18-24 months), and blood oxygen level was 95%. Although breath sounds were not decreased, some bibasilar crackles were noted on chest auscultation. A chest x ray was interpreted as having bilateral peribronchial infiltrates and haziness in the right lower lobe. To aide their decision whether to initiate antibiotic therapy, clinicians requested blood tests, which revealed a white blood cell count of 22.5×109/L (60.0% neutrophils), a CRP of 30 mg/L (normal <5 mg/L), and a PCT of 0.25 μg/L (normal <0.5 μg/L).

Conclusion : What you need to know
• The difficulty of discriminating between viral and bacterial lower respiratory tract infection (LRTI) in children using clinical features alone often leads to overprescription of antibiotics
• Biomarkers such as C reactive protein (CRP) and procalcitonin (PCT) have a limited capacity to rule in bacterial pneumonia in children in ambulatory settings where the prevalence of bacterial pneumonia is low. (CRP and PCT have limited diagnostic value in severely ill children who meet criteria for pneumonia or sepsis and who are candidates for broad spectrum antibiotic therapy)
• There is growing evidence that antibiotic therapy can be safely withheld in children who are not severely ill with equivocal clinical presentation and low CRP (<20 mg/L) and PCT (<0.5 μg/L) levels

Conclusion (proposition de traduction) : Que souhaitez-vous savoir
• La difficulté de faire la distinction entre les infections virales et bactériennes des voies respiratoires inférieures chez les enfants en utilisant uniquement les caractéristiques cliniques conduit souvent à une surprescription d'antibiotiques.
• Les biomarqueurs tels que la protéine C réactive (CRP) et la procalcitonine (PCT) ont une capacité limitée à statuer sur la pneumonie bactérienne chez les enfants en milieu ambulatoire où la prévalence de la pneumonie bactérienne est faible. (La CRP et la PCT ont une valeur diagnostique limitée chez les enfants gravement malades qui répondent aux critères de pneumonie ou de sepsis et qui sont candidats à une antibiothérapie à large spectre).
• Il existe de plus en plus de preuves que l'antibiothérapie peut être suspendue en toute sécurité chez les enfants qui ne sont pas gravement malades avec une présentation clinique équivoque et de faibles taux de CRP (<20 mg/L) et de PCT (<0,5 μg/L)

Impact of High-Dose Prophylactic Anticoagulation in Critically Ill Patients With COVID-19 Pneumonia.
Tacquard C, Mansour A, Godon A, Godet J, Poissy J, Garrigue D, Kipnis E, Rym Hamada S, Mertes PM, Steib A, Ulliel-Roche M, Bouhemad B, Nguyen M, Reizine F, Gouin-Thibault I, Besse MC, Collercandy N, Mankikian S, Levy JH, Gruel Y, Albaladejo P, Susen S, Godier A; French Working Group on Perioperative Hemostasis. | Chest. 2021 Jun;159(6):2417-2427
DOI: https://doi.org/10.1016/j.chest.2021.01.017  | Télécharger l'article au format  
Keywords: COVID-19; anticoagulation; bleeding; thrombosis.

PULMONARY AND CARDIOVASCULAR Original Research

Introduction : Because of the high risk of thrombotic complications (TCs) during SARS-CoV-2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation, although arguments in favor of this strategy are inconsistent.
Research question: What is the incidence of TC in critically ill patients with COVID-19 and what is the relationship between the dose of anticoagulant therapy and the incidence of TC?

Méthode : All consecutive patients referred to eight French ICUs for COVID-19 were included in this observational study. Clinical and laboratory data were collected from ICU admission to day 14, including anticoagulation status and thrombotic and hemorrhagic events. The effect of high-dose prophylactic anticoagulation (either at intermediate or equivalent to therapeutic dose), defined using a standardized protocol of classification, was assessed using a time-varying exposure model using inverse probability of treatment weight.

Résultats : Of 538 patients included, 104 patients experienced a total of 122 TCs with an incidence of 22.7% (95% CI, 19.2%-26.3%). Pulmonary embolism accounted for 52% of the recorded TCs. High-dose prophylactic anticoagulation was associated with a significant reduced risk of TC (hazard ratio, 0.81; 95% CI, 0.66-0.99) without increasing the risk of bleeding (HR, 1.11; 95% CI, 0.70-1.75).

Conclusion : High-dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill patients with COVID-19 without an increased risk of hemorrhage. Randomized controlled trials comparing prophylaxis with higher doses of anticoagulants are needed to confirm these results.

Conclusion (proposition de traduction) : L'anticoagulation prophylactique à haute dose est associée à une réduction des complications thrombotiques chez les patients de réanimation atteints de COVID-19 sans risque accru d'hémorragie. Des essais contrôlés randomisés comparant la prophylaxie à des doses plus élevées d'anticoagulants sont nécessaires pour confirmer ces résultats.

Tracheal suction at birth in non-vigorous neonates born through meconium-stained amniotic fluid.
Nangia S, Thukral A, Chawla D. | Cochrane Database Syst Rev. 2021 Jun 16;6(6):CD012671
DOI: https://doi.org/10.1002/14651858.cd012671.pub2
Keywords: Aucun

Intervention

Introduction : Neonates born through meconium-stained amniotic fluid (MSAF) are at risk of developing meconium aspiration syndrome (MAS). Neonates who are non-vigorous due to intrapartum asphyxia are at higher risk of developing MAS. Clearance of meconium from the airways below the vocal cords by tracheal suction before initiating other steps of resuscitation may reduce the risk of development of MAS. However, conducting tracheal suction may not only be ineffective, it may also delay effective resuscitation, thus prolonging and worsening the hypoxic-ischaemic insult. OBJECTIVES: To evaluate the efficacy of tracheal suctioning at birth in preventing meconium aspiration syndrome and other complications among non-vigorous neonates born through meconium-stained amniotic fluid.

Méthode : We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 11) in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) (1946 to 25 November 2020) for randomised controlled trials (RCTs) and quasi-randomised trials. We also searched clinical trials databases and the reference lists of retrieved articles for RCTs and quasi-randomised trials (up to November 2020).
Selection criteria: We included studies enrolling non-vigorous neonates born through MSAF, if the intervention being tested included tracheal suction at the time of birth with an intent to clear the trachea of meconium before regular breathing efforts began. Tracheal suction could be performed with an endotracheal tube or a wide-gauge suction catheter. Neonates in the control group should have been resuscitated at birth with no effort made to clear the trachea of meconium.
Data collection and analysis: Two review authors independently assessed trial quality and extracted data, consulting with a third review author about any disagreements. We used standard Cochrane methodological procedures, including assessment of risk of bias for all studies. Our primary outcomes were: MAS; all-cause neonatal mortality; and incidence of hypoxic-ischaemic encephalopathy (HIE). Secondary outcomes included: need for mechanical ventilation; incidence of pulmonary air leaks; culture-positive sepsis; and persistent pulmonary hypertension. We used the GRADE approach to assess the certainty of evidence.

Résultats : We included four studies (enrolling 581 neonates) in the review. All four studies were conducted in tertiary care hospitals in India. Three of the four studies included neonates born at and beyond term gestation, whereas one included neonates born at and beyond 34 weeks of gestation. Due to the nature of the intervention, it was not possible to blind the healthcare personnel conducting the intervention. Tracheal suction compared to no suction in non-vigorous neonates born through MSAF In non-vigorous infants, no differences were noted in the risks of MAS (RR 1.00, 95% CI 0.80 to 1.25; RD 0.00, 95% CI -0.07 to 0.08; 4 studies, 581 neonates) or all-cause neonatal mortality (RR 1.24, 95% CI 0.76 to 2.02; RD 0.02, 95% CI -0.03 to 0.07; 4 studies, 575 neonates) with or without tracheal suctioning. No differences were reported in the risk of any severity HIE (RR 1.05, 95% CI 0.68 to 1.63; 1 study, 175 neonates) or moderate to severe HIE (RR 0.68, 95% CI 0.43 to 1.09; 1 study, 152 neonates) among non-vigorous neonates born through MSAF. We are also uncertain as to the effect of tracheal suction on other outcomes such as incidence of mechanical ventilation (RR 0.99, 95% CI 0.68 to 1.44; RD 0.00, 95% CI -0.06 to 0.06; 4 studies, 581 neonates), pulmonary air leaks (RR 1.22, 95% CI 0.38 to 3.93; RD 0.00, 95% CI -0.02 to 0.03; 3 studies, 449 neonates), persistent pulmonary hypertension (RR 1.29, 95% CI 0.60 to 2.77; RD 0.02, 95% CI -0.03 to 0.06; 3 studies, 406 neonates) and culture-positive sepsis (RR 1.32, 95% CI 0.48 to 3.57; RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 406 neonates). All reported outcomes were judged as providing very low certainty evidence.

Conclusion : We are uncertain about the effect of tracheal suction on the incidence of MAS and its complications among non-vigorous neonates born through MSAF. One study awaits classification and could not be included in the review. More research from well-conducted large trials is needed to conclusively answer the review question.

Conclusion (proposition de traduction) : Nous ne sommes pas certains de l'effet de l'aspiration trachéale sur l'incidence du syndrome d'aspiration méconiale et de ses complications chez les nouveau-nés non vigoureux nés dont le liquide amniotique a été teinté par du méconium. Une étude est en attente de classification et n'a pas pu être incluse dans la revue. Il est nécessaire de mener d'autres recherches à partir de grands essais bien conduits pour répondre de manière concluante à la problématique de la revue.

Commentaire : Voir la traduction en français sur :
Aspiration trachéale à la naissance chez les nouveau-nés non-vigoureux nés avec un liquide amniotique teinté de méconium  .

Endovascular thrombectomy and intra‐arterial interventions for acute ischaemic stroke.
Roaldsen MB, Jusufovic M, Berge E, Lindekleiv H. | Cochrane Database Syst Rev. 2021 Jun 14;6(6):CD007574
DOI: https://doi.org/10.1002/14651858.cd007574.pub3
Keywords: Aucun

Intervention

Introduction : Most disabling strokes are due to a blockage of a large artery in the brain by a blood clot. Prompt removal of the clot with intra-arterial thrombolytic drugs or mechanical devices, or both, can restore blood flow before major brain damage has occurred, leading to improved recovery. However, these so-called endovascular interventions can cause bleeding in the brain. This is a review of randomised controlled trials of endovascular thrombectomy or intra-arterial thrombolysis, or both, for acute ischaemic stroke.
Objectives: To assess whether endovascular thrombectomy or intra-arterial interventions, or both, plus medical treatment are superior to medical treatment alone in people with acute ischaemic stroke.

Méthode : We searched the Trials Registers of the Cochrane Stroke Group and Cochrane Vascular Group (last searched 1 September 2020), CENTRAL (the Cochrane Library, 1 September 2020), MEDLINE (May 2010 to 1 September 2020), and Embase (May 2010 to 1 September 2020). We also searched trials registers, screened reference lists, and contacted researchers.
Selection criteria: Randomised controlled trials (RCTs) of any endovascular intervention plus medical treatment compared with medical treatment alone in people with definite ischaemic stroke.
Data collection and analysis: Two review authors (MBR and MJ) applied the inclusion criteria, extracted data, and assessed trial quality. Two review authors (MBR and HL) assessed risk of bias, and the certainty of the evidence using GRADE. We obtained both published and unpublished data if available. Our primary outcome was favourable functional outcome at the end of the scheduled follow-up period, defined as a modified Rankin Scale score of 0 to 2. Eighteen trials (i.e. all but one included trial) reported their outcome at 90 days. Secondary outcomes were death from all causes at in the acute phase and by the end of follow-up, symptomatic intracranial haemorrhage in the acute phase and by the end of follow-up, neurological status at the end of follow-up, and degree of recanalisation.

Résultats : We included 19 studies with a total of 3793 participants. The majority of participants had large artery occlusion in the anterior circulation, and were treated within six hours of symptom onset with endovascular thrombectomy. Treatment increased the chance of achieving a good functional outcome, defined as a modified Rankin Scale score of 0 to 2: risk ratio (RR) 1.50 (95% confidence interval (CI) 1.37 to 1.63; 3715 participants, 18 RCTs; high-certainty evidence). Treatment also reduced the risk of death at end of follow-up: RR 0.85 (95% CI 0.75 to 0.97; 3793 participants, 19 RCTs; high-certainty evidence) without increasing the risk of symptomatic intracranial haemorrhage in the acute phase: RR 1.46 (95% CI 0.91 to 2.36; 1559 participants, 6 RCTs; high-certainty evidence) or by end of follow-up: RR 1.05 (95% CI 0.72 to 1.52; 1752 participants, 10 RCTs; high-certainty evidence); however, the wide confidence intervals preclude any firm conclusion. Neurological recovery to National Institutes of Health Stroke Scale (NIHSS) score 0 to 1 and degree of recanalisation rates were better in the treatment group: RR 2.03 (95% CI 1.21 to 3.40; 334 participants, 3 RCTs; high-certainty evidence) and RR 3.11 (95% CI 2.18 to 4.42; 268 participants, 3 RCTs; high-certainty evidence), respectively.

Conclusion : In individuals with acute ischaemic stroke due to large artery occlusion in the anterior circulation, endovascular thrombectomy can increase the chance of survival with a good functional outcome without increasing the risk of intracerebral haemorrhage or death.

Conclusion (proposition de traduction) : Chez les personnes présentant un accident vasculaire cérébral ischémique aigu dû à une occlusion d'une grosse artère dans la circulation antérieure, la thrombectomie endovasculaire peut augmenter les chances de survie avec une bonne amélioration de l'état fonctionnel sans augmenter le risque d'hémorragie intracérébrale ou de décès.

Commentaire : Voir la traduction en français sur :
Thrombectomie endovasculaire et interventions intra-artérielles dans les accidents ischémiques cérébraux aigus  .

Use of Corticosteroids in Cardiac Arrest-A Systematic Review and Meta-Analysis.
Shah K, Mitra AR. | Crit Care Med. 2021 Jun 1;49(6):e642-e650
DOI: https://doi.org/10.1097/ccm.0000000000004941
Keywords: Aucun

Online Review Article

Introduction :  The objective of this systematic review was to evaluate the impact of intraarrest corticosteroids on neurologic outcomes and mortality in patients with cardiac arrest.
titre_eData sources_plus: We conducted a systematic search using the Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE databases.

Méthode : We included all randomized controlled trials and comparative observational studies. We excluded single arm studies, case reports/series, narrative reviews, and studies irrelevant to the focus of this article.
Data extraction: Two reviewers independently assessed trial eligibility. Data were collected for the following outcomes: primary outcomes included good neurologic outcome, survival to hospital discharge, and survival at greater than or equal to 1 year. Secondary outcomes included incidence of return of spontaneous circulation, ICU and hospital length of stay, duration of vasopressor and inotropic treatment, and blood pressure during cardiopulmonary resuscitation and after return of spontaneous circulation.

Résultats : The pooled estimates from randomized controlled trials for the following subgroups were analyzed using random-effects models: 1) patients with in-hospital cardiac arrest who received vasopressin, steroids, and epinephrine; 2) patients with in-hospital cardiac arrest who used corticosteroids only (i.e., no vasopressin); and 3) patients with out-of-hospital cardiac arrest who used corticosteroids only. Results included an increase in good neurologic outcomes (relative risk, 2.84; 95% CI, 1.36-5.94) and survival to hospital discharge (relative risk, 2.58; 95% CI, 1.36-4.91) in in-hospital cardiac arrest patients receiving vasopressin, steroids, and epinephrine followed by corticosteroids for postresuscitation shock. This was further supported by an increase in return of spontaneous circulation (relative risk, 1.35; 95% CI, 1.12-1.64) and hemodynamics in this population. There was no benefit observed in in-hospital cardiac arrest or out-of-hospital cardiac arrest patients receiving corticosteroids alone.

Conclusion : Our study found that there are limited high-quality data to analyze the association between corticosteroids and reducing mortality in cardiac arrest, but the available data do support future randomized controlled trials. We did find that corticosteroids given as part of a vasopressin, steroids, and epinephrine regimen in in-hospital cardiac arrest patients and for postresuscitation shock did improve neurologic outcomes, survival to hospital discharge, and surrogate outcomes that include return of spontaneous circulation and hemodynamics. We found no benefit in in-hospital cardiac arrest or out-of-hospital cardiac arrest patients receiving corticosteroids only; however, a difference cannot be ruled out due to imprecision and lack of available data.

Conclusion (proposition de traduction) : Notre étude a révélé qu'il existe peu de données de haute qualité pour analyser l'association entre les corticostéroïdes et la réduction de la mortalité dans les arrêts cardiaques, mais les données disponibles soutiennent les futurs essais contrôlés randomisés. Nous avons constaté que les corticostéroïdes administrés dans le cadre d'un régime à base de vasopressine, de stéroïdes et d'épinéphrine chez les patients hospitalisés en arrêt cardiaque et pour le choc post-réanimation ont amélioré les résultats neurologiques, la survie jusqu'à la sortie de l'hôpital et les résultats de substitution qui incluent le retour de la circulation spontanée et de l'hémodynamique. Nous n'avons trouvé aucun avantage chez les patients en arrêt cardiaque à l'hôpital ou en dehors de l'hôpital recevant uniquement des corticostéroïdes ; cependant, une différence ne peut être exclue en raison de l'imprécision et du manque de données disponibles.

Optimizing hemodynamic function during cardiopulmonary resuscitation.
Vammen L, Fjølner J, Hansen K, Granfeldt A. | Curr Opin Crit Care. 2021 Jun 1;27(3):216-222
DOI: https://doi.org/10.1097/mcc.0000000000000819
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION

Introduction : The purpose of this narrative review is to provide an update on hemodynamics during cardiopulmonary resuscitation (CPR) and to describe emerging therapies to optimize perfusion.

Méthode : Cadaver studies have shown large inter-individual variations in blood distribution and anatomical placement of the heart during chest compressions. Using advanced CT techniques the studies have demonstrated atrial and slight right ventricular compression, but no direct compression of the left ventricle. A hemodynamic-directed CPR strategy may overcome this by allowing individualized hand-placement, drug dosing, and compression rate and depth. Through animal studies and one clinical before-and-after study head-up CPR has shown promising results as a potential strategy to improve cerebral perfusion. Two studies have demonstrated that placement of an endovascular balloon occlusion in the aorta (REBOA) can be performed during ongoing CPR.

Conclusion : Modern imaging techniques may help increase our understanding on the mechanism of forward flow during CPR. This could provide new information on how to optimize perfusion. Head-up CPR and the use of REBOA during CPR are novel methods that might improve cerebral perfusion during CPR; both techniques do, however, still await clinical testing.

Conclusion (proposition de traduction) : Les techniques d'imagerie modernes peuvent aider à mieux comprendre le mécanisme du flux vers l'avant pendant la réanimation cardio-pulmonaire. Cela pourrait fournir de nouvelles informations sur la façon d'optimiser la perfusion. La réanimation cardio-pulmonaire tête haute et l'utilisation du REBOA pendant la réanimation cardio-pulmonaire sont de nouvelles méthodes qui pourraient améliorer la perfusion cérébrale pendant la réanimation cardio-pulmonaire ; les deux techniques, cependant, attendent toujours des tests cliniques.

Transportation during and after cardiac arrest: who, when, how and where?.
Ho AFW, Ong MEH. | Curr Opin Crit Care. 2021 Jun 1;27(3):223-231
DOI: https://doi.org/10.1097/mcc.0000000000000816
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION

Introduction : Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients.

Résultats : We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research.

Conclusion : There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.

Conclusion (proposition de traduction) : Il reste des preuves limitées pour guider certaines décisions dans le transport du patient en arrêt cardiaque en dehors de l'hôpital. Des preuves sont nécessaires de toute urgence pour élucider les rôles des centres d'arrêt cardiaque et de l'ECPR (Extracorporeal Cardio Pulmonary Resuscitation) dans l'arrêt cardiaque en dehors hôpital.

Immediate postcardiac arrest treatment: coronary catherization or not?.
Dumas F, Bougouin W, Cariou A. | Curr Opin Crit Care. 2021 Jun 1;27(3):232-238
DOI: https://doi.org/10.1097/mcc.0000000000000831
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION

Introduction : Early coronary angiogram (CAG) remains a cornerstone in postcardiac arrest management as coronary disease (CAD)-related cardiac arrest is the leading cause of sudden death in adults. The opportunity to treat the cause early on with immediate CAG may improve outcome in cardiac arrest patients with AMI. Identifying the patients who will benefit from such an early invasive strategy is an unanswered question. Recent and ongoing trials may improve the level of evidence on this problematic, especially for some subgroup; however, current guidelines remain founded upon a very heterogeneous level of evidence.

Résultats : The key variable to argue for immediate CAD remains the pattern of the ECG monitored after return of spontaneous of circulation (ROSC). ST-segment elevation (STE) on postresuscitation ECG is the strongest argument to rule for an early CAG strategy. In other situations, identifying the best candidates for early CAG is very challenging. Different approaches including elements, such as circumstances of cardiac arrest and expected outcomes. may also drive the strategy.

Conclusion : This review aims to provide an overview of these different discussion points. The indication for early CAG should rely on multiple factors and an individual approach.

Conclusion (proposition de traduction) : Cette revue vise à donner un aperçu des différents points de discussion. L'indication d'une coronarographie précoce doit reposer sur de multiples facteurs et une approche individuelle.

Optimizing defibrillation during cardiac arrest.
Babini G, Ruggeri L, Ristagno G. | Curr Opin Crit Care. 2021 Jun 1;27(3):246-254
DOI: https://doi.org/10.1097/mcc.0000000000000821
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION

Introduction : Current cardiac arrest guidelines are based on a fixed, time-based defibrillation strategy. Rhythm analysis and shock delivery (if indicated) are repeated every 2 min requiring cyclical interruptions of chest compressions. This approach has several downsides, such as the need to temporarily stop cardiopulmonary resuscitation (CPR) for a variable amount of time, thus reducing myocardial perfusion and decreasing the chance of successful defibrillation. A tailored defibrillation strategy should identify treatment priority for each patient, that is chest compressions (CCS) or defibrillation, minimize CCs interruptions, speed up the delivery of early effective defibrillation and reduce the number of ineffective shocks.

Résultats : Real-time ECG analysis (using adaptive filters, new algorithms robust to chest compressions artifacts and shock-advisory algorithms) is an effective strategy to correctly identify heart rhythm during CPR and reduce the hands-off time preceding a shock. Similarly, ventricular fibrillation waveform analysis, that is amplitude spectrum area (AMSA) represents a well established approach to reserve defibrillation in patients with high chance of shock success and postpone it when ventricular fibrillation termination is unlikely. Both approaches demonstrated valuable results in improving cardiac arrest outcomes in experimental and observational study.

Conclusion : Real-time ECG analysis and AMSA have the potential to predict ventricular fibrillation termination, return of spontaneous circulation and even survival, with discretely high confidence. Prospective studies are now necessary to validate these new approaches in the clinical scenario.

Conclusion (proposition de traduction) : L'analyse de l'ECG en temps réel et la zone du spectre d'amplitude ont le potentiel de prédire la fin de la fibrillation ventriculaire, le retour à une activité cardiaque spontanée et même la survie, avec une confiance discrètement élevée. Des études prospectives sont désormais nécessaires pour valider ces nouvelles approches dans la pratique clinique.

Inhaled gases as novel neuroprotective therapies in the postcardiac arrest period.
Magliocca A, Fries M. | Curr Opin Crit Care. 2021 Jun 1;27(3):255-260
DOI: https://doi.org/10.1097/mcc.0000000000000820
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION

Introduction : The purpose of this review is to summarize recent advances about inhaled gases as novel neuroprotective agents in the postcardiac arrest period.

Résultats : Inhaled gases, as nitric oxide (NO) and molecular hydrogen (H2), and noble gases as xenon (Xe) and argon (Ar) have shown neuroprotective properties after resuscitation. In experimental settings, the protective effect of these gases has been demonstrated in both in-vitro studies and animal models of cardiac arrest. They attenuate neuronal degeneration and improve neurological function after resuscitation acting on different pathophysiological pathways. Safety of both Xe and H2 after cardiac arrest has been reported in phase 1 clinical trials. A randomized phase 2 clinical trial showed the neuroprotective effects of Xe, combined with targeted temperature management. Xe inhalation for 24 h after resuscitation preserves white matter integrity as measured by fractional anisotropy of diffusion tensor MRI.

Conclusion : Inhaled gases, as Xe, Ar, NO, and H2 have consistently shown neuroprotective effects in experimental studies. Ventilation with these gases appears to be well tolerated in pigs and in preliminary human trials. Results from phase 2 and 3 clinical trials are needed to assess their efficacy in the treatment of postcardiac arrest brain injury.

Conclusion (proposition de traduction) : Les gaz inhalés, comme le xénon, l'argon, l'oxyde nitrique et l'hydrogène moléculaire ont constamment montré des effets neuroprotecteurs dans les études expérimentales. La ventilation avec ces gaz semble être bien tolérée chez les porcs et dans les essais humains préliminaires. Les résultats des essais cliniques de phase 2 et 3 sont nécessaires pour évaluer leur efficacité dans le traitement des lésions cérébrales d'arrêt de carte postale.

Blood lactate levels in sepsis: in 8 questions.
Vincent JL, Bakker J. | Curr Opin Crit Care. 2021 Jun 1;27(3):298-302
DOI: https://doi.org/10.1097/mcc.0000000000000824
Keywords: Aucun

CARDIOPULMONARY MONITORING

Introduction : Blood lactate concentrations are frequently measured in critically ill patients and have important prognostic value. Here, we review some key questions related to their clinical use in sepsis.

Résultats : Despite the metabolic hurdles, measuring lactate concentrations remains very informative in clinical practice. Although blood lactate levels change too slowly to represent the only guide to resuscitation, serial lactate levels can help to define the patient's trajectory and encourage a review of the therapeutic strategy if they remain stable or increase over time.

Conclusion : Lactate concentrations respond too slowly to be used to guide acute changes in therapy, but can help evaluate overall response. Hyperlactatemia should not be considered as a problem in itself, but as a warning of altered cell function.

Conclusion (proposition de traduction) : Les concentrations de lactate répondent trop lentement pour être utilisées pour guider les changements aigus de la thérapie, mais peuvent aider à évaluer la réponse globale. L'hyperlactatémie ne doit pas être considérée comme un problème en soi, mais comme un avertissement d'une fonction cellulaire altérée.

The role of automated compression devices in out-of- and in- hospital cardiac arrest. Can we spare rescuers’ hands?.
Latsios G, Leopoulou M, Synetos A, Karanasos A, Melidi E, Toutouzas K, Tsioufis K. . | Emerg Care J. 2021 Jun;17(2):9525
DOI: https://doi.org/10.4081/ecj.2021.9923  | Télécharger l'article au format  
Keywords: Cardiac arrest, mechanical compressions, manual compressions

REVIEWS

Editorial : Research regarding the use of mechanical compressions in the setting of a cardiac arrest, either outside of or inside the hospital environment has produced mixed results. The debate whether they can replace manual compressions still remains. The aim of this review is to present current literature contemplating the application of mechanical compressions in both settings, data comparing them to manual compressions as well as current guidelines regarding their implementation in everyday clinical use. Currently, their implementation in the resuscitation protocol seems to benefit the victims of an in-hospital cardiac arrest rather than the victims that sustain a cardiac arrest outside of the hospital.

Conclusion : Les données concernant l'utilisation de la RCP mécanique dans les cas d'arrêt cardiaque à la fois extra-hospitalier et intra-hospitalier sont mitigées. En général, l'utilisation de dispositifs dans les situations OHCA semble montrer des preuves faibles et contradictoires sur les résultats des victimes, alors que dans IHCA, elle a un impact plutôt positif. Une RCP de haute qualité reste la clé d'une réanimation réussie et, en tant que telle, son importance est soulignée dans toutes les études comparant la RCP manuelle et mécanique. Les grands registres et les essais randomisés devraient éclaircir davantage ce débat, la mesure de la qualité de la RCP étant un élément clé de leur conception.

Conclusion (proposition de traduction) : Les données concernant l'utilisation de la RCP mécanique dans les cas d'arrêt cardiaque à la fois extra-hospitalier et intra-hospitalier sont mitigées. En général, l'utilisation de dispositifs dans les situations d'arrêts cardiaques extrahospitaliers semble montrer des preuves faibles et contradictoires sur les résultats pou les victimes, alors que dans les arrêts cardiaques intrahospitaliers, elle a un impact plutôt positif. Une RCP de haute qualité reste la clé d'une réanimation réussie et, en tant que telle, son importance est soulignée dans toutes les études comparant la RCP manuelle et mécanique. Les grands registres et les essais randomisés devraient éclaircir davantage ce débat, la mesure de la qualité de la RCP étant un élément clé de leur conception.

Non-invasive assessment of fluid responsiveness to guide fluid therapy in patients with sepsis in the emergency department: a prospective cohort study.
Koopmans NK, Stolmeijer R, Sijtsma BC, van Beest PA, Boerma CE, Veeger NJ, Ter Avest E. | Emerg Med J. 2021 Jun;38(6):416-422
DOI: https://doi.org/10.1136/emermed-2020-209771
Keywords: bacterial; clinical management; infectious diseases; non invasive; treatment.

SEPSIS

Introduction : Little is known about optimal fluid therapy for patients with sepsis without shock who present to the ED. In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock.

Méthode : In a prospective cohort study, CI, stroke volume (SV) and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90 and 120 s after PLR. Finally, a standardised 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardised fluid challenge.

Résultats : Seven out of 30 (23%) patients demonstrated a >15% increase in CI after PLR and after a 500 mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44-78) vs 37 (23-47), p=0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positive correlated to the change in CI after a 500 mL NaCl 0.9% fluid bolus (r=0.88, p<0.001).

Conclusion : The results of the present study demonstrate that in patients with sepsis in the absence of shock, three out of four patients do not demonstrate a clinically relevant increase in CI after a standardised fluid challenge. Non-invasive CO monitoring in combination with a PLR test has the potential to identify patients who might benefit from fluid resuscitation and may contribute to a better tailored treatment of these patients.

Conclusion (proposition de traduction) : Les résultats de la présente étude montrent que chez les patients présentant un sepsis en l'absence de choc, trois patients sur quatre ne présentent pas d'augmentation cliniquement pertinente de l'indice cardiaque après un test de remplissage standardisée. La surveillance non invasive du débit cardiaque associée à un test passif de soulèvement des jambes a le potentiel d'identifier les patients qui pourraient bénéficier d'une réanimation liquidienne et peut contribuer à un traitement mieux adapté de ces patients.

Mortality benefit of crystalloids administered in 1-6 hours in septic adults in the ED: systematic review with narrative synthesis.
Xantus GZ, Allen P, Norman S, Kanizsai PL. | Emerg Med J. 2021 Jun;38(6):430-438
DOI: https://doi.org/10.1136/emermed-2020-210298
Keywords: acute care; clincial management; death/mortality.

SEPSIS

Introduction : Based on the 2018 update of the Surviving Sepsis Campaign, the Committee for Quality Improvement of the NHSs of England recommended the instigation of the elements of the 'Sepsis-6 bundle' within 1 hour to adult patients screened positive for sepsis. This bundle includes a bolus infusion of 30 mL/kg crystalloids in the ED. Besides the UK, both in the USA and Australia, compliance with similar 1-hour targets became an important quality indicator. However, the supporting evidence may neither be contemporaneous nor necessarily valid for emergency medicine settings.

Méthode : A systematic review was designed and registered at PROSPERO to assess available emergency medicine/prehospital evidence published between 2012 and 2020, investigating the clinical benefits associated with a bolus infusion of a minimum 30 mL/kg crystalloids within 1 hour to adult patients screened positive for sepsis. Due to the small number of papers that addressed this volume of fluids in 1 hour, we expanded the search to include studies looking at 1-6 hours.

Résultats : Seven full-text articles were identified, which investigated various aspects of the fluid resuscitation in adult sepsis. However, none answered completely to the original research question aimed to determine either the effect of time-to-crystalloids or the optimal fluid volume of resuscitation. Our findings demonstrated that in the USA/UK/Australia/Canada, adult ED septic patients receive 23-43 mL/kg of crystalloids during the first 6 hours of resuscitation without significant differences either in mortality or in adverse effects.

Conclusion : This systematic review did not find high-quality evidence supporting the administration of 30 mL/kg crystalloid bolus to adult septic patients within 1 hour of presentation in the ED. Future research must investigate both the benefits and the potential harms of the recommended intervention.

Conclusion (proposition de traduction) : Cette revue systématique n'a pas trouvé de preuves de haute qualité soutenant l'administration d'un bolus cristalloïde de 30 ml/kg à des patients septiques adultes dans l'heure suivant la présentation aux urgences. Les recherches futures doivent étudier à la fois les avantages et les inconvénients potentiels de l'intervention recommandée.

Multiple rib fractures: does flail chest matter?.
Daskal Y, Paran M, Korin A, Soukhovolsky V, Kessel B. | Emerg Med J. 2021 May 13:emermed-2020-210999
DOI: https://doi.org/10.1136/emermed-2020-210999
Keywords: chest; fractures and dislocations; pneumothorax; trauma.

TRAUMA

Introduction : Recent studies have reported significant morbidity and mortality in patients with multiple rib fractures, even without flail chest. The aim of this study was to compare the clinical outcome and incidence of associated chest injuries between patients with and without flail chest, with three or more rib fractures.

Méthode : This study included patients with blunt trauma with at least three rib fractures, hospitalised during 2010-2019 in the Hillel Yaffe Medical Center in central Israel (level II trauma centre). Patients with and without radiologically defined flail chest were compared with regard to demographics, Injury Severity Score (ISS), GCS, systolic blood pressure (SBP) on admission, radiological evidence of flail chest, associated chest injuries, length of stay in intensive care unit, length of hospitalisation and mortality.

Résultats : The study included 407 patients, of which 79 (19.4%) had flail chest. Overall, pneumothorax and haemothorax were more common among patients with flail chest (p<0.05). When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest.

Conclusion : In patients with three to five rib fractures, pneumothorax is more common among patients with flail chest. Clinical significance of flail chest in patients with more than six rib fractures is questionable and flail chest may not be a reliable marker for severity of chest injury in patients with more than six fractures.

Conclusion (proposition de traduction) : Chez les patients présentant trois à cinq fractures de côtes, un pneumothorax est plus fréquent chez les patients qui présentent un volet costal associé. La signification clinique du volet costal chez les patients présentant plus de six fractures des côtes est discutable et le volet costal peut ne pas être un marqueur fiable de la gravité des lésions thoraciques chez les patients présentant plus de six fractures.

Randomised controlled trial comparing immobilisation in above-knee plaster of Paris to controlled ankle motion boots in undisplaced paediatric spiral tibial fractures.
Bradman K, Stannage K, O'Brien S, Green S, Bear N, Borland M. | Emerg Med J. 2021 Jun 22:emermed-2020-210299
DOI: https://doi.org/10.1136/emermed-2020-210299
Keywords: paediatric emergency med; paediatric injury; paediatric orthopadics; paediatrics.

PAEDIATRICS

Introduction : Management of common childhood spiral tibial fractures, known as toddler's fractures, has not significantly changed in recent times despite the availability of immobilisation devices known as controlled ankle motion (CAM) boots. We compared standard therapy with these devices on quality-of-life measures.

Méthode : A prospective randomised controlled trial, comparing immobilisation with an above-knee plaster of Paris cast (AK-POP) with a CAM boot in children aged 1-5 years with proven or suspected toddler's fractures presenting to a tertiary paediatric ED in Perth, Western Australia, between March 2018 and February 2020. The primary outcome measure was ease of personal care, as assessed by a Care and Comfort Questionnaire (eight questions scored from 0, very easy, to 8, impossible) completed by the caregiver and assessed during three treatment time-points and preintervention and postintervention. Secondary outcome measures included weight-bearing status as well as complications of fracture healing and number of pressure injuries.

Résultats : 87 patients were randomised (44 CAM boot, median age 2 (IQR 1.5-2.3), 71% male; 43 AK-POP, median age 2 (IQR 1.7-2.8), 80% male), a significant difference in the care and comfort score was demonstrated at all treatment time-points; with the AK-POP group reporting greater personal care needs on assessment on day 2, day 7-10 and 4-week review (all p≤0.001). Weight-bearing status was significantly different at day 7-10 (77.5% CAM vs 53.8% AK-POP, p=0.027). There was no difference in fracture healing or pressure areas between the two treatment groups.

Conclusion : Immobilisation of toddler's fractures in a CAM boot allows faster return to activities of daily living and weight-bearing without any effect on fracture healing.

Conclusion (proposition de traduction) : L'immobilisation des fractures du tout-petit dans une botte à mouvement contrôlé de la cheville permet un retour plus rapide aux activités de la vie quotidienne et à la mise en charge sans aucun effet sur la guérison des fractures.

Does plain radiography still have a role in cases of fish bone ingestion in emergency rooms? A retrospective analysis.
Wu TC, Huang PW, Tung CB. | Emerg Radiol. 2021 Jun;28(3):627-631
DOI: https://doi.org/10.1007/s10140-021-01913-6  | Télécharger l'article au format  
Keywords: Fish bone; Foreign body; Lateral neck radiography; Radiography in emergency care

Original Article

Introduction : Fish bones are the most common aerodigestive foreign bodies found in adults. Most cases of fish bone impaction improve after primary management by emergency physicians with a mirror laryngoscopy using a tongue depressor, before otolaryngologists perform a fiberoptic nasendoscopy. A computed tomography scan usually follows to determine the next step. Studies have recently been concerned about overdoses of radiation from computed tomography. However, clear algorithms remain unavailable for fish bone ingestion management to date.

Méthode : A retrospective review was conducted on 180 patients who visited the emergency department with complaints of fish bone impaction between January 2017 and January 2019.

Résultats : A total of 81.6% of patients with fish bone impaction got symptomatic relief after primary management by emergency physicians and otolaryngologists. Out of 180 patients, 33 (18.3%) needed an endoscopic procedure due to persistent symptoms. Only one (0.56%) required an operation due to perforation. In the group failing primary management, the plain radiography of eight patients showed a positive finding and an esophagogastroscopy was done to remove the fish bones.

Conclusion : Lateral neck radiography is still beneficial to patients with fish bone ingestion failure from primary management. Positive lateral soft tissue radiography in cases with persistent symptoms post primary management may directly suggest esophagogastroscopy without confirmation from a computed tomography, unless complications are suspected. For patients aged below 40, following up on their conditions after post management radiography shows negative results may increase their safety.

Conclusion (proposition de traduction) : La radiographie latérale du cou est toujours bénéfique pour les patients présentant une douleur après ingestion d'une arrête de poisson lors de la prise en charge primaire. Une radiographie latérale positive des tissus mous en cas de symptômes persistants après la prise en charge primaire peut suggérer la réalisation directement d'une œsophagogastroscopie, sans confirmation par une tomodensitométrie, à moins que des complications ne soient suspectées. Pour les patients âgés de moins de 40 :ans, le suivi de leur état clinique, après une radiographie négative lors de la prise en charge primaire, devrait accroître leur sécurité.

Arterial and venous thromboembolic complications of COVID-19 detected by CT angiogram and venous duplex ultrasound.
Lee E, Krajewski A, Clarke C, O'Sullivan D, Herbst T, Lee S. | Emerg Radiol. 2021 Jun;28(3):469-476
DOI: https://doi.org/10.1007/s10140-020-01884-0  | Télécharger l'article au format  
Keywords: COVID-19; Coronavirus; Deep vein thrombosis; Pulmonary embolism; Thromboembolism.

Original Article

Introduction : To investigate the incidence of thromboembolic events, specifically pulmonary embolism (PE), deep vein thrombosis (DVT), and cerebrovascular accidents (CVA), in patients who tested positive for COVID-19 through RT-PCR in a regional healthcare system in Connecticut.

Méthode : All CT angiogram (CTA) and venous duplex extremity ultrasound (US) examinations performed on 192 consecutively documented cases of COVID-19 were retrospectively reviewed at a multi-centered healthcare system. Clinical characteristics and patient outcomes were evaluated and compared between two groups based on the presence or absence of acute thromboembolic events.

Résultats : Of the 16,264 patients tested for COVID-19, 3727 (23%) were positive. Out of those, 192 patients underwent 245 vascular imaging studies including chest CTA (86), venous duplex ultrasound (134), and CTA head and neck (25). Among those who underwent imaging, 49 (26%) demonstrated acute thromboembolic events which included 13/86 (15%) with PE, 34/134 (25%) with DVT, and 6/25 (24%) with CVA. One patient had positive results on all 3 examinations, and 2 patients had positive results on both chest CTA and venous duplex US. Males were more likely to have a thromboembolic event than females (33/103 (34%) vs. 14/89 (16%), p = 0.009). No significant difference was observed with respect to age, cardiopulmonary comorbidities, malignancy history, diabetes, or dialysis.

Conclusion : Approximately 26% of COVID-19 patients with positive testing who underwent vascular imaging with CTA or venous duplex ultrasound had thromboembolic events including PE, DVT, and CVA. This indicates that COVID-19 patients are at increased risk for thromboembolic complications.

Conclusion (proposition de traduction) : Environ 26 % des patients COVID-19 avec des tests positifs qui ont bénéficié d'une imagerie par angioscanner thoracique ou une échographie doppler veineuse ont eu des événements thromboemboliques, notamment une embolie pulmonaire, une thrombose veineuse profonde et des accidents vasculaires cérébraux. Cela indique que les patients COVID-19 présentent un risque accru de complications thromboemboliques.

Pediatric scaphoid fracture: diagnostic performance of various radiographic views.
Nguyen JC, Shah AS, Nguyen MK, Baghdadi S, Nicholson A, Guariento A, Kaplan SL. | Emerg Radiol. 2021 Jun;28(3):565-572
DOI: https://doi.org/10.1007/s10140-020-01897-9
Keywords: Children; Diagnosis; Fracture; Imaging; Pediatric; Radiographs; Scaphoid.

Original Article

Introduction : The purpose of this study was to systematically investigate the performance of different radiographic views in the identification of scaphoid fractures in children.

Méthode : This case-control study compared 4-view radiographic examinations of the wrist between children with scaphoid fracture and age- and sex-matched children without fractures performed between January 2008 and July 2019. After randomization, each examination was reviewed 3 times, at least 1 week apart, first using each view separately and later using multiple views without (3-view) and with the posteroanterior (PA) scaphoid view (4-view), to determine the presence or absence of a scaphoid fracture. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with inter-rater agreement.

Résultats : The study group of 58 children (48 boys and 10 girls; mean age 13.1 ± 2.1 years) included 29 with scaphoid fractures (8 corner, 9 distal pole, 10 waist, and 2 proximal pole) and 29 without fractures. Multiple views had higher sensitivity (3-view, 93.0%; 4-view, 96.5%) for fracture identification when compared to individual views (41.0-89.6%). The oblique view was 100% specific for the identification of a scaphoid fracture, but it lacked sensitivity. The PA scaphoid view had the highest sensitivity (89.6%) and NPV (90%) when compared to other individual views and its inclusion in the 4-view examinations produced the highest inter-rater agreement (93%, κ = 0.86).

Conclusion : Multiple radiographic views of the wrist with the inclusion of a PA scaphoid view (4-view) produced the highest sensitivity, NPV, and inter-rater agreement for the identification of a scaphoid fracture in children.

Conclusion (proposition de traduction) : Des vues radiographiques multiples du poignet avec l'inclusion d'une vue du scaphoïde postéro-antérieur (4 vues) ont produit la sensibilité la plus élevée, la valeur prédictive négative et la concordance entre les évaluateurs pour l'identification d'une fracture du scaphoïde chez les enfants.

Commentaire :  Examen radiographique à quatre vues du poignet pour suspicion de fracture du scaphoïde.
Les vues postéro-antérieure (PA, a), oblique (b), latérale (c) et du scaphoïde PA (d) du poignet droit d'un garçon de 12 ans, qui a subi une blessure pendant les sports 2 semaines avant l'imagerie, montrent une fracture du corps du scaphoïde (flèches).

Use of backboards in cardiopulmonary resuscitation: a systematic review and meta-analysis.
Paganini M, Mormando G, Carfagna F, Ingrassia PL. | Eur J Emerg Med. 2021 Jun 1;28(3):180-188
DOI: https://doi.org/10.1097/mej.0000000000000784
Keywords: Aucun

Reviews

Editorial : To achieve optimal chest compression depth, victims of cardiac arrest should be placed on a firm surface. Backboards are usually placed between the mattress and the back of a patient in the attempt to increase cardiopulmonary resuscitation (CPR) quality, but their effectiveness remains controversial. A systematic search was performed to include studies on humans and simulation manikins assessing CPR quality with or without backboards. The primary outcome of the meta-analysis was the difference in chest compression depth between these two conditions. Out of 557 records, 16 studies were included in the review and all were performed on manikins. The meta-analysis, performed on 15 articles, showed that the use of backboards during CPR increases chest compression depth by 1.46 mm in manikins. Despite statistically significant, this increase could have a limited clinical impact on CPR, due to the substantial heterogeneity of experimental conditions and the scarcity of other CPR quality indicators.

Conclusion : The present study shows that the use of backboards during CPR on soft surfaces moderately increases chest compression depth. However, due to important heterogeneity and high risk of bias found in the included studies, we cannot provide a clear recommendation on the effectiveness of backboards in CPR.
In conclusion, according to current guidelines, chest compressions should be performed on firm surfaces whenever possible. Backboards could provide a rigid support when, due to circumstances, CPR has to be carried out on soft surfaces, but future human trials are warranted.

Conclusion (proposition de traduction) : La présente étude montre que l'utilisation de planches dorsales pendant la RCP sur des surfaces molles augmente modérément la profondeur de compression thoracique. Cependant, en raison de l'hétérogénéité importante et du risque élevé de biais trouvés dans les études incluses, nous ne pouvons pas fournir une recommandation claire sur l'efficacité des planches dorsales dans la RCP.
En conclusion, selon les directives en vigueur, les compressions thoraciques doivent être effectuées sur des surfaces fermes dans la mesure du possible. Les planches dorsales pourraient fournir un support rigide lorsque, en raison des circonstances, la RCP doit être effectuée sur des surfaces molles, mais de futurs essais humains sont justifiés.

Association between personal protective equipment and SARS-CoV-2 infection risk in emergency department healthcare workers.
Schmitz D, Vos M, Stolmeijer R, Lameijer H, Schönberger T, Gaakeer MI, de Groot B, Eikendal T, Wansink L, Ter Avest E. | Eur J Emerg Med. 2021 Jun 1;28(3):202-209
DOI: https://doi.org/10.1097/mej.0000000000000766  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLES

Introduction : Healthcare personnel working in the emergency department (ED) is at risk of acquiring severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2). So far, it is unknown if the reported variety in infection rates among healthcare personnel is related to the use of personal protective equipment (PPE) or other factors.
Objective: The aim of this study was to investigate the association between PPE use and SARS-CoV-2 infections among ED personnel in the Netherlands.

Méthode : A nationwide survey, consisting of 42 questions about PPE-usage, ED layout - and workflow and SARS-CoV-2 infection rates of permanent ED staff, was sent to members of the Dutch Society of Emergency Physicians. Members were asked to fill out one survey on behalf of the ED of their hospital. The association between PPE use and the infection rate was investigated using univariable and multivariable regression analyses, adjusting for potential confounders.
Outcome measures: Primary outcome was the incidence of confirmed SARS-CoV-2 infections among permanent ED staff between 1 March and 15 May 2020.

Résultats : Surveys were sent to 64 EDs of which 45 responded (70.3%). In total, 164 ED staff workers [5.1 (3.2-7.0)%] tested positive for COVID-19 during the study period compared to 0.087% of the general population. There was significant clustering of infected ED staff in some hospitals (range: 0-23 infection). In 13 hospitals, an FFP2 (filtering facepiece particles >94% aerosol filtration) mask or equivalent and eye protection was worn for all contacts with patients with suspected or confirmed SARS-CoV-2 during the whole study period. The unadjusted staff infection rate was higher in these hospitals [7.3 (3.4-11.1) vs. 4.0 (1.9-6.1)%, absolute difference + 3.3%]. Hospital staff testing policy was identified as a potential confounder of the relation between PPE use and confirmed SARS-CoV-2 infections (collinearity statistic 0.95). After adjusting for hospital testing policy, type of PPE was not associated with incidence of COVID 19 infections among ED staff (P = 0.40).

Conclusion : In this cross-sectional study, the use of high-level PPE (FFP2 or equivalent and eye protection) by ED personnel during all contacts with patients with suspected or confirmed SARS-CoV-2 does not seem to be associated with a lower infection rate of ED staff compared to lower level PPE use. Attention should be paid to ED layout and social distancing to prevent cross-contamination of ED personnel.

Conclusion (proposition de traduction) : Dans cette étude transversale, l'utilisation d'EPI de haut niveau (FFP2 ou équivalent et protection oculaire) par le personnel des urgences lors de tous les contacts avec des patients suspects ou confirmés de SRAS-CoV-2 ne semble pas être associée à un taux d'infection plus faible du personnel des urgences par rapport à l'utilisation d'EPI de niveau inférieur.
Une attention particulière doit être portée à l’aménagement du service d’urgence et à la distanciation physique pour prévenir la contamination croisée du personnel des urgences.

Effect of replacing ambulance physicians with paramedics on outcome of resuscitation for prehospital cardiac arrest.
Bjornsson HM, Bjornsdottir GG, Olafsdottir H, Mogensen BA, Mogensen B, Thorgeirsson G. | Eur J Emerg Med. 2021 Jun 1;28(3):227-232
DOI: https://doi.org/10.1097/mej.0000000000000786
Keywords: Aucun

Original Article

Introduction : Limited evidence suggests that the presence of a prehospital physician improves survival from cardiac arrest. A retrospective study is undertaken to examine this question. In Reykjavik, Iceland, prehospital physicians on ambulances were replaced by emergency medical technicians (EMTs) in 2007. The aim of this study is to compare the outcome of prehospital resuscitation from cardiac arrest during periods of time with and without prehospital physician involvement.

Méthode : All cardiac arrests that underwent prehospital resuscitation by emergency medical systems between 2004 and 2014 were included. The primary outcome was survival to hospital discharge, and the secondary outcome was return of spontaneous circulation (ROSC). Subgroup analyses were performed according to the type of cardiac arrest.

Résultats : A total of 471 cardiac arrests were included for analysis, 200 treated by prehospital physicians from 2004 to 2007 and 271 treated by EMTs from 2008 to 2014. The overall rate of survival to hospital discharge and ROSC was 23 and 50% during the study period. No significant difference was observed in the rate of survival to hospital discharge [25 vs 22%, difference 3% (95% confidence interval (CI): 11-5%)] or ROSC [53 vs 47%, difference -6% (95% CI: 15-3%)] between these two time periods. In the subgroup of patients with pulseless electrical activity, survival to hospital discharge did not differ between the two periods, but the rate of ROSC was higher in the 'physician period' [50 vs 30%, difference -20% (95% CI: -40 to -1%)].

Conclusion : The presence of a prehospital physician on the ambulance was not found to result in a significant improvement in survival or ROSC after cardiac arrest compared to care by EMTs. Patients with pulseless electrical activity experienced an increase in ROSC when a physician was present but without improvement in survival to hospital discharge.

Conclusion (proposition de traduction) : La présence d'un médecin préhospitalier dans l'ambulance ne s'est pas avérée entraîner une amélioration significative de la survie ou du retour à une activité circulatoire spontanée après un arrêt cardiaque par rapport aux soins prodigués par des techniciens médicaux d'urgence. Les patients présentant une activité électrique sans pouls ont connu une augmentation du retour à une activité circulatoire spontanée lorsqu'un médecin était présent, mais sans amélioration de la survie jusqu'à la sortie de l'hôpital.

Ambulatory management of secondary spontaneous pneumothorax: a mirage, or a solution on the horizon?.
Mummadi SR, Porcel JM. | Eur Respir J. 2021 Jun 24;57(6):2100003
DOI: https://doi.org/10.1183/13993003.00003-2021
Keywords: Aucun

EDITORIAL PLEURAL DISEASE

Editorial : Ambulatory management of selected patients with secondary spontaneous pneumothorax using small- bore chest catheters (12F) with an attached one-way flutter valve device seems feasible and safe

Conclusion : Starting with the efforts of STRADLING and POOLE in 1966, various researchers have described the role of minimally invasive and ambulatory management in SSP subgroups in their studies. A 2019 systematic review restricted to randomised studies and studying the most efficacious and safe intervention in spontaneous pneumothorax reported only a 15% prevalence of SSP in their pooled sample. This suggests potential under-recruitment in trials that did not exclude SSP subjects. Therefore, it is no mean feat for WALKER et al. to have focused solely on SSP. This, along with the study’s randomised design, sets it apart from prior studies. This investigation has generated intriguing hypotheses about initial management choices and raised awareness about safety issues with “minimally invasive” devices: a concern noted in previous studies. Continuous efforts using the principles of mistake proofing to improve pleural device safety, including stand-alone Heimlich valves and narrow bore chest tubes, should complement these efforts. Ambulatory management of SSP is no longer a mirage on the horizon, but we do have some distance to cover.

Conclusion (proposition de traduction) : À partir des efforts de STRADLING et POOLE en 1966, divers chercheurs ont décrit le rôle de la gestion mini-invasive et ambulatoire dans les sous-groupes de pneumothorax spontané secondaire dans leurs études. Une revue systématique de 2019 limitée aux études randomisées et étudiant l'intervention la plus efficace et la plus sûre dans le pneumothorax spontané n'a rapporté qu'une prévalence de 15 % de pneumothorax spontané secondaire dans leurs échantillons. Cela suggère un sous-recrutement potentiel dans les essais qui n'excluaient pas les sujets présentant un pneumothorax spontané secondaire. Par conséquent, ce n'est pas une mince affaire pour WALKER et al. de s'être concentré uniquement sur le pneumothorax spontané secondaire. Ceci, ainsi que la conception randomisée de l'étude, la distingue des études précédentes. Cette enquête a généré des hypothèses intrigantes sur les choix de gestion initiaux et a fait prendre conscience des problèmes de sécurité liés aux dispositifs « mini-invasifs » : une préoccupation relevée dans les études précédentes. Des efforts continus utilisant les principes de la correction des erreurs pour améliorer la sécurité des dispositifs pleuraux, y compris les valves de Heimlich autonomes et les drains thoraciques à tunnel étroit, devraient compléter ces efforts. La prise en charge ambulatoire du pneumothorax spontané secondaire n'est plus un mirage à l'horizon, mais nous avons encore du chemin à parcourir.

Commentaire : Pour en savoir plus :
Walker SP, Keenan E, Bintcliffe O and al. Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial. Eur Respir J. 2021 Jun 24;57(6):2003375  

Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial.
Walker SP, Keenan E, Bintcliffe O, Stanton AE, Roberts M, Pepperell J, Fairbairn I, McKeown E, Goldring J, Maddekar N, Walters J, West A, Bhatta A, Knight M, Mercer R, Hallifax R, White P, Miller RF, Rahman NM, Maskell NA. | Eur Respir J. 2021 Jun 24;57(6):2003375
DOI: https://doi.org/10.1183/13993003.03375-2020
Keywords: Aucun

ORIGINAL ARTICLE PLEURAL DISEASE

Editorial : Secondary spontaneous pneumothorax (SSP) is traditionally managed with an intercostal chest tube attached to an underwater seal. We investigated whether use of a one-way flutter valve shortened patients' length of stay (LoS).This open-label randomised controlled trial enrolled patients presenting with SSP and randomised to either a chest tube and underwater seal (standard care: SC) or ambulatory care (AC) with a flutter valve. The type of flutter valve used depended on whether at randomisation the patient already had a chest tube in place: in those without a chest tube a pleural vent (PV) was used; in those with a chest tube in situ, an Atrium Pneumostat (AP) valve was attached. The primary end-point was LoS.Between March 2017 and March 2020, 41 patients underwent randomisation: 20 to SC and 21 to AC (13=PV, 8=AP). There was no difference in LoS in the first 30 days following treatment intervention: AC (median=6 days, IQR 14.5) and SC (median=6 days, IQR 13.3). In patients treated with PV there was a high rate of early treatment failure (6/13; 46%), compared to patients receiving SC (3/20; 15%) (p=0.11) Patients treated with AP had no (0/8 0%) early treatment failures and a median LoS of 1.5 days (IQR 23.8).There was no difference in LoS between ambulatory and standard care. Pleural Vents had high rates of treatment failure and should not be used in SSP. Atrium Pneumostats are a safer alternative, with a trend towards lower LoS.

Conclusion : In conclusion there was no difference in LoS between patients managed with ambulatory care compared to chest drain attached to underwater seal. This may be related to high rates of treatment failure with the pleural vent and a shorter LoS in the standard arm than previously cited. We do not advise use of pleural vent in patients with SSP, and the encouraging results with pleural vent in PSP are not translatable to this population. Our study has, however, shown early supportive evidence of safety in the attachment of an Atrium Pneumostat to an existing chest drain to ambulate patients with SSP. A dedicated trial using this device is now warranted.

Conclusion (proposition de traduction) : En conclusion, il n'y avait pas de différence de durée de séjour entre les patients traités en soins ambulatoires par rapport au drain thoracique en aspiration murale. Cela peut être lié à des taux d'échec élevés du traitement avec le dispositif de drain monté sur une valve antiretour (ndlr : Pleural Vent) et à une durée de séjour plus courte dans le bras standard que précédemment cité.
Nous déconseillons l'utilisation du dispositif de drain monté sur une valve antiretour chez les patients présentant un pneumothorax spontané secondaire, et les résultats encourageants avec le dispositif de drain monté sur une valve antiretour dans le pneumothorax spontané primaire ne sont pas transposables à cette population. Notre étude a cependant montré des preuves précoces de la sécurité de la fixation d'un Pneumostat à valve (Pneumostat Chest Drain Valve) à un drain thoracique existant en ambulatoire pour les patients présentant un pneumothorax spontané secondaire. Un essai dédié utilisant cet appareil est désormais justifié.

Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients.
Jaber S, Rollé A, Godet T, Terzi N, Riu B, Asfar P, Bourenne J, Ramin S, Lemiale V, Quenot JP, Guitton C, Prudhomme E, Quemeneur C, Blondonnet R, Biais M, Muller L, Ouattara A, Ferrandiere M, Saint-Léger P, Rimmelé T, Pottecher J, Chanques G, Belafia F, Chauveton C, Huguet H, Asehnoune K, Futier E, Azoulay E, Molinari N, De Jong A; STYLETO trial group. | Intensive Care Med. 2021 Jun;47(6):653-664
DOI: https://doi.org/10.1007/s00134-021-06417-y  | Télécharger l'article au format  
Keywords: Acute respiratory failure; Airway; Complications; Critical care; Intensive care unit; Intubation; Stylet.

Original

Introduction : The effect of the routine use of a stylet during tracheal intubation on first-attempt intubation success is unclear. We hypothesised that the first-attempt intubation success rate would be higher with tracheal tube + stylet than with tracheal tube alone.

Méthode : In this multicentre randomised controlled trial, conducted in 32 intensive care units, we randomly assigned patients to tracheal tube + stylet or tracheal tube alone (i.e. without stylet). The primary outcome was the proportion of patients with first-attempt intubation success. The secondary outcome was the proportion of patients with complications related to tracheal intubation. Serious adverse events, i.e., traumatic injuries related to tracheal intubation, were evaluated.

Résultats : A total of 999 patients were included in the modified intention-to-treat analysis: 501 (50%) to tracheal tube + stylet and 498 (50%) to tracheal tube alone. First-attempt intubation success occurred in 392 patients (78.2%) in the tracheal tube + stylet group and in 356 (71.5%) in the tracheal tube alone group (absolute risk difference, 6.7; 95%CI 1.4-12.1; relative risk, 1.10; 95%CI 1.02-1.18; P = 0.01). A total of 194 patients (38.7%) in the tracheal tube + stylet group had complications related to tracheal intubation, as compared with 200 patients (40.2%) in the tracheal tube alone group (absolute risk difference, - 1.5; 95%CI - 7.5 to 4.6; relative risk, 0.96; 95%CI 0.83-1.12; P = 0.64). The incidence of serious adverse events was 4.0% and 3.6%, respectively (absolute risk difference, 0.4; 95%CI, - 2.0 to 2.8; relative risk, 1.10; 95%CI 0.59-2.06. P = 0.76).

Conclusion : Among critically ill adults undergoing tracheal intubation, using a stylet improves first-attempt intubation success.

Conclusion (proposition de traduction) : Chez les adultes gravement malades bénéficiant d'une intubation trachéale, l'utilisation d'un stylet améliore le succès de la première tentative d'intubation.

Commentaire : L'incidence des événements indésirables graves évaluée par le taux de lésions traumatiques liées à l'intubation trachéale était similaire dans les deux groupes. Dans le groupe tube trachéal + stylet, la trachée a été intubée avec un tube trachéal et un stylet avec un angle de courbure de 25° à 35° à l'extrémité distale dans le tube trachéal.

• Pour aller plus loin sur le sujet, consulter :
Combes X, Pean D, Lenfant F, Francon D, Marciniak B, Legras A. Matériels d'intubation et de ventilation utilisables en cas de contrôle difficile des voies aériennes. Législation et maintenance: question 4. Ann Fr Anesth Reanim. 2008 Jan;27(1):33-40  , en deuxième page (p 34).

Restrictive fluid management versus usual care in acute kidney injury (REVERSE-AKI): a pilot randomized controlled feasibility trial.
Vaara ST, Ostermann M, Bitker L, Schneider A, Poli E, Hoste E, Fierens J, Joannidis M, Zarbock A, van Haren F, Prowle J, Selander T, Bäcklund M, Pettilä V, Bellomo R; REVERSE-AKI study team. | Intensive Care Med. 2021 Jun;47(6):665-673
DOI: https://doi.org/10.1007/s00134-021-06401-6  | Télécharger l'article au format  
Keywords: Acute kidney injury; Critically ill; Fluid balance; Restrictive fluid management.

Original

Introduction : We compared a restrictive fluid management strategy to usual care among critically ill patients with acute kidney injury (AKI) who had received initial fluid resuscitation.

Méthode : This multicenter feasibility trial randomized 100 AKI patients 1:1 in seven ICUs in Europe and Australia. Restrictive fluid management included targeting negative or neutral daily fluid balance by minimizing fluid input and/or enhancing urine output with diuretics administered at the discretion of the clinician. Fluid boluses were administered as clinically indicated. The primary endpoint was cumulative fluid balance 72 h from randomization.

Résultats : Mean (SD) cumulative fluid balance at 72 h from randomization was - 1080 mL (2003 mL) in the restrictive fluid management arm and 61 mL (3131 mL) in the usual care arm, mean difference (95% CI) - 1148 mL (- 2200 to - 96) mL, P = 0.033. Median [IQR] duration of AKI was 2 [1-3] and 3 [2-7] days, respectively (median difference - 1.0 [- 3.0 to 0.0], P = 0.071). Altogether, 6 out of 46 (13%) patients in the restrictive fluid management arm and 15 out of 50 (30%) in the usual care arm received renal replacement therapy (RR 0.42; 95% CI 0.16-0.91), P = 0.043. Cumulative fluid balance at 24 h and 7 days was lower in the restrictive fluid management arm. The dose of diuretics was not different between the groups. Adverse events occurred more frequently in the usual care arm.

Conclusion : In critically ill patients with AKI, a restrictive fluid management regimen resulted in lower cumulative fluid balance and less adverse events compared to usual care. Larger trials of this intervention are justified.

Conclusion (proposition de traduction) : Chez les patients de réanimation en insuffisance rénale aigüe, un régime restrictif dans l'apport de liquides a entraîné un bilan hydrique cumulatif inférieur et moins d'événements indésirables par rapport aux soins habituels. Des essais plus importants de cette intervention sont justifiés.

A narrative review of coronavirus disease 2019 (COVID-19): clinical, epidemiological characteristics, and systemic manifestations.
Krishnan A, Hamilton JP, Alqahtani SA, A Woreta T. | Intern Emerg Med. 2021 Jun;16(4):815-830
DOI: https://doi.org/10.1007/s11739-020-02616-5  | Télécharger l'article au format  
Keywords: COVID-19; Clinical symptoms; Coronavirus; Epidemiology; SARS-CoV-2; Transmission.

Review

Editorial : Coronavirus disease 2019 (COVID-19) is an emerging infectious disease which has had a rapid surge in cases and deaths since it is first documented in Wuhan, China, in December 2019. COVID-19 is caused by the Betacoronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 uses angiotensin-converting enzyme 2, which is highly expressed in the human lower respiratory tract but also in other tissues, as the cellular entry receptor. Thus, COVID-19 mainly affects the respiratory system but can cause damage to other body systems, including the cardiovascular, gastrointestinal, hepatobiliary, renal, and central nervous systems. We review the pathogenesis and clinical manifestations of the infection, focusing on our current understanding of the disease mechanisms and their translation to clinical outcomes, as well as adverse effects on different body systems. We also discuss the epidemiology pathogenesis, clinical, and multi-organ consequences, and highlight some of the research gaps regarding COVID-19.

Conclusion : The recent SARS-CoV-2 pandemic outbreak is an ongoing crisis that is causing global uncertainty on an unprecedented scale. This pandemic has become a health threat to the gen- eral population and healthcare workers worldwide, with con- tinued increases in the number of cases and deaths. Given the high rate of transmission of the infection among humans, it is important to recognize the basis of its structure replica- tion and pathogenicity, which can lead to the discovery of effective treatments and a vaccine for prevention.

Conclusion (proposition de traduction) : La récente épidémie de pandémie de SRAS-CoV-2 est une crise en cours qui provoque une incertitude mondiale à une échelle sans précédent. Cette pandémie est devenue une menace pour la santé de la population en général et du personnel de santé dans le monde entier, avec une augmentation continue du nombre de cas et de décès. Étant donné le taux élevé de transmission de l'infection chez les humains, il est important de reconnaître la base de sa réplication de structure et de sa pathogénicité, ce qui peut conduire à la découverte de traitements efficaces et d'un vaccin pour la prévention.

Cryptococcal meningitis: a review for emergency clinicians.
Fisher KM, Montrief T, Ramzy M, Koyfman A, Long B. | Intern Emerg Med. 2021 Jun;16(4):1031-1042
DOI: https://doi.org/10.1007/s11739-020-02619-2
Keywords: Antifungal therapy; Antiretroviral therapy; Cryptococcosis; HIV; Immunosuppression; Meningitis.

EM - REVIEW

Introduction : Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization.

Méthode : This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM.

Discussion : This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS).

Conclusion : CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.

Conclusion (proposition de traduction) : La méningite cryptococcique reste une présentation clinique rare, mais entraîne une morbidité et une mortalité importantes. Les médecins doivent diagnostiquer rapidement ces patients tout en évaluant d'autres maladies et complications. Une consultation précoce avec un spécialiste des maladies infectieuses est impérative, tout comme la mise en place de soins symptomatiques.

Using gel for difficult mask ventilation on the bearded patients: a simulation-based study.
Althunayyan SM, Mubarak AM, Alotaibi RN, Alharthi MZ, Aljanoubi MA, Alshabanat S, Mobrad AM. | Intern Emerg Med. 2021 Jun;16(4):1043-1049
DOI: https://doi.org/10.1007/s11739-020-02547-1  | Télécharger l'article au format  
Keywords: Aucun

EM - ORIGINAL

Editorial : The beard is a well-known cause of difficult mask ventilation due to excessive air leaks. Various techniques have been proposed to overcome this difficulty, such as applying a gel on the mask edge. Our objective was to determine whether the gel technique will improve ventilation and to assess the comfort of the provider. A randomized crossover design was conducted to assess the efficacy of gel in a bearded simulation model. Respiratory therapists (RT) were recruited by convenience sampling to hold the mask using a two-handed technique for a two-minute ventilation session. During the session, the ventilator provided a fixed Tidal Volume (TV) of 550 mL and a respiratory rate of 12 per minute, and the simulated model measured the received volumes. We compared the median TV and number of failed ventilation attempts with or without the gel. The comfort level while using the gel was assessed with constructed questions. We recruited 74 respiratory therapists working in Riyadh city. More than half of the participants had more than 5 years experience. The median tidal volume for standard mask ventilation without the gel was 283 mL [interquartile range (IQR) 224, 327], whereas that with the gel was 467 mL [451, 478], respectively (p < 0.01). The number of successful ventilations was recorded out of 24 breaths during the 2-min ventilation period for each technique; the proportion of successful ventilations increased significantly by 65% (95% CI 51-75%, p < 0.01) with the gel. In addition, only nine participants believed the technique was not comfortable, while the remaining individuals found it comfortable or natural. In our bearded simulation model, applying the gel significantly improved ventilation without negatively affecting comfort. Further studies and education are encouraged in the field of basic airway management.

Conclusion : In conclusion, in our bearded simulation model, applying the gel significantly improved ventilation without negatively affecting the provider comfort. Moreover, adding the gel could minimize the ventilation variation caused by differences in the operators’ characteristics. Further studies and education are encouraged in the field of basic airway management.

Conclusion (proposition de traduction) : En conclusion, dans notre modèle de simulation avec une barbe, l'application du gel a considérablement amélioré la ventilation sans affecter négativement le confort de l'opérateur. De plus, l'ajout de gel pourrait minimiser la variation de ventilation causée par les différences dans les caractéristiques des opérateurs. Des études et une formation complémentaires sont encouragées dans le domaine de la gestion de base des voies respiratoires.

Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs.
Cipriano A, Park N, Pecori A, Bionda A, Bardini M, Frassi F, Lami V, Leoli F, Manca ML, Del Prato S, Santini M, Ghiadoni L. | Intern Emerg Med. 2021 Jun;16(4):1061-1070
DOI: https://doi.org/10.1007/s11739-020-02576-w
Keywords: Anticoagulation; Direct oral anticoagulants; Intracranial hemorrhage; Mild traumatic brain injury.

EM - ORIGINAL

Editorial : Although mild traumatic brain injury (MTBI) in people on oral anticoagulant treatment (OAT) is a frequent challenge for Emergency Department (ED), strong guidelines recommendations are lacking. In the attempt to assess the safety profile of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs), we have recruited 473 patients with a MTBI on OAT (43.6% males; age 81.8 ± 8.7 years), admitted to the Pisa's University Hospital ED (Jan 2016-Oct 2018). All patients underwent a head CT scan with those with no sign of acute bleedings remaining under clinical observation for the ensuing 24 h. Fifty patients (10.6%, 95% CI: 8.1-13.7%) had immediate intracranial hemorrhage (ICH), with a prevalence of patient-important outcomes due to immediate ICH of 1.1% (95% CI 0.4-2.4%); 3 patients died (0.6%, 95% CI 0.2-1.8) and 2 required neurosurgical intervention. Immediate ICHs were more frequent in VKA-treated than in DOAC-treated patients (15.9 vs. 6.4%. RR 2.5. 95%CI 1.4-4.4. p < 0.05). Multivariate analysis identified that post-traumatic amnesia, evidence of trauma above clavicles, high blood glucose, high blood pressure (BP) at arrival, and low prothrombin activity were predictors of immediate ICH. The prevalence of delayed ICH was 1.0% (95%CI 0.4-2.5%) without differences between DOACs and VKAs.

Conclusion : Despite ICH being a frequent complication of MTBI in patients on OAT, immediate and delayed patient-important outcomes are rare. DOACs have a better safety profile than VKAs. Simple clinical parameters such as blood pressure at arrival or blood glucose might provide useful predictors of immediate ICH.

Conclusion (proposition de traduction) : Bien que l'hémorragie intracrânienne soit une complication fréquente des lésions cérébrales traumatiques légères chez les patients sous traitement anticoagulant, les résultats immédiats et retardés importants pour le patient sont rares. Les AOD ont un meilleur profil d'innocuité que les AVK. Des paramètres cliniques simples tels que la pression artérielle à l'arrivée ou la glycémie pourraient fournir des prédicteurs utiles d'une hémorragie intracrânienne immédiate.

Cassan P | JEUR. 2021 June 33(2):65-72
DOI: https://doi.org/10.1016/j.jeurea.2021.05.003
Keywords: Cardiac arrest; Defibrillation; Cardiopulmonary resuscitation; ERC; ILCOR

Recommandations

Editorial : La réanimation cardiopulmonaire de base est le chaînon le plus important de la chaîne de survie de l’arrêt cardiaque mais est aussi le plus fragile. Si les recommandations internationales 2020 en matière de BLS ne sont pas une révolution, elles renforcent le niveau de preuves scientifiques retrouvées pour de nombreux sujets traités en 2015. La reconnaissance de l’arrêt cardiaque, la RCP de qualité, la place de la ventilation et le déploiement de la défibrillation automatisée externe sont les principaux éléments de ces recommandations mais s’y ajoutent de nouveaux sujets tels que l’adaptation à la crise COVID et aussi l’implication des nouvelles technologies.

Conclusion (proposition de traduction) : Si les recommandations internationales 2020 en matière de BLS ne sont pas une révolution, elles renforcent le niveau de preuves scientifiques retrouvées pour de nombreux sujets traités en 2015.
Les chances de survie des victimes d’arrêt cardiaques extrahospitaliers dépendent de nombreux éléments et particulièrement ceux inclus dans la formation au BLS que sont : la reconnaissance de l’arrêt cardiaque, la RCP de qualité, la place de la ventilation et le déploiement de la défibrillation automatisée externe. Pour le futur, la prise en compte de nouveaux sujets tels que l’adaptation à la crise COVID et aussi l’implication des nouvelles technologies devrait permettre de renforcer encore cette partie essentielle de la chaîne de survie.

Carli P, Lamhaut L. | JEUR. 2021 june 33(2):73-77
DOI: https://doi.org/10.1016/j.jeurea.2021.04.003
Keywords: Cardiac arrest; Advanced cardiac life support; Prehospital resuscitation; Ventricular fibrillation; Asystole; Adrenaline; Orotracheal intubation; Ultrasound; ECMO

Mise au point

Editorial : Les nouvelles recommandations concernant la réanimation cardio-pulmonaire (RCP) spécialisée des arrêts cardiaques (AC) publiées fin 2020 par l’AHA et début 2021 par l’ERC confirment certains points présentés en 2015 et introduisent de nouvelles notions immédiatement intégrables dans la pratique des équipes françaises. Ainsi, il ne faut pas oublier dans la pratique que des signes prémonitoires peuvent annoncer l’AC et que leur reconnaissance peut même éviter sa survenue. Pour l’administration des médicaments, la voie intraveineuse reste le premier choix la voir intra-osseuse étant une alternative. L’adrénaline reste le médicamentde base du traitement des asystoles et des rythmes non chocables. Il faut l’administrer le plus précocement possible pour obtenir un meilleur résultat neurologique pour les survivants. Le contrôle des voies aériennes est avant tout une affaire de compétence. Les équipes médica-lisées bien entraînées peuvent recourir de première intention l’intubation orotrachéale. Aucours de la réanimation, l’échographie peut être utile dans des mains expertes pour objectiver une cause réversible de l’AC. Elle ne doit pas provoquer une interruption prolongée et donc dangereuse du massage cardiaque externe. Enfin, la circulation extracorporelle (ECMO ouECPR) est un traitement de sauvetage de plus en plus utilisé. Elle s’intègre dans un systèmede soins performant. Ses indications et des modalités sont mieux connues mais doivent encore être précisées.

Conclusion (proposition de traduction) : Les nouvelles recommandations concernant la réanimation cardio-pulmonaire (RCP) spécialisée des arrêts cardiaques(AC) publiées fin 2020 par l’AHA et début 2021 par l’ERC confirme de nombreux points qui avait été envisagés dans celle de 2015. Dans le cadre de la réanimation spécialisée, des arrêts cardiaques pré hospitaliers elles apportent ainsi un niveau important de maturité à la réflexion scientifique qui guide la pratique clinique. La déclinaison française des recommandations qui sera présentée par le CFRC fin2 021 permettra de présenter, dans toutes ses dimensions, une vision globale de cette prise en charge qui est plus que jamais un domaine de recherche clinique particulièrement important.

Hutin A, Dagron C, An K, Amar H, Lamhaut L, Carli P. | JEUR. 2021 June 33(2):78-81
DOI: https://doi.org/10.1016/j.jeurea.2021.05.005
Keywords: Refractory cardiac arrest; ECPR

Mise au point

Editorial : L’ECPR représente la deuxième ligne de traitement de l’arrêt cardiaque extrahospitalier après échec de la réanimation cardiopulmonaire conventionnelle. Les données actuelles suggèrent la nécessité de mettre en place une assistance circulatoire dans les 60 minutes qui suivent l’arrêt cardiaque, afin d’optimiser les chances de survie sans séquelles neurologiques. Malgré l’absence de consensus, concernant les critères de sélection des patients, éligibles à cette thérapeutique, une chaîne de survie optimale et une filière de soins préétablie sont indispensables.

Conclusion (proposition de traduction) : Les données actuelles confirment donc la nécessité d’intégrer l’ECPR dans la prise en charge de l’arrêt cardiaque. Sa mise en place nécessite une prise en charge multidisciplinaire concertée et anticipée afin de couvrir le territoire national.

Guedeney P, Collet JP, Ecollan P, Montalescot G. | JEUR. 2021 June 33(2):82-87
DOI: https://doi.org/10.1016/j.jeurea.2021.04.004
Keywords: acute coronary syndrome; Antithrombotic agent; Percutaneous coronary Intervention

Mise au point

Editorial : Le syndrome coronaire aigu est le centre d’une recherche scientifique importante depuis des décennies. Les recommandations de la société européennes de 2020 sur le syndrome coronaire aiguë sans élévation du segment ST ont inclus les résultats d’essais scientifiques récents portant sur le diagnostic et la prise en charge du SCA ST-. Dans cette mise au point, nous détaillons et expliquons les données dernières les nouveautés en matière de recommandations, notamment sur la stratégie diagnostique de troponine à H0 et H1/H2, la place du coroscanner, le délai d’exploration invasive en fonction du profil de risque et la gestion du traitement antithrombotique de ces patients

Conclusion (proposition de traduction) : La prise en charge du SCA ST- est en constante évolution comme démontré par les nombreuses nouveautés des recommandations de l’ESC de 2020. Le développement du coroscanner permet de limiter le recours à l’exploration coronaire invasive chez les patients à faible risque de SCA. De nombreux stratégies antithrombotique existent afin d’optimiser la prévention du risque ischémique en limitant au maximum le risque hémorragique et permettant de personnaliser le traitement de chaque patient

Aerosol containment device for airway management of patients with COVID-19: a narrative review.
Saito T, Asai T. | J Anesth. 2021 Jun;35(3):384-389
DOI: https://doi.org/10.1007/s00540-020-02879-4  | Télécharger l'article au format  
Keywords: Aerosol box; COVID-19; Tracheal intubation.

Special Feature: Review Article

Editorial : Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is highly contagious. To protect healthcare workers from infection during airway management, some expert recommendations and guidelines recommended wearing P2/N95 masks, goggles or glasses, glove, face-shields, and gowns as standard personal protective equipment (PPE). Nevertheless, several simulation studies have suggested that the standard PPE may not fully protect healthcare workers. Dr. Hsien Yung Lai introduced an acrylic box ("aerosol box") as a part of PPE during airway management. Since then, several companies and healthcare workers have made their own modified devices ("aerosol containment device"), and the use of such a device has spread worldwide, without being formally assessed for its effectiveness, efficacy and safety. Several simulation studies have indicated that "aerosol containment device" would make tracheal intubation more difficult. In addition, the device would prevent the spread of droplets from a patient, but may increase the risk of healthcare workers being exposed to a higher concentration of viral aerosols. Therefore, the current state of knowledge indicates that an "aerosol containment device" without vacuum mechanism has only limited efficacy in protecting healthcare workers from viral transmission.

Conclusion : Although limited, several simulation studies have indi- cated that an “aerosol containment device” may be use- ful to prevent the spread of viral droplets from a patient during aerosol-generating procedures, but it may increase the risk of healthcare workers being exposed to a higher concentration of viral aerosols. A vacuum filtering sys- tem attached to the “aerosol containment device” would effectively minimize the spread of aerosols. Therefore, the current state of knowledge indicates that an “aerosol containment device” without vacuum mechanism has only limited efficacy in protecting healthcare workers from viral transmission.
If an “aerosol containment device” with a vacuum mechanism is to be used, tracheal intubation should be performed by an experienced operator who has made enough experience with the use of the device in a mani- kin, and a suitable videolaryngoscope such as the Airway- scope® should be used.

Conclusion (proposition de traduction) : Bien que limitées, plusieurs études de simulation ont indiqué qu'un « dispositif de confinement des aérosols » peut être utile pour empêcher la propagation des gouttelettes virales d'un patient lors de procédures générant des aérosols, mais il peut augmenter le risque d'exposition des travailleurs de la santé à une concentration plus élevée d'aérosols viraux. Un système de filtration sous vide relié au « dispositif de confinement des aérosols » minimiserait efficacement la propagation des aérosols. Par conséquent, l'état actuel des connaissances indique qu'un « dispositif de confinement des aérosols » sans mécanisme de vide n'a qu'une efficacité limitée pour protéger les travailleurs de la santé contre la transmission virale.
Si un « dispositif de confinement d'aérosol » avec un mécanisme à vide doit être utilisé, l'intubation trachéale doit être effectuée par un opérateur expérimenté qui a suffisamment d'expérience avec l'utilisation du dispositif dans un mannequin, et un vidéolaryngoscope approprié tel que le Airway-scope^® doit être utilisé.

Preparing for the SARS-CoV-2 pandemic: creation and implementation of new recommendations.
Conrad D, Hoffmann P, Berwanger U, Hüppe T, Volk T, Fink T. | J Anesth. 2021 Jun;35(3):390-393
DOI: https://doi.org/10.1007/s00540-020-02827-2  | Télécharger l'article au format  
Keywords: Anesthesia; COVID-19; Intubation; Pandemic; SARS-CoV-2

Special Feature: Short Communication

Editorial : During the SARS-CoV-2 pandemic in 2020, departments of anesthesiology worldwide have encountered new and unique challenges. In this short communication, we present and assess our recommendations for orotracheal intubation, a frequent high-risk procedure. We will point out that interdisciplinary cooperation with "non-patient care" departments like the Institute for Medical Microbiology and Hygiene tremendously helped us in creating this and other new, clear standards for anesthesiological procedures. Moreover, to reliably implement our newly created measures, we distributed incisive posters and organized comprehensive training sessions. Eventually, we summarize and analyze the occurring problems of our suggestions for intubation during their realization.

Conclusion (proposition de traduction) : Au cours de la pandémie de SRAS-CoV-2 en 2020, les services d'anesthésiologie du monde entier ont été confrontés à des défis nouveaux et uniques. Dans cette courte communication, nous présentons et évaluons nos recommandations pour l'intubation orotrachéale, une procédure fréquente à haut risque. Nous soulignerons que la coopération interdisciplinaire avec les départements « non-patients » comme l'Institut de microbiologie et d'hygiène médicales nous a énormément aidés à créer cette norme et d'autres nouvelles normes claires pour les procédures d'anesthésie. De plus, pour mettre en œuvre de manière fiable nos mesures nouvellement créées, nous avons distribué des affiches incisives et organisé des sessions de formation complètes. Enfin, nous résumons et analysons les problèmes rencontrés par nos suggestions d'intubation lors de leur réalisation.

Commentaire :  A titre d'exemple, présentation du développement et de la mise en œuvre de nos recommandations pour l'« intubation des patients COVID-19 - suspectés ou confirmés ».
La figure décrit la procédure d'intubation des patients atteints de la COVID-19. Les principes sont placés tout au début (en gris). Plus important encore, ils comprennent l'autoprotection et l'utilisation de la vidéo-laryngoscopie. Les préparatifs suivent. Celles-ci concernent le personnel, les EPI et les préparatifs. Avant l'induction de l'anesthésie, l'équipe doit faire un « Team time out » (contrôle sécurité pour vérifier et valider les données contenues dans la check liste de sécurité). L'induction proprement dite de l'anesthésie est réalisée sous forme d'une « induction en séquence rapide ». Il est particulièrement important d’éviter la formation d’aérosols et la contamination de l’environnement qui en résulte (en bleu). Si l’intubation est difficile, l’insertion d’un dispositif de voies respiratoires supraglottiques est la première option (plan B) (en rouge). Par conséquent, l’élimination correcte des consommables et le retrait correct des vêtements de protection individuelle sont également importants (en vert).

Assessment of fluid resuscitation on time to hemodynamic stability in obese patients with septic shock.
Kiracofe-Hoyte BR, Doepker BA, Riha HM, Wilkinson R, Rozycki E, Adkins E, Lehman A, Van Berkel MA. | J Crit Care. 2021 Jun;63:196-201
DOI: https://doi.org/10.1016/j.jcrc.2020.09.006
Keywords: Body mass index; Fluid therapy; In-hospital death; Obesity; Sepsis; Septic shock.

Sepsis - Infection - Research article

Introduction : Assess time to hemodynamic stability (HDS) in obese patients with septic shock who received <30 vs. ≥30 ml/kg of initial fluid resuscitation based on actual body weight (ABW).

Méthode : Multicenter, retrospective, cohort analysis of 322 patients.

Résultats : Overall 216 (67%) patients received <30 ml/kg of initial fluid resuscitation. Initial fluid received was lower in the <30 ml/kg vs. ≥30 ml/kg group (16 vs. 37 ml/kg). The ≥30 ml/kg group had shorter time to HDS (multivariable p = 0.038) and lower riskof in-hospital death (multivariable p = 0.038). An exploratory subgroup analysis (n = 227) was performed, classifying patients by dosing strategy [ABW, adjusted body weight (AdjBW), ideal body weight (IBW)] based on fluid received at 3 h divided by 30 ml/kg. ABW dosed patients had a shorter time to HDS (multivariable p = 0.013) and lower risk of in-hospital death (multivariable p = 0.008) vs. IBW. Similar outcomes were observed between ABW vs. AdjBW.

Conclusion : Obese patients given ≥30 ml/kg based on ABW had a shorter time to HDS and a lower risk of in-hospital death. Exploratory results suggest improved outcomes resuscitating by ABW vs. IBW; ABW showed no strong benefit over AdjBW. Further prospective studies are needed to confirm the optimal fluid dosing in obese patients.

Conclusion (proposition de traduction) : Les patients obèses ayant reçu ≥ 30 ml/kg sur la base du poids corporel réel avaient un délai de stabilisation hémodynamique plus court et un risque plus faible de décès à l'hôpital. Les résultats des explorations suggèrent une amélioration des résultats de la réanimation selon le poids corporel réel par rapport au poids corporel idéal ; le poids corporel réel n’a montré aucun avantage important par rapport au poids corporel ajusté. D’autres études prospectives sont nécessaires pour confirmer la dose optimale de remplissage chez les patients obèses.

Effect of early hyperoxemia on the outcome in servere blunt chest trauma: A propensity score-based analysis of a single-center retrospective cohort.
Duclos G, Rivory A, Rességuier N, Hammad E, Vigne C, Meresse Z, Pastène B, D'journo XB, Jaber S, Zieleskiewicz L, Leone M. | J Crit Care. 2021 Jun;63:179-186
DOI: https://doi.org/10.1016/j.jcrc.2020.09.008
Keywords: ARDS; Blunt chest trauma; Critical care; Hyperoxia; Mechanical ventilation; Pneumonia.

Quality, Outcome and Epidemiology of Care - Research article

Introduction : Our study aimed to explore the association between early hyperoxemia of the first 24 h on outcomes in patients with severe blunt chest trauma.

Méthode : In a level I trauma center, we conducted a retrospective study of 426 consecutive patients. Hyperoxemic groups were classified in severe (average PaO2 ≥ 200 mmHg), moderate (≥150 and < 200 mmHg) or mild (≥ 100 and < 200 mmHg) and compared to control group (≥60 and < 100 mmHg) using a propensity score based analysis. The first endpoint was the incidence of a composite outcome including death and hospital-acquired pneumonia occurring from admission to day 28. The secondary endpoints were the incidence of death, the number of hospital-acquired pneumonia, mechanical ventilation-free days and intensive care unit-free day at day 28.

Résultats : The incidence of the composite endpoint was lower in the severe hyperoxemia group(OR, 0.25; 95%CI, 0.09-0.73; P < 0.001) compared with control. The 28-day mortality incidence was lower in severe (OR, 0.23; 95%CI, 0.08-0.68; P < 0.001) hyperoxemia group (OR, 0.41; 95%CI, 0.17-0.97; P = 0.04). Significant association was found between hyperoxemia and secondary outcomes.

Conclusion : In our cohort early hyperoxemia during the first 24 h of admission after severe blunt chest trauma was not associated with worse outcome.

Conclusion (proposition de traduction) : Dans notre cohorte, l'hyperoxémie précoce au cours des 24 premières heures d'admission après un traumatisme thoracique fermé sévère n'était pas associée à un plus mauvais résultat.

Commentaire : Voir les articles suivants :
• Yamamoto R, Fujishima S, Sasaki J and al; Japanese Association for Acute Medicine (JAAM) Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) Study Group. Hyperoxemia during resuscitation of trauma patients and increased intensive care unit length of stay: inverse probability of treatment weighting analysis. World J Emerg Surg. 2021 Apr 29;16(1):19  .
• Baekgaard JS, Abback PS, Boubaya M and al; Traumabase® Study Group. Early hyperoxemia is associated with lower adjusted mortality after severe trauma: results from a French registry. Crit Care. 2020 Oct 12;24(1):604  .
• Alali AS, Temkin N, Vavilala MS and al. Matching early arterial oxygenation to long-term outcome in severe traumatic brain injury: target values. J Neurosurg. 2019 Feb 8;132(2):537-544  .
• Eskesen TG, Baekgaard JS, Christensen RE and al. Supplemental oxygen and hyperoxemia in trauma patients: A prospective, observational study. Acta Anaesthesiol Scand. 2019 Apr;63(4):531-536  .

Predictive Factors for Failure of Limb Salvage in Blunt Leg Trauma Associated with Vascular Injuries.
Al-Zoubi NA, Shatnawi NJ, Khader Y, Heis M, Aleshawi AJ. | J Emerg Trauma Shock. 2021 Apr-Jun;14(2):80-85
DOI: https://doi.org/10.4103/jets.jets_37_20  | Télécharger l'article au format  
Keywords: Amputation; blunt injuries; leg trauma; vascular.

Original article

Introduction : Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization.

Méthode : A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality.

Résultats : Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality.

Conclusion : Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries.

Conclusion (proposition de traduction) : Les fractures osseuses multisegmentaires sévères, la prolongation de l'ischémique > 10 h et le score MESS ≥ 9 sont des prédicteurs significatifs de la perte d'un membre chez les patients présentant un traumatisme fermé de la jambe associé à des lésions vasculaires.

Commentaire : Le score MESS (Mangled Extremity Severity Score) est en ligne sur MDCalc  .
Les auteurs ont constaté qu'un seuil MESS ≥7 prédisait une faible probabilité de viabilité des membres/extrémités (100 % sensible dans la validation).

• Référence originale : Johansen K, Daines M, Howey T and al. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990 May;30(5):568-72  
• Validation : Togawa S, Yamami N, Nakayama H and al. The validity of the mangled extremity severity score in the assessment of upper limb injuries. J Bone Joint Surg Br. 2005 Nov;87(11):1516-9  .

Prevalence and Risk Factors of Obstructive Sleep Apnea in Hypertensive Emergency.
Khamsai S, Kachenchart S, Sawunyavisuth B, Limpawattana P, Chindaprasirt J, Senthong V, Chotmongkol V, Pongkulkiat P, Sawanyawisuth K. | J Emerg Trauma Shock. 2021 Apr-Jun;14(2):104-107
DOI: https://doi.org/10.4103/jets.jets_47_20  | Télécharger l'article au format  
Keywords: Body mass index; hypertensive emergency; obesity; obstructive sleep apnea; prevalence.

Original article

Introduction : Obstructive sleep apnea (OSA) is a common factor associated with hypertensive crises. There is limited evidence of prevalence and risk factors of OSA in hypertensive emergency.

Méthode : This study recruited adult patients who diagnosed as hypertensive emergency and tested for OSA. The study period was between July 2019 and January 2020. The patients were categorized as OSA and non-OSA groups by the evidence from polysomnography. Prevalence and risk factors for OSA were executed.

Résultats : During the study, there were 52 eligible patients. Of those, 30 patients (57.69%) were diagnosed with OSA. The stepwise logistic regression analysis for predicting OSA had two remaining factors: body mass index and diastolic blood pressure. Only body mass index was independently associated with OSA with an adjusted odds ratio of 1.166 (95% confidence interval of 1.033, 1.316). The body mass index of 25.02 kg/m2 gave sensitivity and specificity of 80.00% and 59.09%, respectively. The area under the receiver operating characteristic curve was 70.98%.

Conclusion : OSA had high incidence rate in patients with hypertensive emergency. High body mass index was a predictor for OSA associated with hypertensive emergency.

Conclusion (proposition de traduction) : L'apnée obstructive du sommeil avait un taux d'incidence élevé chez les patients en urgence hypertensive. Un indice de masse corporelle élevé était un prédicteur d'apnée obstructive du sommeil associée à une urgence hypertensive.

Insight into the use of tympanic temperature during target temperature management in emergency and critical care: a scoping review.
Masè M, Micarelli A, Falla M, Regli IB, Strapazzon G. | J Intensive Care. 2021 Jun 12;9(1):43
DOI: https://doi.org/10.1186/s40560-021-00558-4  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cooling devices; Ear canal; Hearables; Hypothermia; Physiological monitoring; Stroke; Target temperature management; Temperature; Tympanic membrane.

Review

Introduction : Target temperature management (TTM) is suggested to reduce brain damage in the presence of global or local ischemia. Prompt TTM application may help to improve outcomes, but it is often hindered by technical problems, mainly related to the portability of cooling devices and temperature monitoring systems. Tympanic temperature (T_Ty) measurement may represent a practical, non-invasive approach for core temperature monitoring in emergency settings, but its accuracy under different TTM protocols is poorly characterized. The present scoping review aimed to collect the available evidence about T_Ty monitoring in TTM to describe the technique diffusion in various TTM contexts and its accuracy in comparison with other body sites under different cooling protocols and clinical conditions.

Méthode : The scoping review was conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-ScR). PubMed, Scopus, and Web of Science electronic databases were systematically searched to identify studies conducted in the last 20 years, where T_Ty was measured in TTM context with specific focus on pre-hospital or in-hospital emergency settings.

Résultats : The systematic search identified 35 studies, 12 performing T_Ty measurements during TTM in healthy subjects, 17 in patients with acute cardiovascular events, and 6 in patients with acute neurological diseases. The studies showed that T_Ty was able to track temperature changes induced by either local or whole-body cooling approaches in both pre-hospital and in-hospital settings. Direct comparisons to other core temperature measurements from other body sites were available in 22 studies, which showed a faster and larger change of T_Ty upon TTM compared to other core temperature measurements. Direct brain temperature measurements were available only in 3 studies and showed a good correlation between T_Ty and brain temperature, although T_Ty displayed a tendency to overestimate cooling effects compared to brain temperature.

Conclusion : T_Ty was capable to track temperature changes under a variety of TTM protocols and clinical conditions in both pre-hospital and in-hospital settings. Due to the heterogeneity and paucity of comparative temperature data, future studies are needed to fully elucidate the advantages of T_Ty in emergency settings and its capability to track brain temperature.

Conclusion (proposition de traduction) : La température tympanique était capable de suivre les changements de température dans le cadre d'une variété de protocoles de gestion de la température cible et de conditions cliniques à la fois en milieu préhospitalier et en milieu hospitalier. En raison de l'hétérogénéité et de la rareté des données comparatives sur la température, de futures études sont nécessaires pour élucider pleinement les avantages de la température tympanique dans les situations d'urgence et sa capacité à suivre la température du cerveau.

Clinical Applications of Ultrasonography in Neurocritically Ill Patients.
Caballero-Lozada AF, Nanwani KL, Pavón F, Zorrilla-Vaca A, Zorrilla-Vaca C. | J Intensive Care Med. 2021 Jun;36(6):627-634
DOI: https://doi.org/10.1177/0885066620905796
Keywords: Doppler; critical care; neurology; ultrasonography.

Analytic Review

Editorial : Ultrasonography is part of the multimodal monitoring of the neurocritical patient. Through transcranial color Doppler ultrasound, carotid-color Doppler ultrasound, and ocular ultrasound it is possible to diagnose and monitor a multitude of pathological conditions, such as cerebrovascular events, vasospasm, Terson syndrome, carotid atheromatosis, and brain death. Furthermore, these techniques enable the monitoring of the intracranial pressure, the cerebral perfusion pressure, and the midline deviation, which allows us to understand the patient's neurocritical pathology at their bedside, in a noninvasive way. Although none of these tools have yet been shown to improve patient prognosis, the dissemination of knowledge and management of neurovascular ultrasonography could significantly improve the comprehensive management of neurocritical patients.

Conclusion : Ultrasound in the neurocritical patient allows, through TCD ultrasound, carotid-color Doppler ultrasound, and OU, the diagnosis and monitoring of multiple pathological conditions, both neurological and non-neurological. The knowledge of both vascular and structural brain pathology is part of the multimodal monitoring of the neurocritical patient, and although it has not been shown to improve the prognosis of these patients, it has allowed for a better understanding of this pathology, therefore further studies are needed to demonstrate the benefits of ultrasonography in this context.

Conclusion (proposition de traduction) : L'échographie chez le patient neurocritique permet, grâce à l'échographie Doppler couleur transcrânienne, à l'échographie Doppler couleur carotidienne et à l'échographie oculaire, le diagnostic et le suivi de multiples pathologies, tant neurologiques que non neurologiques. La connaissance à la fois de la pathologie cérébrale vasculaire et structurelle fait partie du suivi multimodal du patient neurocritique, et bien qu'il n'ait pas été démontré qu'elle améliore le pronostic de ces patients, elle a permis une meilleure compréhension de cette pathologie, donc d'autres études sont nécessaires pour démontrer les avantages de l'échographie dans ce contexte.

Commentaire :  Orientation du transducteur dans la fenêtre temporale (A) montrant le graphique de la vitesse du flux sanguin (B) en échographie Doppler transcrânienne de l'artère cérébrale moyenne (C).

Orientation du transducteur dans la fenêtre sous-occipitale (A) approche sous-occipitale de l'échographie mesurant la vitesse du flux sanguin de l'artère basilaire (B et C).

Orientation du transducteur en fenêtre ophtalmique (A) échographie oculaire estimant les mesures de l'artère ophtalmique (B et C).

A Comparison of Methylprednisolone and Dexamethasone in Intensive Care Patients With COVID-19.
Ko JJ, Wu C, Mehta N, Wald-Dickler N, Yang W, Qiao R. | J Intensive Care Med. 2021 Jun;36(6):673-680
DOI: https://doi.org/10.1177/0885066621994057
Keywords: COVID-19; corticosteroids; dexamethasone; hypoxia; methylprednisolone; mortality.

Original Research

Introduction : This study retrospectively compares the effectiveness of methylprednisolone to dexamethasone in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) requiring intensive care.
Design : This is an institutional review board approved cohort study in patients with COVID-19 requiring intensive care unit (ICU) admission. Patients admitted and requiring oxygen supplementation were treated with no steroids, methylprednisolone, or dexamethasone.

Méthode : This study takes place in the ICU's at a large, tertiary, public teaching hospital serving a primarily low-income community in urban Los Angeles.
Patients : All eligible patients admitted to the ICU for COVID-19 respiratory failure from March 1 to July 31, 2020 were included in this study.
Interventions : A total of 262 patients were grouped as receiving usual care (n = 75), methylprednisolone dosed at least at 1mg/kg/day for ≥ 3 days (n = 104), or dexamethasone dosed at least at 6 mg for ≥7 days (n = 83).

Résultats : All-cause mortality within 50 days of initial corticosteroid treatment as compared to usual care was calculated. The mortality effect was then stratified based on levels of respiratory support received by the patient. In this cohort of 262 patients with severe COVID-19, all-cause mortalities in the usual care, methylprednisolone, and dexamethasone groups were 41.3%, 16.4% and 26.5% at 50 days (P < 0.01) respectively. In patients requiring mechanical ventilation, mortality was 42% lower in the methylprednisolone group than in the dexamethasone group (hazard ratio 0.48, 95% CI: 0.235-0.956, P = 0.0385).

Conclusion : In COVID-19 patients requiring mechanical ventilation, sufficiently dosed methylprednisolone can lead to a further decreased mortality as compared to dexamethasone.

Conclusion (proposition de traduction) : Chez les patients COVID-19 nécessitant une ventilation mécanique, la méthylprednisolone à la bonne posologie peut donner une diminution supplémentaire de la mortalité par rapport à la dexaméthasone.

Commentaire : Méthylprednisolone 1 mg/kg/jour pendant ≥ 3 jours versus dexaméthasone 6 mg/jour pendant ≥ 7 jours.

Critical Care Transport of Patients With COVID-19.
Frakes MA, Richards JB, Cocchi MN, Cohen A, Cohen JE, Dargin J, Friedman FD, Kaye AS, Rettig JS, Seethala R, Wilcox SR. | J Intensive Care Med. 2021 Jun;36(6):704-710
DOI: https://doi.org/10.1177/08850666211001797
Keywords: COVID-19; acute respiratory distress syndrome; critical care transport; mortality

Original Research

Introduction : Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described.

Méthode : We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020.

Résultats : Of 254 charts identified, 250 patients were transported. Nine patients (3.5%) had cardiac arrest prior to transport. Twenty-nine (11.6%) had hypotension, 22 (8.8%) had a critical desaturation, and 4 (1.6%) had both en route. Hospital follow-up data were available for 189 patients. Of those intubated during their hospitalization, 44 (25.0%) had died, 59 (33.5%) had been extubated, and 13 (17.6%) had been discharged alive. For the subgroup with prior cardiac arrest, follow-up data available for 6. Of these 6, 2 died and 4 (66.7%) have been discharged alive.

Conclusion : Few patients with COVID-19 had an adverse event in transport. The in-hospital mortality rate was 25%, with a 33.5% extubation rate. Patients resuscitated from cardiac arrest prior to transport had a 66.7% discharge rate among those transported to consortium hospitals.

Conclusion (proposition de traduction) : Peu de patients atteints de la COVID-19 ont eu un événement indésirable au cours du transport. Le taux de mortalité hospitalière était de 25 %, avec un taux d'extubation de 33,5 %. Les patients réanimés d'un arrêt cardiaque avant le transport avaient un taux de sortie de 66,7 % parmi ceux transportés vers les hôpitaux du groupe.

Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation.
Lurie A, Wang J, Hinnegan KJ, McIntyre WF, Belley-Côté EP, Amit G, Healey JS, Connolly SJ, Wong JA. | J Am Coll Cardiol. 2021 Jun 15;77(23):2875-2886
DOI: https://doi.org/10.1016/j.jacc.2021.04.036
Keywords: anticoagulation; atrial fibrillation; cardioversion; catheter ablation; left atrial thrombus; prevalence; transesophageal echocardiography.

ORIGINAL INVESTIGATION

Introduction : The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is not well known, yet this may inform transesophageal echocardiogram (TEE) use before cardioversion or catheter ablation.
Objectives: The purpose of this study was to quantify LA thrombus prevalence among patients with AF/AFL on guideline-directed anticoagulation and to identify high-risk subgroups.

Méthode : EMBASE, MEDLINE, and CENTRAL were systematically searched from inception to July 2020 for studies reporting on LA thrombus prevalence among patients with AF/AFL undergoing TEE following at least 3 weeks of continuous therapeutic oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Meta-analysis was performed using random effects models.

Résultats : Thirty-five studies describing 14,653 patients were identified. The mean-weighted LA thrombus prevalence was 2.73% (95% confidence interval [CI]: 1.95% to 3.80%). LA thrombus prevalence was similar for VKA- and DOAC-treated patients (2.80%; 95% CI: 1.86% to 4.21% vs. 3.12%; 95% CI: 1.92% to 5.03%; p = 0.674). Patients with nonparoxysmal AF/AFL had a 4-fold higher LA thrombus prevalence compared with paroxysmal patients (4.81%; 95% CI: 3.35% to 6.86% vs. 1.03%; 95% CI: 0.52% to 2.03%; p < 0.001). LA thrombus prevalence was higher among patients undergoing cardioversion versus ablation (5.55%; 95% CI: 3.15% to 9.58% vs. 1.65%; 95% CI: 1.07% to 2.53%; p < 0.001). Patients with CHA₂DS₂-VASc scores ≥3 had a higher LA thrombus prevalence compared with patients with scores ≤2 (6.31%; 95% CI: 3.72% to 10.49% vs. 1.06%; 95% CI: 0.45% to 2.49%; p < 0.001).

Conclusion : LA thrombus prevalence is high in subgroups of anticoagulated patients with AF/AFL, who may benefit from routine pre-procedural TEE use before cardioversion or catheter ablation.

Conclusion (proposition de traduction) : La prévalence du thrombus auriculaire gauche est élevée dans les sous-groupes de patients anticoagulés atteints de fibrillation auriculaire ou de flutter auriculaire, qui peuvent bénéficier d'une échocardiographie transœsophagienne pré-opératoire systématique avant la cardioversion ou l'ablation par cathéter.

Commentaire : Dans cette revue systématique et méta-analyse rapportant la prévalence de la présence d'un thrombus de l'oreillette gauche chez les patients présentant une fibrillation atriale ou un flutter auriculaire qui bénéficiaient d'au moins 3 semaines d'anticoagulation, la prévalence du thrombus était d'environ 3 %. La fibrillation atriale non paroxystique et les scores CHADS₂/CHA₂DS₂-VASc élevés étaient associés à une prévalence accrue de thrombus de l'oreillette gauche. L'imagerie par échocardiographie transœsophagienne chez certains patients présentant un risque élevé de thrombus de l'oreillette gauche, malgré le statut d'anticoagulation, peut être une approche raisonnable pour minimiser le risque de complications thromboemboliques après une cardioversion ou une ablation par cathéter.

Meta-Analysis of Reversal Agents for Severe Bleeding Associated With Direct Oral Anticoagulants.
Gómez-Outes A, Alcubilla P, Calvo-Rojas G, Terleira-Fernández AI, Suárez-Gea ML, Lecumberri R, Vargas-Castrillón E. | J Am Coll Cardiol. 2021 Jun 22;77(24):2987-3001
DOI: https://doi.org/10.1016/j.jacc.2021.04.061
Keywords: andexanet alfa; bleeding; direct oral anticoagulants; idarucizumab; reversal agents.

ORIGINAL INVESTIGATION

Introduction : Direct oral anticoagulants (DOACs) have shown a positive benefit-risk balance in both clinical trials and real-world data, but approximately 2% to 3.5% of patients experience major bleeding annually. Many of these patients require hospitalization, and the administration of reversal agents may be required to control bleeding.
Objectives: The aim of this study was to investigate clinical outcomes associated with the use of 4-factor prothrombin complex concentrates, idarucizumab, or andexanet for reversal of severe DOAC-associated bleeding.

Méthode : The investigators systematically searched for studies of reversal agents for the treatment of severe bleeding associated with DOAC. Mortality rates, thromboembolic events, and hemostatic efficacy were meta-analyzed using a random effects model.

Résultats : The investigators evaluated 60 studies in 4,735 patients with severe DOAC-related bleeding who were treated with 4-factor prothrombin complex concentrates (n = 2,688), idarucizumab (n = 1,111), or andexanet (n = 936). The mortality rate was 17.7% (95% confidence interval [CI]: 15.1% to 20.4%), and it was higher in patients with intracranial bleedings (20.2%) than in patients with extracranial hemorrhages (15.4%). The thromboembolism rate was 4.6% (95% CI: 3.3% to 6.0%), being particularly high with andexanet (10.7%; 95% CI: 6.5% to 15.7%). The effective hemostasis rate was 78.5% (95% CI: 75.1% to 81.8%) and was similar regardless of the reversal agent considered. The rebleeding rate was 13.2% (95% CI: 5.5% to 23.1%) and 78% of rebleeds occurred after resumption of anticoagulation. The risk of death was markedly and significantly associated with failure to achieve effective hemostasis (relative risk: 3.63; 95% CI: 2.56 to 5.16). The results were robust regardless of the type of study or the hemostatic scale used.

Conclusion : The risk of death after severe DOAC-related bleeding remains significant despite a high rate of effective hemostasis with reversal agents. Failure to achieve effective hemostasis strongly correlated with a fatal outcome. Thromboembolism rates are particularly high with andexanet. Comparative clinical trials are needed.

Conclusion (proposition de traduction) : Le risque de décès après une hémorragie sévère liée aux AOD reste important malgré un taux élevé d'hémostase efficace par les agents de réversion. L'incapacité à obtenir une hémostase efficace était fortement corrélée à une issue fatale. Les taux de thromboembolie sont particulièrement élevés avec l'andexanet. Des essais cliniques comparatifs sont nécessaires.

Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis..
VanderPluym JH, Halker Singh RB, Urtecho M, Morrow AS, Nayfeh T, Torres Roldan VD, Farah MH, Hasan B, Saadi S, Shah S, Abd-Rabu R, Daraz L, Prokop LJ, Murad MH, Wang Z. | JAMA. 2021 Jun 15;325(23):2357-2369
DOI: https://doi.org/10.1001/jama.2021.7939  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy.
Objective: To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults.

Méthode : Multiple databases from database inception to February 24, 2021.
Study selection: Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks.
Data extraction and synthesisData extraction and synthesis: Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small.
Main outcomes and measures: The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews.

Résultats : Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham.

Conclusion : There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.

Conclusion (proposition de traduction) : Il existe plusieurs traitements aigus pour la migraine, avec une puissance variable des preuves. L'utilisation de triptans, d'anti-inflammatoires non stéroïdiens, de paracétamol, de dihydroergotamine, d'antagoniste du CGRP (calcitonin gene-related peptide ), de lasmiditan (agoniste des récepteurs de la sérotonine) et de certains traitements non pharmacologiques a été associée à une amélioration de la douleur et de la fonction. Les données probantes pour de nombreuses autres interventions, y compris les opioïdes, étaient limitées.

Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis.
VanderPluym JH, Halker Singh RB, Urtecho M, Morrow AS, Nayfeh T, Torres Roldan VD, Farah MH, Hasan B, Saadi S, Shah S, Abd-Rabu R, Daraz L, Prokop LJ, Murad MH, Wang Z. | JAMA. 2021 Jun 15;325(23):2357-2369
DOI: https://doi.org/10.1001/jama.2021.7939
Keywords: Aucun

Original Investigation

Introduction : Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy.
Objective: To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults.

Méthode : Multiple databases from database inception to February 24, 2021.
Study selection: Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks.
Data extraction and synthesis: Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small.
Main outcomes and measures: The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews.

Résultats : Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham.

Conclusion : There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.

Conclusion (proposition de traduction) : Il existe plusieurs traitements en aigu pour la migraine, avec des niveau de preuves variable à l'appui. L'utilisation de triptans, d'anti-inflammatoires non stéroïdiens, d'acétaminophène, de dihydroergotamine, d'antagonistes peptidiques liés au gène de la calcitonine, de lasmiditan et de certains traitements non pharmacologiques a été associée à une amélioration de la douleur et de la reprise des activités. Les preuves pour de nombreuses autres interventions, y compris les opioïdes, étaient limitées.

Meta-Analysis of Reversal Agents for Severe Bleeding Associated With Direct Oral Anticoagulants.
Gómez-Outes A, Alcubilla P, Calvo-Rojas G, Terleira-Fernández AI, Suárez-Gea ML, Lecumberri R, Vargas-Castrillón E. | J Am Coll Cardiol. 2021 Jun 22;77(24):2987-3001
DOI: https://doi.org/10.1016/j.jacc.2021.04.061
Keywords: andexanet alfa; bleeding; direct oral anticoagulants; idarucizumab; reversal agents.

Original Investigation

Introduction : Direct oral anticoagulants (DOACs) have shown a positive benefit-risk balance in both clinical trials and real-world data, but approximately 2% to 3.5% of patients experience major bleeding annually. Many of these patients require hospitalization, and the administration of reversal agents may be required to control bleeding.
Objectives: The aim of this study was to investigate clinical outcomes associated with the use of 4-factor prothrombin complex concentrates, idarucizumab, or andexanet for reversal of severe DOAC-associated bleeding.

Méthode : The investigators systematically searched for studies of reversal agents for the treatment of severe bleeding associated with DOAC. Mortality rates, thromboembolic events, and hemostatic efficacy were meta-analyzed using a random effects model.

Résultats : The investigators evaluated 60 studies in 4,735 patients with severe DOAC-related bleeding who were treated with 4-factor prothrombin complex concentrates (n = 2,688), idarucizumab (n = 1,111), or andexanet (n = 936). The mortality rate was 17.7% (95% confidence interval [CI]: 15.1% to 20.4%), and it was higher in patients with intracranial bleedings (20.2%) than in patients with extracranial hemorrhages (15.4%). The thromboembolism rate was 4.6% (95% CI: 3.3% to 6.0%), being particularly high with andexanet (10.7%; 95% CI: 6.5% to 15.7%). The effective hemostasis rate was 78.5% (95% CI: 75.1% to 81.8%) and was similar regardless of the reversal agent considered. The rebleeding rate was 13.2% (95% CI: 5.5% to 23.1%) and 78% of rebleeds occurred after resumption of anticoagulation. The risk of death was markedly and significantly associated with failure to achieve effective hemostasis (relative risk: 3.63; 95% CI: 2.56 to 5.16). The results were robust regardless of the type of study or the hemostatic scale used.

Conclusion : The risk of death after severe DOAC-related bleeding remains significant despite a high rate of effective hemostasis with reversal agents. Failure to achieve effective hemostasis strongly correlated with a fatal outcome. Thromboembolism rates are particularly high with andexanet. Comparative clinical trials are needed.

Conclusion (proposition de traduction) : Le risque de décès après une hémorragie sévère liée aux AOD reste important malgré un taux élevé d'hémostase efficace avec des agents de réversion. L'incapacité à obtenir une hémostase efficace était fortement corrélée à une issue fatale. Les taux d’accidents veineux thromboemboliques sont particulièrement élevés avec l'andexanet [ndlr : 10,7 % avec l’andexanet et relativement faible avec l’Idarucizumab (3,8 %) et le complexe prothrombique humain (PPSB) concentré de 4 facteurs de coagulation (4,3 %)]. Des essais cliniques comparatifs sont nécessaires.

Commentaire : Voir l'analyse de l'article sur le site Medscape : AOD: les antidotes réduisent les saignements mais les décès restent encore élevés  . Rédigé par le Dr Patrice Wendling, le 19 juillet 2021.

L’efficacité clinique de l'andexanet alfa (Ondexxya 200 mg poudre pour solution pour perfusion) est basée sur la réversion de l’activité anti-FXa chez des volontaires sains ayant reçu de l’apixaban (Eliquis^®) ou du rivaroxaban (Xarelto^®). L’andexanet alfa n’est pas adapté à l’utilisation en pré-traitement d’une chirurgie en urgence. L’utilisation n’est pas recommandée pour la réversion de l’edoxaban (Lixiana^®) ou de l’énoxaparine (Lovenox^®) en raison d’un manque de données. L’andexanet alfa ne modifie pas les effets des inhibiteurs non basés sur le FXa. [Résumé des caractéristiques du produit  ]
Les concentrés de complexes prothrombiniques (CCP), anciennement appelés prothrombine proconvertine Stuart B (PPSB), sont composés de 4 facteurs de la coagulation, les facteurs vitamine K dépendants : II, VII, IX et X sous forme inactive (Kanokad^®, Octaplex^®, Kaskadil^® et Confidex^®). Les CCP représentent l’antidote de choix pour la réversion rapide de l’effet des AVK. Les CCP sont également capables de réduire l’effet anti-coagulant des AOD, mais les posologies nécessaires sont a priori 2 fois plus élevées que pour les AVK soit 50 UI/kg pour les AOD contre 25 UI/kg pour les AVK. [Antidotes et anticoagulants oraux directs  ]
L'idarucizumab (Praxbind^®), est l'agent de neutralisation du dabigatran (Pradaxa^®). Il a l’AMM chez les adultes traités par dabigatran quand une neutralisation rapide de ses effets anticoagulants est requise pour une urgence chirurgicale ou des procédures urgentes ou en cas de saignements incontrôlés ou menaçant le pronostic vital. La dose recommandée est de 5 g (2 x 2,5 g/50 mL). [HAS  ]

Rosay H | Prat Anesth Reanim. 2021 June;25(3):113-117
DOI: https://doi.org/10.1016/j.pratan.2021.05.007
Keywords: Central venous accessComplicationsVascular injuryArterial injury

Mise au point

Editorial : Pendant la pose des voies veineuses centrales, les plaies vasculaires sont très rares, mais potentiellement très graves. Dans un établissement de santé, l’activité de pose de voies veineuses centrales doit être organisée. La prise en charge des accidents doit être anticipée. Pour minimiser le risque, le choix du bon dispositif est essentiel. La ponction échoguidée avec une aiguille fine, une poussée douce sur une faible distance du dilatateur relèvent de la prudence. En cas de canulation artérielle ou de lacération veineuse importante, il ne faut pas enlever le matériel. Il faut évaluer l’état respiratoire et neurologique, faire réaliser sans retard une iconographie et éventuellement prendre un avis chirurgical ou radiologique le plus rapidement possible selon les possibilités locales.

Conclusion : Les plaies vasculaires sont rarissimes mais potentiellementtrès graves. L’activité de poses de voies veineuses centrales doit être bien organisée. La prise en charge d’accidents doit être anticipée. Pour minimiser le risque, le choix du bon dispositif pour le bon patient est essentiel. La ponction sous échographie, une poussée douce sur une faible distance du dilatateur complètent les règles de prudence. En cas de canulation artérielle ou de plaie veineuse importante, il ne faut pas enlever le matériel, prendre un avis chirurgical ou radiologique le plus rapide possible, éventuellement faire réaliser une iconographie sans retard.

Ayoub N, Le Gouez A. | Prat Anesth Reanim. 2021 June;25(3):125-133
DOI: https://doi.org/10.1016/j.pratan.2021.05.002
Keywords: Cardiac arrestDeliveryPregnancy

Mise au point

Editorial : L’arrêt cardiaque au cours de l’accouchement, éventualité rare, engage le pronostic vital de la mère et de l’enfant à naître. L’âge croissant des parturientes et les comorbidités cardiovasculaires, sont des facteurs de risque. Les étiologies font intervenir les hémorragies de la délivrance, les complications de l’anesthésie, les accidents obstétricaux. Une césarienne dite périmortem doit être pratiquée dans le temps du massage cardiaque pour en augmenter l’efficacité en levant notamment la compression cave et préserver les chances de survie du fœtus. Une démarche étiologique doit être entreprise en parallèle. L’entraînement par la simulation fait partie des recommandations internationales.

Conclusion : L’ACR chez la femme enceinte reste un évènement rare,mais aux conséquences dramatiques s’il n’est pas pris en charge par des équipes entraînées. Il est crucial d’apporter une attention particulière au temps écoulé et à la communication entre équipes ; la rapidité de la prise en charge et de la réalisation de la césarienne périmortem après 20 SA est la pierre angulaire d’une réanimation réussie, et le facteur déterminant de la survie maternelle, éventuellement fœtale. Les aides cognitives de crise sont des outils très utiles dans ce contexte et leur emploi doit être encouragé. Les compétences techniques et non techniques des équipesdoivent être travaillées en amont par la simulation haute-fidélité. Même s’il est impossible en l’état actuel de mesurer son impact sur une diminution de la mortalité maternelle, elle a fait la preuve d’une amélioration de la gestion des situations de crise. Il serait intéressant d’investiguer dans de futures enquêtes le devenir des patientes et de leur enfant ayant survécu un ACR, notamment sur l’existence éventuelle de séquelles principalement neurologiques.

Predictors of Severe Clinical Course in Children With Carbon Monoxide Poisoning.
Akcan Yildiz L, Gultekingil A, Kesici S, Bayrakci B, Teksam O. | Pediatr Emerg Care. 2021 Jun 1;37(6):308-311
DOI: https://doi.org/10.1097/PEC.0000000000001580
Keywords: Aucun

Original Article

Introduction : Carbon monoxide (CO) is a gas, which is produced by incomplete combustion of hydrocarbon-containing substances, and causes significant tissue and organ damage in the common event of CO poisoning. This study aims to evaluate the demographic, clinical, and laboratory characteristics of patients diagnosed with CO poisoning in the emergency department and to determine the factors associated with severe course in the acute phase of poisoning.

Méthode : A total of 331 patients diagnosed with CO poisoning in Hacettepe University Children's Hospital, Pediatric Emergency Unit, between January 2004 and March 2014 were included in the study. Their demographic characteristics, presenting complaints, physical examination findings, Glasgow Coma Scale scores, carboxyhemoglobin, leukocyte, hemoglobin, troponin T, pH and lactate levels, type of treatment (normobaric or hyperbaric oxygen), intensive care unit admissions, and outcome of poisoning were investigated.

Résultats : Ninety-three patients were given hyperbaric oxygen. Fifty-one patients were admitted to the pediatric intensive care unit, 18 patients have had a severe clinical course, and 6 patients have died. The risk factors associated with severe disease course were determined to be low Glasgow Coma Scale score, high leukocyte count, and high troponin T levels at presentation.

Conclusion : Glasgow Coma Scale score, leukocyte count, and troponin T level may be beneficial in predicting clinical outcomes and tailoring therapy in children with CO poisoning.

Conclusion (proposition de traduction) : Le score de Glasgow, le nombre de leucocytes et le taux de troponine T semble pouvoir prédire l'évolution clinique et permettre d'adapter le traitement chez les enfants intoxiqués au CO.

Esophageal Retained Lithium Battery in Children Younger than 6 Years: A Prompt Structured Multidisciplinary Approach Is Essential to Reduce Long-Term Consequences.
Lisi G, Illiceto MT, Romeo EF, Lauriti G, Faraci S, Lombardi G, Dall'Oglio L, Chiesa PL. | Pediatr Emerg Care. 2021 Jun 1;37(6):e295-e300
DOI: https://doi.org/10.1097/pec.0000000000001590  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Disk battery esophageal retention in children younger than 6 years represents an increasing endoscopic emergency, followed by a relevant risk of life-threatening late complications. Surgical removal after a failed endoscopic approach is rarely reported in the literature. We describe our experience in this scenario.

Méthode : Two female asymptomatic patients aged 26 and 29 months presented within 4 hours after a witnessed ingestion of a 2-cm, 3-V lithium battery (CR2032) retained in the cervical esophagus. Both patients underwent a prolonged unsuccessful emergent endoscopic removal with a flexible instrument performed by an adult gastroenterologist. Both batteries fused with the esophageal wall were extracted through a longitudinal left cervical esophagotomy combined with minimal resection of necrotic tissues and repaired over a 12F feeding tube.

Résultats : Patients were extubated after 12 and 72 hours, respectively. Contrast study was performed after 20 and 13 days, respectively, before resuming oral feeding. At endoscopy, the first patient developed a 3-cm-long severe esophageal stenosis (35th day), followed by an asymptomatic tracheoesophageal fistula (60th day), which was conservatively treated. After spontaneous resolution of the tracheoesophageal fistula, esophageal stenosis progressed, partially responsive to esophageal stenting. Short esophagectomy is under evaluation. The second patient developed an asymptomatic limited stenosis, not requiring dilatation.

Conclusion : The emergent management of lithium battery ingestion needs a structured timely multidisciplinary approach in the emergency department, an experienced pediatric endoscopist, and a simultaneous engagement of pediatric surgical expertise, even in patients who do not show bleeding, to reduce esophageal exposure time to high-voltage current released by batteries, which represents the main factor conditioning tissue damage and prognosis.

Conclusion (proposition de traduction) : L'apparition de l'ingestion de piles au lithium nécessite une approche multidisciplinaire structurée en temps opportun au service des urgences, un endoscopiste pédiatrique expérimenté et un engagement simultané d'une expertise chirurgicale pédiatrique, même chez les patients qui ne présentent pas de saignement, afin de réduire le temps d'exposition de l'œsophage à la haute tension de courant libéré par les batteries, qui représente le principal facteur conditionnant les lésions tissulaires et le pronostic.

Prehospital Intubations Are Associated with Elevated Endotracheal Tube Cuff Pressures: A Cross-Sectional Study Characterizing ETT Cuff Pressures at a Tertiary Care Emergency Department.
Chen RS, O'Connor L, Rebesco MR, LaBarge KL, Remotti EJ, Tennyson JC. | Prehosp Disaster Med. 2021 Jun;36(3):283-286
DOI: https://doi.org/10.1017/s1049023x21000297
Keywords: airway; prehospital care; resuscitation.

Original Research

Introduction : Emergency Medical Services (EMS) providers are trained to place endotracheal tubes (ETTs) in the prehospital setting when indicated. Endotracheal tube cuffs are traditionally inflated with 10cc of air to provide adequate seal against the tracheal lumen. There is literature suggesting that many ETTs are inflated well beyond the accepted safe pressures of 20-30cmH2O, leading to potential complications including ischemia, necrosis, scarring, and stenosis of the tracheal wall. Currently, EMS providers do not routinely check ETT cuff pressures. It was hypothesized that the average ETT cuff pressure of patients arriving at the study site who were intubated by EMS exceeds the safe pressure range of 20-30cmH2O.
Objectives: While ETT cuff inflation is necessary to close the respiratory system, thus preventing air leaks and aspiration, there is evidence to suggest that over-inflated ETT cuffs can cause long-term complications. The purpose of this study is to characterize the cuff pressures of ETTs placed by EMS providers.

Méthode : This project was a single center, prospective observational study. Endotracheal tube cuff pressures were measured and recorded for adult patients intubated by EMS providers prior to arrival at a large, urban, tertiary care center over a nine-month period. All data were collected by respiratory therapists utilizing a cuff pressure measurement device which had a detectable range of 0-100cmH2O and was designed as a syringe. Results including basic patient demographics, cuff pressure, tube size, and EMS service were recorded.

Résultats : In total, 45 measurements from six EMS services were included with ETT sizes ranging from 6.5-8.0mm. Mean patient age was 52.2 years (67.7% male). Mean cuff pressure was 81.8cmH2O with a range of 15 to 100 and a median of 100. The mode was 100cmH2O; 40 out of 45 (88.9%) cuff pressures were above 30cmH2O. Linear regression showed no correlation between age and ETT cuff pressure or between ETT size and cuff pressure. Two-tailed T tests did not show a significant difference in the mean cuff pressure between female versus male patients.

Conclusion : An overwhelming majority of prehospital intubations are associated with elevated cuff pressures, and cuff pressure monitoring education is indicated to address this phenomenon.

Conclusion (proposition de traduction) : Une écrasante majorité des intubations préhospitalières sont associées à des pressions de ballonnet élevées, et l'éducation à la surveillance de la pression du ballonnet est indiquée pour lutter contre ce phénomène.

Commentaire : Les soins primaires définis comme un niveau de soins. Dans ce cadre, les soins primaires sont toujours présentés comme la base de la pyramide, se différenciant ainsi des soins secondaires et tertiaires.
Le niveau primaire est non segmenté, ni par âge, ni par sexe, ni par type de problèmes de santé, ni par capacité financière des patients. Il doit pouvoir répondre à 90 % des problèmes de santé. Inversement, les niveaux secondaire et tertiaire sont spécialisés et donc segmentés. Le niveau secondaire regroupe la médecine spécialisée au sens large (en ville ou à l’hôpital), et le niveau tertiaire est celui de la médecine de haute technologie (hôpitaux universitaires).

Ketamine Stability over Six Months of Exposure to Moderate and High Temperature Environments.
Foertsch MJ, McMullan JT, Harger NJ, Rodriquez D Jr, Salvator A, PharmD EWM, Droege CA. | Prehosp Emerg Care. 2021 Jun 21:1-6
DOI: https://doi.org/10.1080/10903127.2021.1934203
Keywords: degradation; heat; ketamine; stability; temperature.

Article

Introduction : All medications should be stored within temperature ranges defined by manufacturers, but logistical and operational challenges of prehospital and military settings complicate adherence to these recommendations. Lorazepam and succinylcholine experience clinically relevant heat-related degradation, whereas midazolam does not. Because ketamine's stability when stored outside manufacturer recommendations is unknown, we evaluated the heat-related degradation of ketamine exposed to several temperature ranges.

Méthode : One hundred twenty vials of ketamine (50 mg/mL labeled concentration) from the same manufacturer lot were equally distributed and stored for six months in five environments: an active EMS unit in southwest Ohio (May-October 2019); heat chamber at constant 120 °F (C1); heat chamber fluctuating over 24 hours from 86 °F-120 °F (C2); heat chamber fluctuating over 24 hours from 40 °F-120 °F (C3); heat chamber kept at constant 70 °F (manufacturer recommended room temperature, C4). Four ketamine vials were removed every 30 days from each environment and sent to an FDA-accredited commercial lab for high performance liquid chromatography testing. Data loggers and thermistors allowed temperature recording every minute for all environments. Cumulative heat exposure was quantified by mean kinetic temperature (MKT), which accounts for additional heat-stress over time caused by temperature fluctuations and is a superior measure than simple ambient temperature. MKT was calculated for each environment at the time of ketamine removal. Descriptive statistics were used to describe the concentration changes at each time point.

Résultats : The MKT ranged from 73.6 °F-80.7 °F in the active EMS unit and stayed constant for each chamber (C1 MKT: 120 °F, C2 MKT: 107.3 °F, C3 MKT: 96.5 °F, C4 MKT: 70 °F). No significant absolute ketamine degradation, or trends in degradation, occurred in any environment at any time point. The lowest median concentration occurred in the EMS-stored samples removed after 6 months [48.2 mg/mL (47.75, 48.35)], or 96.4% relative strength to labeled concentration.

Conclusion : Ketamine samples exhibited limited degradation after 6 months of exposure to real world and simulated extreme high temperature environments exceeding manufacturer recommendations. Future studies are necessary to evaluate ketamine stability beyond 6 months.

Conclusion (proposition de traduction) : Les échantillons de kétamine présentaient une dégradation limitée après 6 mois d'exposition à des environnements réels et simulés à des températures extrêmement élevées dépassant les recommandations du fabricant. De futures études sont nécessaires pour évaluer la stabilité de la kétamine au-delà de 6 mois.

Pulseless electrical activity vs. asystole in adult in-hospital cardiac arrest: Predictors and outcomes.
Høybye M, Stankovic N, Lauridsen KG, Lauridsen MJ, Holmberg MJ, Andersen LW, Granfeldt A. | Resuscitation. 2021 June 11; article in press
DOI: https://doi.org/10.1016/j.resuscitation.2021.05.036  | Télécharger l'article au format  
Keywords: In-hospital cardiac arrest, Non-shockable, Initial rhythm, Pulseless electrical activity, Asystole, Predictors, Comorbidities, Cardiac arrest characteristics, Survival

Clinical paper

Introduction : This observational cohort study aimed to identify factors associated with pulseless electrical activity (PEA) and asystole in in-hospital cardiac arrest (IHCA) patients and to determine whether differences in outcome based on the initial rhythm were explained by patient- and cardiac arrest characteristics.

Méthode : Adults with IHCA from 2017 to 2018 were included from the Danish IHCA Registry (DANARREST). Additional data came from population- based registries. Unadjusted (RRs) and adjusted risk ratios (aRRs) were estimated for predictors of initial rhythm, return of spontaneous circulation (ROSC), and survival.

Résultats : We included 1495 PEA and 1285 asystole patients. The patients did not differ substantially in patient characteristics. Female sex, age > 90 years, pulmonary disease, and obesity were associated with initial asystole. Ischemic heart disease and witnessed and monitored cardiac arrest were associated with initial PEA. In unadjusted and adjusted analyses, PEA was associated with increased ROSC (aRR = 1.21, 95% confidence interval [CI] 1.10; 1.33). PEA was also associated with increased 30-day and 1-year survival in the unadjusted analysis, while there was no clear association between the initial rhythm and 30-day (aRR = 0.88, 95% CI 0.71; 1.11) and 1-year (aRR = 0.85, 95% CI 0.69; 1.04) survival when patient- and cardiac arrest characteristics were adjusted for.

Conclusion : In patients with IHCA presenting with PEA or asystole, there were no major differences in patient demographics and comorbidities. The patients differed substantially in cardiac arrest characteristics. Initial PEA was associated with higher risk of ROSC, but there was no difference in 30-day and 1-year survival.

Conclusion (proposition de traduction) : Chez les patients ayant subi un arrêt cardiaque à l'hôpital présentant une activité électrique sans pouls ou une asystolie, il n'y avait pas de différences majeures dans les caractéristiques démographiques et les comorbidités des patients. Les patients différaient considérablement dans les caractéristiques de l'arrêt cardiaque. L'activité électrique initiale sans pouls était associée à une chance plus élevé de retour de la circulation spontanée, mais il n'y avait pas de différence dans la survie à 30 jours et à 1 an.

Rapid dispatch for out-of-hospital cardiac arrest is associated with improved survival.
Jensen B, Bøggild H, Ringgren KB, Blomberg SNF, Christensen HC, Kragholm K, Lippert F, Folke F, Torp-Pedersen C. | Resuscitation. 2021 Jun;163:176-183
DOI: https://doi.org/10.1016/j.resuscitation.2021.03.015
Keywords: Automated external defibrillators; Cardiopulmonary resuscitation; Emergency medical dispatch; Emergency medical response; Emergency medical services; Out-of-hospital cardiac arrest; Public health; Time to dispatch.

Rapid Response Systems

Introduction : As proxy for initiation of the first link in the Chain of Survival by the dispatcher, we aimed to investigate the effect of time to first dispatch on 30-day survival among patients with OHCA ultimately receiving the highest-level emergency medical response.

Méthode : We linked data on all OHCA unwitnessed by emergency medical services (EMS) treated by Copenhagen EMS from 2016 through 2018 to corresponding emergency call records. Among patients receiving highest priority emergency response, we calculated time to dispatch as time from start of call to time of first dispatch.

Résultats : We included 3548 patients with OHCA. Of these, 94.1% received the highest priority response (median time to dispatch 0.84 min, 25th-75th percentile 0.58-1.24 min). Patients with time to dispatch within one minute compared to three or more minutes were more likely to receive bystander cardiopulmonary resuscitation (77.3 vs 54.2%), bystander defibrillation (11.5 vs 6.5%) and defibrillation by emergency medical services (24.1 vs 7.5%) and were 2.6-fold more likely to survive 30 days after the OHCA (P = 0.004). Results from multivariate logistic regression were similar: odds ratio (OR) of survival 0.83 per minute increase (95% confidence interval 0.70-1.00, P = 0.04). However, survival was similar between those who received highest priority response and those who did not: OR of survival 0.88 (95% confidence interval 0.53-1.46, P = 0.61).

Conclusion : Rapid time to dispatch among patients with highest priority response was significantly associated with a higher probability of 30-day survival following OHCA.

Conclusion (proposition de traduction) : Le délai d'intervention rapide pour les patients ayant la priorité la plus élevée était significativement associé à une probabilité plus élevée de survie à 30 jours après un arrêt cardiaque extra-hospitalier.

Impact of prehospital airway interventions on outcome in cardiac arrest following drowning: A study from the CARES Surveillance Group.
Ryan KM, Bui MD, Dugas JN, Zvonar I, Tobin JM. | Resuscitation. 2021 Jun;163:130-135
DOI: https://doi.org/10.1016/j.resuscitation.2020.12.027
Keywords: Airway management; Basic airway management; Drowning; Emergency medical services; Laryngoscopy; Orotracheal intubation; Outcome; Return of spontaneous circulation.

Clinical Papers

Introduction : Drowning results in more than 360,000 deaths annually, making it the 3rd leading cause of unintentional injury death worldwide. Prior studies have examined airway interventions affecting patient outcomes in cardiac arrest, but less is known about drowning patients in arrest. This study evaluated the outcomes of drowning patients in the Cardiac Arrest Registry to Enhance Survival (CARES) who received advanced airway management.

Méthode : A retrospective analysis of the CARES database identified cases of drowning etiology between 2013 and 2018. Patients were stratified by airway intervention performed by EMS personnel. Demographics, sustained return of spontaneous circulation [ROSC], survival to hospital admission, survival to hospital discharge, and neurological outcomes were compared between airway groups using chi-squared tests and logistic regression.

Résultats : Among 2388 drowning patients, 70.4% were male, 41.8% white, and 13.1% survived to hospital discharge. Patients that received supraglottic airways [SGA] had statistically significantly lower odds of survival to hospital admission compared to endotracheal tube [ETT] use (adjusted odds ratio [aOR] = 0.56, 95% confidence interval [CI] 0.42-0.76) as well as lower odds of survival to discharge compared to bag valve mask [BVM] use (aOR = 0.40, 95% CI 0.19-0.86) when accounting for relative ROSC timing.

Conclusion : In this national cohort of drowning patients in cardiac arrest, SGA use was associated with significantly lower odds of survival to hospital admission and discharge. However, survival to discharge with favorable neurological outcome did not differ significantly between airway management techniques. Further studies will need to examine if airway intervention order or time to intervention affects outcomes.

Conclusion (proposition de traduction) : Dans cette cohorte nationale de noyades en arrêt cardiaque, l'utilisation de dispositifs supraglottiques pour la gestion des voies aériennes supérieures était associée à des chances de survie significativement plus faibles jusqu'à l'admission et la sortie de l'hôpital. Cependant, la survie à la sortie avec des résultats neurologiques favorables ne différait pas significativement entre les techniques de gestion des voies respiratoires. D'autres études devront examiner si l'ordre d'intervention des voies respiratoires ou le délai d'intervention affecte les résultats.

Commentaire : Voir l'article suivant :
Benger JR, Kirby K, Black S and al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791  .

Ambulance deceleration causes increased intra cranial pressure in supine position: a prospective observational proof of principle study.
Maissan IM, Vlottes B, Hoeks S, Bosch J, Stolker RJ, den Hartog D. | Scand J Trauma Resusc Emerg Med. 2021 Jun 30;29(1):87
DOI: https://doi.org/10.1186/s13049-021-00904-3  | Télécharger l'article au format  
Keywords: Ambulance; EMS; ICP; Intra cranial pressure; ONSD; Optical nerve sheath diameter; POCUS; TBI; Transportation; Traumatic brain injury; Ultrasound.

Original research

Introduction : Ambulance drivers in the Netherlands are trained to drive as fluent as possible when transporting a head injured patient to the hospital. Acceleration and deceleration have the potential to create pressure changes in the head that may worsen outcome. Although the idea of fluid shift during braking causing intra cranial pressure (ICP) to rise is widely accepted, it lacks any scientific evidence. In this study we evaluated the effects of driving and deceleration during ambulance transportation on the intra cranial pressure in supine position and 30° upright position.

Méthode : Participants were placed on the ambulance gurney in supine position. During driving and braking the optical nerve sheath diameter (ONSD) was measured with ultrasound. Because cerebro spinal fluid percolates in the optical nerve sheath when ICP rises, the diameter of this sheath will distend if ICP rises during braking of the ambulance. The same measurements were taken with the headrest in 30° upright position.

Résultats : Mean ONSD in 20 subjects in supine position increased from 4.80 (IQR 4.80-5.00) mm during normal transportation to 6.00 (IQR 5.75-6.40) mm (p < 0.001) during braking. ONSD's increased in all subjects in supine position. After raising the headrest of the gurney 30° mean ONSD increased from 4.80 (IQR 4.67-5.02) mm during normal transportation to 4.90 (IQR 4.80-5.02) mm (p = 0.022) during braking. In 15 subjects (75%) there was no change in ONSD at all.

Conclusion : ONSD and thereby ICP increases during deceleration of a transporting vehicle in participants in supine position. Raising the headrest of the gurney to 30 degrees reduces the effect of breaking on ICP.

Conclusion (proposition de traduction) : Le diamètre de la gaine du nerf optique et donc la pression intracrânienne augmentent pendant la décélération d’un véhicule de transport chez les participants en position couchée. Le relèvement de l’appuie-tête du brancard à 30 degrés réduit l’effet de la rupture sur la pression intracrânienne..

Commentaire : Correction to: Ambulance deceleration causes increased intra cranial pressure in supine position: a prospective observational proof of principle study. Maissan IM, Vlottes B, Hoeks S, Bosch J, Stolker RJ, den Hartog D.
Scand J Trauma Resusc Emerg Med. 2021 Jul 31;29(1):109. doi: 10.1186/s13049-021-00926-x  .
[Following the publication of the original article, the authors informed as of an error in the title. The word “prove” of the original title has been changed to “proof”].

Management of respiratory distress following prehospital implementation of noninvasive ventilation in a physician-staffed emergency medical service: a single-center retrospective study.
Dunand A, Beysard N, Maudet L, Carron PN, Dami F, Piquilloud L, Caillet-Bois D, Pasquier M. | Scand J Trauma Resusc Emerg Med. 2021 Jun 29;29(1):85
DOI: https://doi.org/10.1186/s13049-021-00900-7  | Télécharger l'article au format  
Keywords: Acute pulmonary edema; Acute respiratory failure; Chronic obstructive pulmonary disease exacerbation; Emergency medical services; Noninvasive ventilation; Prehospital; Respiratory distress.

Original research

Introduction : Noninvasive ventilation (NIV) is recognized as first line ventilatory support for the management of acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. We aimed to study the prehospital management of patients in acute respiratory distress with an indication for NIV and whether they received it or not.

Méthode : This retrospective study included patients ≥18 years old who were cared for acute respiratory distress in a prehospital setting. Indications for NIV were oxygen saturation (SpO2) <90% and/or respiratory rate (RR) >25/min with a presumptive diagnosis of APE or COPD exacerbation. Study population characteristics, initial and at hospital vital signs, presumptive and definitive diagnosis were analyzed. For patients who received NIV, dyspnea level was evaluated with a dyspnea verbal ordinal scale (D-VOS, 0-10) and arterial blood gas (ABG) values were obtained at hospital arrival.

Résultats : Among the 187 consecutive patients included in the study, most (n = 105, 56%) had experienced APE or COPD exacerbation, and 56 (30%) received NIV. In comparison with patients without NIV, those treated with NIV had a higher initial RR (35 ± 8/min vs 29 ± 10/min, p < 0.0001) and a lower SpO2 (79 ± 10 vs 88 ± 11, p < 0.0001). The level of dyspnea was significantly reduced for patients treated with NIV (on-scene D-VOS 8.4 ± 1.7 vs 4.4 ± 1.8 at admission, p < 0.0001). Among the 131 patients not treated with NIV, 41 (31%) had an indication. In the latter group, initial SpO2 was 80 ± 10% in the NIV group versus 86 ± 11% in the non-NIV group (p = 0.0006). NIV was interrupted in 9 (16%) patients due to either discomfort (n = 5), technical problem (n = 2), persistent desaturation (n = 1), or vomiting (n = 1).

Conclusion : The results of this study contribute to a better understanding of the prehospital management of patients who present with acute respiratory distress and an indication for NIV. NIV was started on clinically more severe patients, even if predefined criteria to start NIV were present. NIV allows to improve vital signs and D-VOS in those patients. A prospective study could further elucidate why patients with a suspected diagnosis of APE and COPD are not treated with NIV, as well as the clinical impact of the different strategies.

Conclusion (proposition de traduction) : Les résultats de cette étude aident à mieux comprendre la prise en charge préhospitalière des patients qui se présentent avec une détresse respiratoire aiguë et une indication du VNI. La VNI a été initié chez des patients cliniquement plus sévères, même si des critères prédéfinis pour démarrer la VNI étaient présents (ndlr : pour la débuter plus précocement). La VNI permet d’améliorer les signes vitaux et la dyspnée sur l'échelle verbale ordinale chez ces patients. Une étude prospective permettrait de mieux comprendre pourquoi les patients chez lesquels on soupçonne un œdème pulmonaire aigu et une bronchopneumopathie chronique obstructive ne sont pas traités par le VNI, ainsi que l’impact clinique des différentes stratégies.

Ischemic Stroke With Atrial Fibrillation: Characteristics and Time Trends 2006 to 2017 in the Dijon Stroke Registry.
Gabet A, Guenancia C, Duloquin G, Olié V, Béjot Y. | Stroke. 2021 Jun;52(6):2077-2085
DOI: https://doi.org/10.1161/strokeaha.120.030812
Keywords: Aucun

RESEARCH ARTICLE

Introduction : Because of the aging population, an increase in the prevalence of atrial fibrillation (AF) is currently observed, thus leading to a rise in AF-related ischemic stroke (IS). We analyzed the current prevalence of AF among patients with IS, their characteristics, and temporal trends from 2006 to 2017 in the population-based Dijon Stroke Registry.

Méthode : We used data from the Dijon Stroke Registry, an ongoing population-based study that records all cases of acute stroke among residents of the city of Dijon. All patients with IS between 2006 and 2017 were included. Previous AF was defined if it was mentioned in the medical file before stroke and newly diagnosed AF if it was diagnosed during the diagnostic workup of patients with acute stroke.

Résultats : During the period 2014 to 2017, among the 796 patients with IS recorded in the Dijon Stroke Registry, 239 (30.0%) had AF, of whom 79 (9.9% of total patients with IS) had newly diagnosed AF, and 98 (12.3%) had previous AF treated with oral anticoagulants. Patients with IS with AF had more disabilities and a higher initial severity according to the National Institutes of Health Stroke Scale compared with those without AF. The age-adjusted prevalence of AF in patients with IS increased between 2006 and 2017 (+9% per time period), with an important increase in men aged 65 to 74 years (+81%) and women aged ≥85 years (+24%), and a significant decrease in women aged 65 to 74 years (−39%). The use of oral anticoagulant treatment in previous AF patients increased between 2006 and 2009 and 2014 and 2017 (29.3% to 61.3%, P<0.0001). However, 37.5% of patients with previous AF and CHADS2 score ≥2 were not treated with OAC.

Conclusion : The increase in AF prevalence in patients with IS could be related to a better diagnosis of this condition. The underuse of oral anticoagulation treatment was still observed.

Conclusion (proposition de traduction) : L'augmentation de la prévalence de la fibrillation atriale chez les patients ayant subi un AVC ischémique pourrait être liée à un meilleur diagnostic de cette affection. La sous-utilisation du traitement anticoagulant oral était encore observée.

Hemostatic Efficacy and Anti-FXa (Factor Xa) Reversal With Andexanet Alfa in Intracranial Hemorrhage.
Demchuk AM, Yue P, Zotova E, Nakamya J, Xu L, Milling TJ Jr, Ohara T, Goldstein JN, Middeldorp S, Verhamme P, Lopez-Sendon JL, Conley PB, Curnutte JT, Eikelboom JW, Crowther M, Connolly SJ; ANNEXA-4 Investigators. | Stroke. 2021 Jun;52(6):2096-2105
DOI: https://doi.org/10.1161/strokeaha.120.030565  | Télécharger l'article au format  
Keywords: Aucun

RESEARCH ARTICLE

Introduction : Andexanet alfa is a recombinant modified human FXa (factor Xa) developed to reverse FXa inhibition from anticoagulants. Hemostatic efficacy and reversal of anti-FXa activity with andexanet were assessed in patients from the ANNEXA-4 study (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXa Inhibitors) with intracranial hemorrhage (ICrH).

Méthode : ANNEXA-4 was a single-arm study evaluating andexanet in patients presenting with major bleeding ≤18 hours after taking an FXa inhibitor. Patients received a bolus plus 2-hour infusion of andexanet. Brain imaging in patients with ICrH was performed at baseline and at 1 and 12 hours postandexanet infusion. Coprimary efficacy outcomes were change in anti-FXa activity and hemostatic efficacy at 12 hours (excellent/good efficacy defined as ≤35% increase in hemorrhage volume/thickness). Safety outcomes included occurrence of thrombotic events and death at 30 days.

Résultats : A total of 227 patients with ICrH were included in the safety population (51.5% male; mean age 79.3 years) and 171 in the efficacy population (99 spontaneous and 72 traumatic bleeds). In efficacy evaluable patients, excellent/good hemostasis 12 hours postandexanet occurred in 77 out of 98 (78.6%) and in 58 out of 70 (82.9%) patients with spontaneous and traumatic bleeding, respectively. In the subanalysis by FXa inhibitor treatment group in the efficacy population, median of percent change in anti-FXa from baseline to nadir showed a decrease of 93.8% for apixaban-treated patients (n=99) and by 92.6% for rivaroxaban-treated patients (n=59). Within 30 days, death occurred in 34 out of 227 (15.0%) patients and thrombotic events occurred in 21 out of 227 (9.3%) patients (safety population).

Conclusion : Andexanet reduced anti-FXa activity in FXa inhibitor-treated patients with ICrH, with a high rate of hemostatic efficacy. Andexanet may substantially benefit patients with ICrH, the most serious complication of anticoagulation.

Conclusion (proposition de traduction) : L'Andexanet a réduit l'activité anti-FXa chez les patients traités par inhibiteur du facteur Xa présentant une hémorragie intracrânienne, avec un taux élevé d'efficacité hémostatique. L'Andexanet peut être très bénéfique pour les patients souffrant d'hémorragie intracrânienne, la complication la plus grave de l'anticoagulation.

Commentaire : Correction to: Hemostatic Efficacy and Anti-FXa (Factor Xa) Reversal With Andexanet Alfa in Intracranial Hemorrhage: ANNEXA-4 Substudy. [No authors listed] Stroke. 2021 Aug;52(8):e525  .

Dual Antiplatelet Therapy Versus Aspirin in Patients With Stroke or Transient Ischemic Attack: Meta-Analysis of Randomized Controlled Trials.
Bhatia K, Jain V, Aggarwal D, Vaduganathan M, Arora S, Hussain Z, Uberoi G, Tafur A, Zhang C, Ricciardi M, Qamar A. | Stroke. 2021 Jun;52(6):e217-e223
DOI: https://doi.org/10.1161/strokeaha.120.033033
Keywords: aspirin; hemorrhage; incidence; ischemic attack, transient; ischemic stroke.

IN BRIEF

Introduction : Antiplatelet therapy is key for preventing thrombotic events after transient ischemic attack or ischemic stroke. Although the role of aspirin is well established, there is emerging evidence for the role of short-term dual antiplatelet therapy (DAPT) in preventing recurrent stroke.

Méthode : We conducted a systematic review and study-level meta-analyses of randomized controlled trials comparing outcomes of early initiation of short-term DAPT (aspirin+P2Y12 inhibitor for up to 3 months) versus aspirin alone in patients with acute stroke or transient ischemic attack. Primary efficacy outcome was risk of recurrent stroke and primary safety outcome was incidence of major bleeding. Secondary outcomes studied were risk of any ischemic stroke, hemorrhagic stroke, major adverse cardiovascular events, and all-cause death. Pooled risk ratios (RRs) and CIs were calculated using a random-effects model.

Résultats : Four trials with a total of 21 459 patients were included. As compared to aspirin alone, DAPT had a lower risk of recurrent stroke (RR, 0.76 [95% CI, 0.68–0.83]; P<0.001; I²=0%) but a higher risk of major bleeding events (RR, 2.22 [95% CI, 1.14–4.34], P=0.02, I²=46.5%). Patients receiving DAPT had a lower risk of major adverse cardiovascular events (RR, 0.76 [95% CI, 0.69–0.84], P<0.001, I²=0%) and recurrent ischemic events (RR, 0.74 [95% CI, 0.67–0.82], P<0.001, I2=0%).

Conclusion : As compared to aspirin alone, short-term DAPT within 24 hours of high-risk transient ischemic attack or mild-moderate ischemic stroke reduces the risk of recurrent stroke at the expense of higher risk of major bleeding.

Conclusion (proposition de traduction) : Par rapport à l'aspirine seule, une double antiagrégation plaquettaire à court terme dans les 24 heures suivant un accident ischémique transitoire à haut risque ou un AVC ischémique léger à modéré réduit le risque d'AVC récurrent au détriment d'un risque plus élevé d'hémorragie majeure.

Commentaire : 

Optimal sessions of hyperbaric oxygen therapy in patients with carbon monoxide poisoning: A prospective observational study.
Han S, Nah S, Choi S, Kim GW, Lee YH. | Am J Emerg Med. 2021 Jun;44:132-136
DOI: https://doi.org/10.1016/j.ajem.2020.10.062
Keywords: Carbon monoxide; Complications; Hyperbaric oxygenation; Neurotoxicity; Poisoning.

Research article

Introduction : Hyperbaric oxygen (HBO) therapy may be a useful treatment to prevent the development of delayed neuropsychiatric sequelae (DNS) in patients with acute carbon monoxide (CO) poisoning. However, there is no clear consensus regarding the optimal number of HBO therapy sessions in patients with CO poisoning. Here, we compared the development of DNS after 3 and > 3 sessions of HBO therapy in patients with acute CO poisoning.

Méthode : This prospective observational study recruited 299 patients with CO poisoning. Demographic and clinical information were obtained, including comorbidities, vital signs, and symptoms. Patients were divided into two groups according to whether they received 3 or > 3 sessions of HBO therapy (3 HBO vs. >3 HBO). A propensity score-matching process was used to balance potential prognostic factors in both groups.

Résultats : Of the 299 patients with acute CO poisoning enrolled in this study, 183 (59.0%) were included in the analysis. Patients were excluded for the following reasons: age < 18 years, not underwent HBO therapy, discharged against medical advice, and loss to follow-up. The overall rate of DNS development was 17.5%. The >3 HBO group had a higher incidence of DNS development compared to the 3 HBO group (36.3% vs. 16.3%; p = 0.09). Propensity score-matching analysis revealed similar incidences of DNS (31.3% vs. 28.1%, respectively; p > 0.99).

Conclusion : There is a critical need to determine the optimal number of HBO therapy sessions for patients with acute CO poisoning. This study showed no difference in DNS development after 3 and > 3 sessions of HBO therapy.

Conclusion (proposition de traduction) : Il existe un besoin critique de déterminer le nombre optimal de séances d'oxygénothérapie hyperbare pour les patients présentant une intoxication aiguë au CO. Cette étude n'a montré aucune différence dans le développement des séquelles neuropsychiatriques après 3 et > 3 séances d'oxygénothérapie hyperbare.

Is ketamine sedation without local anesthesia sufficient for pediatric laceration repair? A double-blind randomized clinical trial.
Kwon H, Lee JH, Choi YJ, Jung JY. | Am J Emerg Med. 2021 Jun;44:208-212
DOI: https://doi.org/10.1016/j.ajem.2020.03.030
Keywords: Aucun

Research article

Introduction : The objective of this study was to evaluate whether sedation with ketamine without local anesthesia was sufficient in children undergoing primary repair.

Méthode : Randomized, double-blind trial conducted between December 2013 and October 2016 in a tertiary care pediatric emergency department in Korea. Children aged 1 to 10 years requiring sedation for primary repair were randomly assigned to receive local lidocaine anesthesia with ketamine sedation or local saline injection with ketamine sedation. Children's Hospital of Eastern Ontario Pain Scale scores was recorded during the procedures. The pain scales were recorded by nurses who were blinded to the study drugs, before ketamine sedation, after sedation, during the first injection of the study drugs for wound repair, during the first stitch, and after the procedure.

Résultats : Twenty-five were randomized to receive ketamine sedation with local anesthesia and twenty-two to receive ketamine sedation without local anesthesia. There was no significant difference in pain scale before ketamine sedation (difference (mean): -1.11, CI: -2.78-0.55, P value: 0.18), after sedation (difference (mean): -0.60, CI: -2.20-1.01, P = 0.46), during the first injection of the study drugs for wound repair (difference (mean): -0.03, CI: -0.31-0.25, P = 0.84), during the first stitch (difference (mean): -0.15, CI: 6.19-6.79, P = 0.62), during the primary repair (difference (mean): 0.20, CI: -55-0.95, P = 0.59), and after the procedure (difference (mean): 0.17, CI: -0.48-0.82, P = 0.59).

Conclusion : Sedating with ketamine for primary wound repair, there was no difference in pain and sedation scales between the patients treated with or without lidocaine local anesthesia, and local anesthesia was not needed.

Conclusion (proposition de traduction) : Avec la sédation par kétamine pour la réparation primaire des plaies, il n'y avait aucune différence dans les échelles de douleur et de sédation entre les patients traités avec ou sans anesthésie locale à la lidocaïne, et une anesthésie locale n'était pas nécessaire.

Coronavirus Disease (COVID-19): A primer for emergency physicians.
Chavez S, Long B, Koyfman A, Liang SY. | Am J Emerg Med. 2021 Jun;44:220-229
DOI: https://doi.org/10.1016/j.ajem.2020.03.036  | Télécharger l'article au format  
Keywords: COVID-19; Coronavirus Disease; Infectious disease; Pulmonary.

Research article

Introduction : Rapid worldwide spread of Coronavirus Disease 2019 (COVID-19) has resulted in a global pandemic.

Méthode : This review article provides emergency physicians with an overview of the most current understanding of COVID-19 and recommendations on the evaluation and management of patients with suspected COVID-19.

Résultats : Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for causing COVID-19, is primarily transmitted from person-to-person through close contact (approximately 6 ft) by respiratory droplets. Symptoms of COVID-19 are similar to other viral upper respiratory illnesses. Three major trajectories include mild disease with upper respiratory symptoms, non-severe pneumonia, and severe pneumonia complicated by acute respiratory distress syndrome (ARDS). Emergency physicians should focus on identifying patients at risk, isolating suspected patients, and informing hospital infection prevention and public health authorities. Patients with suspected COVID-19 should be asked to wear a facemask. Respiratory etiquette, hand washing, and personal protective equipment are recommended for all healthcare personnel caring for suspected cases. Disposition depends on patient symptoms, hemodynamic status, and patient ability to self-quarantine.

Conclusion : This narrative review provides clinicians with an updated approach to the evaluation and management of patients presenting to the emergency department with suspected COVID-19.

Conclusion (proposition de traduction) : Cette revue narrative fournit aux cliniciens une approche mise à jour pour l'évaluation et la gestion des patients se présentant au service des urgences avec une suspicion de COVID-19.

Ramped versus sniffing position for tracheal intubation: A systematic review and meta-analysis.
Okada Y, Nakayama Y, Hashimoto K, Koike K, Watanabe N. | Am J Emerg Med. 2021 Jun;44:250-256
DOI: https://doi.org/10.1016/j.ajem.2020.03.058
Keywords: Airway management; Difficult airway; Head elevated laryngoscopy position; Intratracheal intubation; Laryngoscopy.

Research article

Introduction : Whether the ramped or sniffing laryngoscopy position is better for tracheal intubation is unclear. This study aimed to determine the efficacy and safety of tracheal intubation in the ramped versus sniffing position.

Méthode : We conducted a systematic review and meta-analysis of randomized clinical trials to compare the ramped position with the sniffing position for tracheal intubation. We searched the databases of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Excerpta Medica Database (Embase), ClinicalTrials.gov, and World Health Organization Clinical Trials Registry Platform up to December 2018. We included randomized-controlled trials, trials of participants who required tracheal intubation in any setting, and that compared tracheal intubation in the ramped and the sniffing positions. Two authors independently screened the trials, extracted the data, and assessed the risk of bias. We conducted the meta-analysis using the random-effects model to calculate the pooled risk ratio with 95% confidence interval.

Résultats : Of the 2631 titles/abstracts screened, three studies (representing 513 patients) were included in the meta-analysis. The pooled risk ratio with 95% confidence interval (CI) of the sniffing versus the ramped position was as follows: a first successful attempt, 0.97 (95% CI, 0.86-1.09; I2 = 55%); laryngoscopy attempts ≤2, 1.08 (95% CI, 0.88-1.31; I2 = 93%); and good glottic view with Cormack-Lehane grade ≤ 2, 0.86 (95% CI, 0.69-1.07; I2 = 86%).

Conclusion : This systematic review and meta-analysis indicated no favorable aspects of the ramped position as compared to the sniffing position. Thus, further research is warranted to identify which is better in tracheal intubation.

Conclusion (proposition de traduction) : Cette revue systématique et cette méta-analyse n'ont indiqué aucun aspect favorable pour la position « ramped » par rapport à la position « sniffing ». Ainsi, des recherches supplémentaires sont nécessaires pour identifier ce qui est le mieux dans l'intubation trachéale.

Commentaire : 

High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series.
Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. | Am J Emerg Med. 2021 Jun;44:262-266
DOI: https://doi.org/10.1016/j.ajem.2020.03.062
Keywords: Acute heart failure (AHF); Bilevel positive airway pressure (BPAP); Flash pulmonary edema; High-dose nitroglycerin; Sympathetic crashing acute pulmonary edema (SCAPE).

Research article

Editorial : Sympathetic crashing acute pulmonary edema (SCAPE) describes the most severe presentation of acute heart failure (AHF). Immediate intervention is required to prevent hemodynamic decompensation and endotracheal intubation. Although high-dose nitroglycerin (>100 μg/min) has been described for this clinical scenario in limited case reports, the concern for adverse effects such as hypotension and syncope limit providers comfortability in initiating nitroglycerin at these doses. Described here is a case series of four patients who safely and effectively received high-dose nitroglycerin infusions for the management of SCAPE.

Conclusion : Four patients clinically diagnosed with SCAPE in our ED were man- aged with nitroglycerin infusions and three with concomitant BPAP. To the best of our knowledge, this is the first report describing safe and effective administration of prolonged high-dose nitroglycerin infu- sions for SCAPE. All four patients achieved symptomatic improvement and required no additional acute pharmacologic therapy or invasive mechanical ventilation.

Conclusion (proposition de traduction) : Quatre patients cliniquement diagnostiqués avec un SCAPE dans notre service d'urgence ont été traités avec des perfusions de nitroglycérine et trois concomitamment avec une pression positive à deux niveaux. À notre connaissance, il s'agit du premier rapport décrivant l'administration sûre et efficace de perfusions prolongées de nitroglycérine à fortes doses dans le SCAPE. Les quatre patients ont obtenu une amélioration symptomatique et n'ont nécessité aucune thérapie pharmacologique aiguë supplémentaire ni ventilation mécanique invasive.

The efficacy of intravenous lidocaine and its side effects in comparison with intravenous morphine sulfate in patients admitted to the ED with right upper abdominal pain suspected of biliary colic.
Akhgar A, Pouryousefi T, Nejati A, Rafiemanesh H, Hossein-Nejad H. | Am J Emerg Med. 2021 Jun;44:300-305
DOI: https://doi.org/10.1016/j.ajem.2020.04.010
Keywords: Emergency department; Lidocaine; Morphine sulfate; Pain management; Side effects.

Research article

Introduction : Intravenous (IV) Lidocaine can be used as analgesic in acute pain management in the emergency department (ED).
Objective: Efficacy of IV Lidocaine in comparison with IV morphine in acute pain management in the ED.

Méthode : This is a double-blind randomized clinical trial on adult (18-64 year) patients with right upper abdominal pain suspected of biliary colic who needed pain management. Participants randomly received IV lidocaine (5 cc = 100 mg) or morphine sulfate (5 cc = 5 mg). In both groups, patients' pain scores were recorded and assessed by Numeric Rating Scale (NRS) at baseline, 10, 20, 30, 45, 60 and 120 min after drug administration. Adverse side effects of lidocaine and morphine sulfate and changes in vital signs were also recorded and compared.

Résultats : A total number of 104 patients were enrolled in the study, including 49 men and 55 women. IV lidocaine reduced pain in less time in comparison with morphine sulfate. Mean (±SD) basic pain score was 8.23 (±1.76) in the lidocaine group and 8.73 (±0.96) in the morphine group. Patients' mean (±SD) pain score in both groups had no significant difference during the study except that of NRS2 (10 min after drug administration), which was 5.05 (±2.69) in lidocaine group compared with 6.39 (±2.06) in the morphine group and NRS4 (30 min after drug administration), which was significantly lower (P-value = 0.01) in the morphine group [3.84(±1.73) vs 4.41(±2.82)]. Only 9 patients had adverse effects in either group.

Conclusion : The findings of this study suggest that IV lidocaine can be a good choice in pain management in biliary colic and can reduce pain in less time than morphine sulfate (in 10 min) without adding significant side effects; however, our primary outcome was the comparison of these two drugs after 60 min of drug administration in pain reduction which showed no significant difference between two groups.

Conclusion (proposition de traduction) : Les résultats de cette étude suggèrent que la lidocaïne IV peut être un bon choix dans la gestion de la douleur dans les coliques biliaires et peut réduire la douleur en moins de temps que le sulfate de morphine (en 10 min) sans ajouter d'effets secondaires importants ; cependant, notre critère de jugement principal était la comparaison de ces deux médicaments après 60 :minutes d'administration du médicament dans la réduction de la douleur qui n'a montré aucune différence significative entre les deux groupes.

Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study.
Lin J, Figuerado Y, Montgomery A, Lee J, Cannis M, Norton VC, Calvo R, Sikand H. | Am J Emerg Med. 2021 Jun;44:306-311
DOI: https://doi.org/10.1016/j.ajem.2020.04.013
Keywords: Agitation; Haloperidol; Ketamine; Lorazepam; Sedation.

Research article

Introduction : Clinicians often encounter agitated patients, and current treatment options include benzodiazepines and antipsychotics. Ketamine rapidly induces dissociation, maintains cardiovascular stability, spontaneous respirations, and airway reflexes. There are no prospective, randomized studies comparing ketamine to other agents in the initial management of acute agitation in the Emergency Department (ED). Objective: Determine the efficacy and safety of ketamine compared to parenteral haloperidol plus lorazepam for initial control of acute agitation.

Méthode : This study was a prospective, single-institution, randomized, open-label, real world, standard of care pilot study. Adult patients with combative agitation were randomized to ketamine (4 mg/kg IM or 1 mg/kg IV) or haloperidol/lorazepam (haloperidol 5-10 mg IM or IV + lorazepam 1-2 mg IM or IV). The primary outcome was sedation within 5 min, and secondary outcomes included sedation within 15 min, time to sedation, and safety.

Résultats : Ninety three patients were enrolled from January 15, 2018 to October 10, 2018. Significantly more patients who received ketamine compared to haloperidol/lorazepam were sedated within 5 min (22% vs 0%, p = 0.001) and 15 min (66% vs 7%, p < 0.001). The median time to sedation in patients who received ketamine compared to haloperidol/lorazepam was 15 vs 36 min respectively (p < 0.001). Patients who received ketamine experienced a significant, but transient tachycardia (p = 0.01) and hypertension (p = 0.01).

Conclusion : In patients with combative agitation, ketamine was significantly more effective than haloperidol/lorazepam for initial control of acute agitation, and was not associated with any significant adverse effects.

Conclusion (proposition de traduction) : Chez les patients présentant une agitation avec agressivité, la kétamine s'est avérée significativement plus efficace que l'halopéridol/lorazépam pour le contrôle initial de l'agitation aiguë et n'a été associée à aucun effet indésirable significatif.

Effect of parental pressure on emergency physicians for computerized tomography imaging request in children with head trauma.
Boğan M, Sabak M, Oktay M, Gümüşboğa H, Aykol E. | Am J Emerg Med. 2021 Jun;44:339-345
DOI: https://doi.org/10.1016/j.ajem.2020.04.040
Keywords: Childhood emergency admissions; Cranial computed tomography; Head trauma; Parents pressure.

Research article

Introduction : Both minor and major head traumas constitute an important proportion of childhood emergency admissions. In this study, the findings of cranial computed tomography (CCT) scans performed as a result of the parental pressure were evaluated.

Méthode : The frequency and findings of CCT scans performed as a result of parental pressure were examined in a separate subgroup.

Résultats : A total of 227 patients were included in the study; 158 (69.9%) patients had undergone CCT scans; a pathological finding was detected in 24 (10.6%) of these patients and undergone a consultation by the neurosurgeon (most common finding was isolated linear fracture; n = 12; 50%). The patients undergoing CCT scans were divided in two subgroups: the PECARN group [n = 123 (77.8%)] and the Parental pressure group [n = 33 (22.2%)].

Conclusion : One third of the parents of children who presented to the emergency department with head trauma and had no indication for CCT according to PECARN rules insisted on CCT imaging, and none of these cases showed ciTBI, surgical operation, or mortality. None of the patients in the parental pressure group had a history of surgical intervention or mortality within one month after discharge.

Conclusion (proposition de traduction) : Un tiers des parents d'enfants qui se sont présentés aux urgences avec un traumatisme crânien et n'avaient aucune indication de scanner cérébral selon les règles du PECARN ont insisté sur le scanner cérébral, et aucun de ces cas n'a montré de lésion cérébrale traumatique cliniquement importante, d'opération chirurgicale, ou de mortalité. Aucun des patients du groupe de pression parentale n’avait d’antécédents d’intervention chirurgicale ou de décès dans le mois suivant la sortie.

Diagnostic accuracy of combined WBC, ANC and CRP in adult emergency department patients suspected of acute appendicitis.
Huckins DS, Copeland K. | Am J Emerg Med. 2021 Jun;44:401-406
DOI: https://doi.org/10.1016/j.ajem.2020.04.086
Keywords: Absolute neutrophil count (ANC); Adult; Appendicitis; C-reactive protein (CRP); Computed tomography; Diagnostic accuracy; Sensitivity; White blood cell count (WBC).

Research article

Introduction : To assess the sensitivity, specificity, and negative predictive value (NPV) of normal total white blood cell count (WBC) and normal absolute neutrophil count (ANC) combined with a normal proprietary C-reactive protein (pCRP) level in adult emergency department (ED) patients with abdominal pain suspected of possible acute appendicitis.

Méthode : We prospectively enrolled patients ≥18 years of age at seven U.S. emergency departments with ≤72 h of abdominal pain and other signs and symptoms suggesting possible acute appendicitis. Sensitivity, specificity, and NPV for normal WBC and ANC combined with normal pCRP were correlated with the final diagnosis of acute appendicitis.

Résultats : We enrolled 422 patients with a prevalence of acute appendicitis of 19.1%. The combination of normal WBC and pCRP exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), an NPV of 98.8% (95% CI, 95.9-99.7%) and a specificity of 50.0% (95% CI, 44.7-55.3%) for acute appendicitis. Normal ANC and pCRP resulted in a sensitivity of 100% (95% CI, 95.4-100%), a negative predictive value of 100% (95% CI, 97.5-100%) and a specificity of 44.4% (95% CI, 39.2-49.7%) for acute appendicitis. Normal WBC and pCRP correctly identified 171 of 342 (50.0%) patients who did not have appendicitis with 2 (2.5%) false negatives, while normal ANC and pCRP identified 150 of 338 (44.3%) of patients without appendicitis with no false negatives.

Conclusion : The combination of normal WBC and ANC with normal pCRP levels exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult patient cohort. Confirmation and validation of these findings with further study using commercially available CRP assays is needed.

Conclusion (proposition de traduction) : La combinaison d'un nombre normal de globules blancs et du nombre absolu de neutrophiles avec des taux de CRP exclusivement normaux a montré une sensibilité élevée et une valeur prédictive négative pour l'appendicite aiguë dans cette cohorte prospective de patients adultes. La confirmation et la validation de ces résultats par une étude plus approfondie utilisant des tests de CRP disponibles dans le commerce sont nécessaires.

A randomized cohort study of the efficacy of PO magnesium in the treatment of acute concussions in adolescents.
Standiford L, O'Daniel M, Hysell M, Trigger C. | Am J Emerg Med. 2021 Jun;44:419-422
DOI: https://doi.org/10.1016/j.ajem.2020.05.010
Keywords: Aucun

Research article

Introduction : Concussions are becoming a growing concern in society today with one out of every five adolescents being affected. This accounts for 1.6 to 3.8 million emergency department visits annually. The current standard of care involves an initial period of mental rest with symptomatic care and symptom-based return to daily activities/sports. High dose IV magnesium has been proven to be neuroprotective in severe TBI. We hypothesized that oral magnesium replacement following a concussion will decrease the overall symptomatic period allowing a quicker return to functional baseline.

Méthode : We used a randomized cohort study involving patients aged 12-18 who presented within 48 h after a concussion. Our study design had a treatment arm including acetaminophen, ondansetron, and magnesium PO and a placebo arm of acetaminophen and ondansetron. We then utilized the Post- Concussion Severity Score (PCSS) to evaluate the extent of the patient's symptoms. This score was collected immediately prior to obtaining medications, 1 h, 48 h, and 120 h after starting the study. The study relied on outpatient follow up through phone conversations, and a Sports Medicine clinic locally.

Résultats : Our data shows that there was a statistically significant decrease in the PCSS at 48 h (p = 0.016) in the magnesium group relative to the placebo treatment arm. This study does imply that magnesium supplementation has potential benefit in treatment of concussions acutely.

Conclusion : Oral magnesium replacement decreases symptoms acutely following a concussion and should be provided with symptomatic management following a concussion in the emergency setting.

Conclusion (proposition de traduction) : L’administration orale de magnésium réduit les symptômes aiguë après une commotion cérébrale et devrait être proposé comme traitement symptomatique après une commotion cérébrale en situation d’urgence.

Wearing a N95 mask increases rescuer's fatigue and decreases chest compression quality in simulated cardiopulmonary resuscitation.
Tian Y, Tu X, Zhou X, Yu J, Luo S, Ma L, Liu C, Zhao Y, Jin X. | Am J Emerg Med. 2021 Jun;44:434-438
DOI: https://doi.org/10.1016/j.ajem.2020.05.065  | Télécharger l'article au format  
Keywords: COVID-19; Chest compression; Fatigue; N95 mask.

Research article

Introduction : N95 mask is essential for healthcare workers dealing with the coronavirus disease 2019 (COVID-19). However, N95 mask causes discomfort breathing with marked reduction in air exchange. This study was designed to investigate whether the use of N95 mask affects rescuer's fatigue and chest compression quality during cardiopulmonary resuscitation (CPR).

Méthode : After a brief review of CPR, each participant performed a 2-minute continuous chest compression on a manikin wearing N95 (N95 group, n = 40) or surgical mask (SM group, n = 40). Compression rate and depth, the proportions of correct compression rate, depth, complete chest recoil and hand position were documented. Participants' fatigue was assessed using Borg score.

Résultats : Significantly lower mean chest compression rate and depth were both achieved in the N95 group than in the SM group (p < 0.05, respectively). In addition, the proportion of correct compression rate (61 ± 19 vs. 75 ± 195, p = 0.0067), depth (67 ± 16 vs. 90 ± 14, p < 0.0001) and complete recoil (91 ± 16 vs. 98 ± 5%, p = 0.0248) were significantly decreased in the N95 group as compared to the SM group. At the end of compression, the Borg score in the N95 group was significantly higher than that in the SM group (p = 0.027).

Conclusion : Wearing a N95 mask increases rescuer's fatigue and decreases chest compression quality during CPR. Therefore, the exchange of rescuers during CPR should be more frequent than that recommended in current guidelines when N95 masks are applied.

Conclusion (proposition de traduction) : Le port d'un masque FFP2 augmente la fatigue du secouriste et diminue la qualité de la compression thoracique pendant la RCP. Par conséquent, l'échange de sauveteurs pendant la RCP devrait être plus fréquent que celui recommandé dans les directives actuelles lorsque des masques N95 sont appliqués.

Commentaire : Le masque N95 est l'équivalent américain du masque FFP2

Assessment of the SpO₂/FiO₂ ratio as a tool for hypoxemia screening in the emergency department.
Catoire P, Tellier E, de la Rivière C, Beauvieux MC, Valdenaire G, Galinski M, Revel P, Combes X, Gil-Jardiné C. | Am J Emerg Med. 2021 Jun;44:116-120
DOI: https://doi.org/10.1016/j.ajem.2021.01.092  | Télécharger l'article au format  
Keywords: COVID-19; Oximetry; ROC curve; Respiratory insufficiency; Triage.

Short communication

Introduction : We assessed the performance of the ratio of peripheral arterial oxygen saturation to the inspired fraction of oxygen (SpO₂/FiO₂) to predict the ratio of partial pressure arterial oxygen to the fraction of inspired oxygen (PaO₂/FiO₂) among patients admitted to our emergency department (ED) during the SARS-CoV-2 outbreak.

Méthode : We retrospectively studied patients admitted to an academic-level ED in France who were undergoing a joint measurement of SpO₂ and arterial blood gas. We compared SpO₂ with SaO₂ and evaluated performance of the SpO₂/FiO₂ ratio for the prediction of 300 and 400 mmHg PaO₂/FiO₂ cut-off values in COVID-19 positive and negative subgroups using receiver-operating characteristic (ROC) curves

Résultats : During the study period from February to April 2020, a total of 430 arterial samples were analyzed and collected from 395 patients. The area under the ROC curves of the SpO₂/FiO₂ ratio was 0.918 (CI 95% 0.885-0.950) and 0.901 (CI 95% 0.872-0.930) for PaO₂/FiO₂ thresholds of 300 and 400 mmHg, respectively. The positive predictive value (PPV) of an SpO₂/FiO₂ threshold of 350 for PaO₂/FiO₂ inferior to 300 mmHg was 0.88 (CI95% 0.84-0.91), whereas the negative predictive value (NPV) of the SpO₂/FiO₂ threshold of 470 for PaO₂/FiO₂ inferior to 400 mmHg was 0.89 (CI95% 0.75-0.96). No significant differences were found between the subgroups.

Conclusion : The SpO₂/FiO₂ ratio may be a reliable tool for hypoxemia screening among patients admitted to the ED, particularly during the SARS-CoV-2 outbreak.

Conclusion (proposition de traduction) : Le rapport SpO₂/FiO₂ peut être un outil fiable pour le dépistage de l'hypoxémie chez les patients admis aux urgences, en particulier pendant l'épidémie de SRAS-CoV-2.

Evaluation and management of the critically ill adult asthmatic in the emergency department setting.
Long B, Lentz S, Koyfman A, Gottlieb M. | Am J Emerg Med. 2021 Jun;44:441-451
DOI: https://doi.org/10.1016/j.ajem.2020.03.029
Keywords: Asthma; Beta agonist; Critical; Glucocorticoids; Lung; Obstruction; Pulmonary; Severe.

Review article

Introduction : Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management.
Objective: This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma.

Discussion : It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission.

Conclusion : This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.

Conclusion (proposition de traduction) : Cette revue fournit des recommandations fondées sur des preuves pour l'évaluation et la gestion de l'asthme sévère en mettant l'accent sur le clinicien d'urgence.

Comparison of intravascular access methods applied by nurses wearing personal protective equipment in simulated COVID-19 resuscitation: A randomized crossover simulation trial.
Drozd A, Smereka J, Pruc M, Malysz M, Gasecka A, Sonmez LO, Cyran M, Konge L, Szarpak L. | Am J Emerg Med. 2021 Jun 3;49:189-194
DOI: https://doi.org/10.1016/j.ajem.2021.05.080  | Télécharger l'article au format  
Keywords: COVID-19; Cardiopulmonary resuscitation; Child; Coronavirus; Infection; Intraosseous access; Intravascular access; Medical simulation; Personal protective equipment; SARS-CoV-2.

RESEARCH ARTICLE

Introduction : Prehospital emergency care of children is challenging. In the era of the COVID-19 pandemic, when medical personnel should use personal protective equipment against aerosol-generating procedures, the efficiency of medical procedures may decrease. The study objective was to evaluate the effectiveness of different intravascular access methods applied by nurses wearing biosafety Level-2 suits in simulated paediatric COVID-19 resuscitation.

Méthode : A prospective, randomized, crossover, single-blinded simulation trial was performed. Nursing staff attending Advanced Cardiovascular Life Support courses accredited by the American Heart Association participated in the study. A total of 65 nurses were recruited and randomly assigned to different study groups. They received standard training on intravascular access methods employing distinct devices. The participants wore biosafety Level-2 suits and performed vascular access with the following intraosseous devices: NIO-P, EZ-IO, and Jamshidi needle; intravenous (IV) access was used as a reference method. Both the order of participants and the access methods were random. Each participant performed intravascular access with each of the four methods tested. The effectiveness of the first attempt to obtain intravascular access and the following time parameters were analysed: the time between grasping the intravascular device out of the original packing until infusion line connection. The ease of the procedure was measured with a visual analogue scale (1 - easy; 10 - difficult).

Résultats : The first attempt success rate of intravascular access by using NIO-P and EZ-IO equalled 100% and was statistically significantly higher than that with the Jamshidi needle (80.0%; p = 0.02) and with the IV method (69.2%; p = 0.005). The time required to connect the infusion line varied and amounted to 33 ± 4 s for NIO-P compared to 37 ± 6.7 s for EZ-IO (p<0.001), 43 ± 7 s for Jamshidi (p<0.001), and 98.5 ± 10 s for IV access (p<0.001). The procedure was easiest in the case of NIO-P and EZ-IO (2 ± 1 points; p=1.0) compared with Jamshidi (5 ± 3 points; p<0.001) and IV access (7 ± 2 points; p<0.001).

Conclusion : The study provides evidence that nurses wearing biosafety Level-2 suits were able to obtain intraosseous access faster and more effectively as compared with IV access during simulated COVID-19 paediatric resuscitation. The most effective method of intravascular access was the NIO-P intraosseous device. Further clinical trials are necessary to confirm the results.

Conclusion (proposition de traduction) : L'étude fdémontre que les infirmières portant des combinaisons de biosécurité de niveau 2 ont pu obtenir un accès intra-osseux plus rapidement et plus efficacement par rapport à l'accès IV lors d'une simulation de réanimation pédiatrique présentant une COVID-19. La méthode d'accès intravasculaire la plus efficace était le dispositif intra-osseux NIO-P (PerSys Medical). D'autres essais cliniques sont nécessaires pour confirmer les résultats.

Commentaire : Dispositif intra-osseux NIO-P (PerSys Medical) :

Dispositif intra-osseux EZ-IO :

Dispositif intra-osseux Jamshidi needle :

High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study.
Mathew R, , Kumar A, Sahu A, Wali S, Aggarwal P.. | J Emerg Med. 2021 Jun 29:S0736-4679(21)00467-4
DOI: https://doi.org/10.1016/j.jemermed.2021.05.011
Keywords: Flash pulmonary edema; High-dose nitroglycerin; Noninvasive ventilation; SCAPE; Sympathetic crashing acute pulmonary edema.

BRIEF REPORT

Introduction : Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute heart failure with a dramatic presentation. Rapid identification and management in the emergency department (ED) is key to saving these patients and preventing morbidity associated with endotracheal intubation and intensive care treatment. Use of high-dose nitroglycerin (NTG) and noninvasive ventilation (NIV) has been advocated in management of such patients.

Méthode : To study the feasibility and safety of high-dose NTG combined with NIV in SCAPE.
This was a prospective observational pilot study done in the ED of a tertiary care hospital. All patients were treated with high-dose NTG and NIV. The primary objective was to study the feasibility and safety of the SCAPE management protocol in terms of the outcome of the patient. Resolution of symptoms in 6 h and need for intubation were recorded as endpoints. Any complications associated with high-dose NTG were also recorded.

Résultats : A total of 25 patients were recruited. The mean bolus dose of NTG given was 872 μg, and mean cumulative dose, 35 mg. There was no incidence of hypotension after the bolus dose of nitroglycerin. Eleven patients had resolution of symptoms at 3 h of therapy. Twenty-four patients were discharged from the ED itself after a brief period of observation, and one patient was intubated and shifted to the intensive care unit.

Conclusion : Use of our specific SCAPE treatment algorithm, which included high-dose NTG and NIV, was safe and provided rapid resolution of symptoms.

Conclusion (proposition de traduction) : L'utilisation de notre algorithme de traitement spécifique dans l'OAP flash, qui comprenait une dose élevée de dérivés nitrés et la VNI, était sûre et permettait une résolution rapide des symptômes.

Commentaire :  Protocol for SCAPE ED Management –SCAPE Treatment Protocol (STP).
SCAPE = sympathetic crashing acute pulmonary edema; ED = emergency department; IV = intravenous; NTG = nitroglycerin; SBP = systolic blood pressure; Bi-PAP = bilevel positive airway pressure; IP = injection pressure; EP = epidural pressure; NIV = noninvasive ventilation; RR = respiratory rate.

Les « hautes » doses utilisées en France sont plutôt de 3 mg d'isosorbide dinitrate (Risordan^®) toutes les 5 minutes (Cotter G et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998 Feb;351(9100):389–93  ) jusqu'à un objectif de TA systolique entre 110 à 140 mmHg, contrairement aux propositions américaines dans cet article (0,6 à 1 mg en bolus).
Pour la VNI en Bi-PAP, on préconise plutôt une PEP élevée (10 ± 2 mmHg, jusqu'à 12 ou 15 :mmHg) et une AI modérée (4 à 6 mmHg) avec une FiO₂ suffisante pour un objectif cible d'une SpO₂ entre 96 et 80 %.
Ces patients sont plutôt sur le versant « sec » profil « dry » de la conférence de consensus de ESC 2016 (Guidelines for the diagnosis and treatment of acute and chronic heart failure  ). L'utilisation du furosemide doit être modérée.

Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19.
Wilcox SR, Condella A. | J Emerg Med. 2021 Jun;60(6):729-742
DOI: https://doi.org/10.1016/j.jemermed.2020.12.014  | Télécharger l'article au format  
Keywords: COVID-19; acute respiratory distress syndrome; airway management; critical care medicine; hypoxemic respiratory failure.

Clinical Review

Introduction : While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic.
Objective: We review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department.

Discussion : COVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma.

Conclusion : High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit et la ventilation non invasive à pression positive ont un rôle plus limité dans COVID-19 en raison du risque d'aérosolisation et du bénéfice minimal dans les cas graves, mais peuvent être envisagées. Les patients stables qui peuvent tolérer le changement de position doivent être placés en décubitus ventral bien que réveillés. Une fois intubés, les patients doivent être pris en charge avec des stratégies de ventilation adaptées au SDRA, notamment en ciblant les volumes de protection pulmonaire et les basses pressions. L'augmentation de la pression expiratoire positive peut être bénéfique. Les vasodilatateurs pulmonaires inhalés ne diminuent pas la mortalité mais peuvent être administrés pour améliorer l'hypoxémie réfractaire. Le positionnement en décubitus ventral des patients intubés est associé à une réduction de la mortalité dans le SDRA et peut être envisagé chez les patients présentant une hypoxémie persistante. Une curarisation doit également être administré aux patients qui restent asynchrones avec le ventilateur malgré une sédation adéquate. Enfin, les patients présentant une insuffisance respiratoire hypoxémique sévère réfractaire due au COVID-19 doivent pouvoir bénéficier d'une oxygénation veino-veineuse par membrane extracorporelle (ECMO).

Comparison of Endotracheal Intubation Skills With Video Laryngoscopy and Direct Laryngoscopy in Providing Airway Patency in a Moving Ambulance.
Gok PG, Ozakin E, Acar N, Karakilic E, Kaya FB, Tekin N, Yazlamaz NO. | J Emerg Med. 2021 Jun;60(6):752-759
DOI: https://doi.org/10.1016/j.jemermed.2020.12.009
Keywords: airway manikin; direct laryngoscopy; endotracheal intubation; mobile ambulance; video laryngoscopy.

Selected Topics: Prehospital Care

Introduction : Early and successful management of the airway in the prehospital and hospital settings is critical in life-threatening situations.
Objective: We aimed to perform endotracheal intubation (ETI) by direct laryngoscopy (DL) and video laryngoscopy (VL) on airway manikins on a moving track and to compare the properties of intubation attempts.

Méthode : Overall, 79 participants with no previous VL experience were given 4 h of ETI training with DL and VL using a standard airway manikin. ETI skill was tested inside a moving ambulance. The number of attempts until successful ETI, ETI attempt times, time needed to see the vocal cords, and the degree of convenience of both ETI methods were recorded.

Résultats : Overall, 22 of 79 individuals were men; mean age was 30.3 ± 4.5 years. No difference was found in the comparison of the two methods (p = 0.708). Time needed to see the vocal cords for those who were successful in their first attempt were between 1 and 8 s in both methods. In the VL method, time needed to see the vocal cords (p = 0.001) and the intubation time (p < 0.001) in the first attempt were shorter than in the DL method. The VL method was easier (p < 0.001). The success rate was 97.5% in DL and 93.7% in VL.

Conclusion : The VL method is rapid and easier to see the vocal cords and perform successful ETI. Therefore, it might be preferred in out-of-hospital ETI applications.

Conclusion (proposition de traduction) : La méthode de la vidéo-laryngoscopie est rapide et plus simple pour visualiser les cordes vocales et réussir l'intubation endotrachéale. Par conséquent, il pourrait être préféré dans l'intubation endotrachéale extra-hospitalière.

Video Laryngoscopy Improves Intubation Times With Level C Personal Protective Equipment in Novice Physicians: A Randomized Cross-Over Manikin Study.
Pantazopoulos I, Kolonia K, Laou E, Mermiri M, Tsolaki V, Koutsovasilis A, Zakynthinos G, Gourgoulianis K, Arnaoutoglou E, Chalkias A. | J Emerg Med. 2021 Jun;60(6):764-771
DOI: https://doi.org/10.1016/j.jemermed.2021.01.001
Keywords: intubation; personal protective equipment; video laryngoscope.

Brief Report

Introduction : The use of video laryngoscopes by novice physicians may improve first-pass success rates compared with direct laryngoscopy.
Objective: The aim of the present study was to assess whether time to intubation, number of laryngoscopy attempts, and first-pass success rate during laryngoscopy with the video laryngoscope or conventional Macintosh laryngoscope are affected by personal protective equipment (PPE) donning.

Méthode : Seventy inexperienced physicians were randomly assigned to video laryngoscope or Macintosh groups and were instructed to perform intubation with both devices on a manikin, using PPE or a standard uniform. The primary outcomes were insertion time, number of laryngoscopy attempts, and first-pass success rates for each device with or without donning PPE.

Résultats : In the Macintosh group, significantly less time was needed for the first successful intubation without PPE vs. with PPE (12.17 ± 3.69 s vs. 24.07 ± 5.09 s, respectively; p < 0.0001). On the other hand, such difference was not observed in the video laryngoscope group (14.99 ± 3.01 s vs. 14.01 ± 3.35 s, respectively; p = 0.07). With PPE, the first-pass success rate was significantly higher in the video laryngoscope group [41 (58.6%) vs. 66 (94.3%), p < 0.001]. The use of the video laryngoscope resulted in a significant decrease in insertion time compared with the Macintosh blade (14.01 ± 3.35 s vs. 24.07 ± 5.09 s, respectively; p < 0.0001).

Conclusion : First-pass success and insertion time with the video laryngoscope were not affected by PPE donning. However, both were negatively affected with the Macintosh laryngoscope.

Conclusion (proposition de traduction) : Le succès au premier essai et le temps d'insertion avec le vidéo-laryngoscope n'ont pas été affectés par le port de l'EPI. Cependant, les deux ont été affectés négativement avec le laryngoscope Macintosh.

Commentaire : L'EPI de niveau C comprenait :
une coiffe jetable, un masque FFP2 ajusté, une combinaison de protection résistante aux fluides, 2 couches de gants, lunettes, écran facial et couvre-chaussures résistant aux liquides.

Prehospital tourniquet use: An evaluation of community application and outcome.
Barnard LM, Guan S, Zarmer L, Mills B, Blackwood J, Bulger E, Yang BY, Johnston P, Vavilala MS, Sayre MR, Rea TD, Murphy DL. | J Trauma Acute Care Surg. 2021 Jun 1;90(6):1040-1047
DOI: https://doi.org/10.1097/ta.0000000000003145
Keywords: Aucun

Original article

Introduction : There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application.

Méthode : We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course.

Résultats : A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of <90 mm Hg, 8% had Glasgow Coma Scale score of <13, and 3% had cardiac arrest. Among initial applications, 48% were placed by law enforcement, 33% by laypersons, and 18% by EMS. Among tourniquets applied by layperson or law enforcement (n = 137), EMS relied solely on the original tourniquet in 45% (n = 61), placed a second tourniquet in 20% (n = 28), and removed the tourniquet without replacement in 35% (n = 48). Overall, 24% required massive transfusion, 59% underwent urgent surgery, and 21% required vascular surgery. Mortality was 3% (n = 4). At hospital discharge, the tourniquet limb was fully functional in 81%, partially functional in 10%, and nonfunctional in 9%; decreased function was not attributed to tourniquet application.

Conclusion : The high rate of application, need for urgent hospital intervention in a subset, and low incidence of apparent complication suggest that efforts to increase access and early tourniquet use can provide public health benefit.

Conclusion (proposition de traduction) : Le taux élevé d'utilisation, la nécessité d'une intervention hospitalière urgente dans un sous-ensemble et la faible incidence de complications apparentes suggèrent que les efforts visant à accroître l'accès et l'utilisation précoce du garrot peuvent être bénéfiques pour la santé publique.

β-Blockers for traumatic brain injury: A systematic review and meta-analysis.
Ding H, Liao L, Zheng X, Wang Q, Liu Z, Xu G, Li X, Liu L. | J Trauma Acute Care Surg. 2021 Jun 1;90(6):1077-1085
DOI: https://doi.org/10.1097/ta.0000000000003094
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Paroxysmal sympathetic hyperactivity (PSH) and catecholamine surge, which are associated with poor outcome, may be triggered by traumatic brain injury (TBI).β Adrenergic receptor blockers (β-blockers), as potential therapeutic agents to prevent paroxysmal sympathetic hyperactivity and catecholamine surge, have been shown to improve survival after TBI. The principal aim of this study was to investigate the effect of β-blockers on outcomes in patients with TBI.

Méthode : For this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and Cochrane Library databases from inception to September 25, 2020, for randomized controlled trials, nonrandomized controlled trials, and observational studies reporting the effect of β-blockers on the following outcomes after TBI: mortality, functional measures, and cardiopulmonary adverse effects of β-blockers (e.g., hypotension, bradycardia, and bronchospasm). With use of random-effects model, we calculated pooled estimates, confidence intervals (CIs), and odds ratios (ORs) of all outcomes.

Résultats : Fifteen studies with 12,721 patients were included. Exposure to β-blockers after TBI was associated with a significant reduction in adjusted in-hospital mortality (OR, 0.39; 95% CI, 0.30-0.51; I2 = 66.3%; p < 0.001). β-Blockers significantly improved the long-term (≥6 months) functional outcome (OR, 1.75; 95% CI, 1.09-2.80; I2 = 0%; p = 0.02). Statistically significant difference was not seen for cardiopulmonary adverse events (OR, 0.91; 95% CI, 0.55-1.50; I2 = 25.9%; p = 0.702).

Conclusion : This meta-analysis demonstrated that administration of β-blockers after TBI was safe and effective. Administration of β-blockers may therefore be suggested in the TBI care. However, more high-quality trials are needed to investigate the use of β-blockers in the management of TBI.

Conclusion (proposition de traduction) : Cette méta-analyse a démontré que l'administration de β-bloquants après une lésion cérébrale traumatique était sûre et efficace. L'administration de β-bloquants peut donc être suggérée dans la prise en charge des traumatismes crâniens. Cependant, davantage d'essais de haute qualité sont nécessaires pour étudier l'utilisation des β-bloquants dans la prise en charge des lésions cérébrales traumatiques.

Commentaire : Les agents β-bloquants, en diminuant la pression hydrostatique intracapillaire, diminuent l’œdème vasogénique qui aggrave les lésions du traumatisme crânien. Ils diminuent la demande cérébrale en oxygène et agissent également sur les organes soumis à la décharge catécholaminergique liée au traumatisme crânien. L’enjeu principal de la prise en charge est la prévention de l’apparition de lésions cérébrales secondaires.
Mathieu C, Pastene B, Bechis C, Leone M. Bêtabloquants en réanimation. Le Congrès - Médecins. Conférence d’Actualisation^© 2015 SFAR  .

Therapeutic versus prophylactic anticoagulation for patients admitted to hospital with COVID-19 and elevated D-dimer concentration (ACTION): an open-label, multicentre, randomised, controlled trial.
Lopes RD, de Barros E Silva PGM and al; ACTION Coalition COVID-19 Brazil IV Investigators . | Lancet. 2021 Jun 12;397(10291):2253-2263
DOI: https://doi.org/10.1016/s0140-6736(21)01203-4  | Télécharger l'article au format  
Keywords: Aucun

Article

Introduction : COVID-19 is associated with a prothrombotic state leading to adverse clinical outcomes. Whether therapeutic anticoagulation improves outcomes in patients hospitalised with COVID-19 is unknown. We aimed to compare the efficacy and safety of therapeutic versus prophylactic anticoagulation in this population.

Méthode : We did a pragmatic, open-label (with blinded adjudication), multicentre, randomised, controlled trial, at 31 sites in Brazil. Patients (aged ≥18 years) hospitalised with COVID-19 and elevated D-dimer concentration, and who had COVID-19 symptoms for up to 14 days before randomisation, were randomly assigned (1:1) to receive either therapeutic or prophylactic anticoagulation. Therapeutic anticoagulation was in-hospital oral rivaroxaban (20 mg or 15 mg daily) for stable patients, or initial subcutaneous enoxaparin (1 mg/kg twice per day) or intravenous unfractionated heparin (to achieve a 0·3-0·7 IU/mL anti-Xa concentration) for clinically unstable patients, followed by rivaroxaban to day 30. Prophylactic anticoagulation was standard in-hospital enoxaparin or unfractionated heparin. The primary efficacy outcome was a hierarchical analysis of time to death, duration of hospitalisation, or duration of supplemental oxygen to day 30, analysed with the win ratio method (a ratio >1 reflects a better outcome in the therapeutic anticoagulation group) in the intention-to-treat population. The primary safety outcome was major or clinically relevant non-major bleeding through 30 days.

Résultats : From June 24, 2020, to Feb 26, 2021, 3331 patients were screened and 615 were randomly allocated (311 [50%] to the therapeutic anticoagulation group and 304 [50%] to the prophylactic anticoagulation group). 576 (94%) were clinically stable and 39 (6%) clinically unstable. One patient, in the therapeutic group, was lost to follow-up because of withdrawal of consent and was not included in the primary analysis. The primary efficacy outcome was not different between patients assigned therapeutic or prophylactic anticoagulation, with 28 899 (34·8%) wins in the therapeutic group and 34 288 (41·3%) in the prophylactic group (win ratio 0·86 [95% CI 0·59-1·22], p=0·40). Consistent results were seen in clinically stable and clinically unstable patients. The primary safety outcome of major or clinically relevant non-major bleeding occurred in 26 (8%) patients assigned therapeutic anticoagulation and seven (2%) assigned prophylactic anticoagulation (relative risk 3·64 [95% CI 1·61-8·27], p=0·0010). Allergic reaction to the study medication occurred in two (1%) patients in the therapeutic anticoagulation group and three (1%) in the prophylactic anticoagulation group.

Conclusion : In patients hospitalised with COVID-19 and elevated D-dimer concentration, in-hospital therapeutic anticoagulation with rivaroxaban or enoxaparin followed by rivaroxaban to day 30 did not improve clinical outcomes and increased bleeding compared with prophylactic anticoagulation. Therefore, use of therapeutic-dose rivaroxaban, and other direct oral anticoagulants, should be avoided in these patients in the absence of an evidence-based indication for oral anticoagulation.

Conclusion (proposition de traduction) : Chez les patients hospitalisés pour COVID-19 et une taux élevé de D-dimères, l'anticoagulation thérapeutique à l'hôpital avec du rivaroxaban ou de l'énoxaparine suivie de rivaroxaban jusqu'au jour 30 n'a pas amélioré les résultats cliniques et a augmenté les saignements par rapport à l'anticoagulation prophylactique. Par conséquent, l'utilisation de rivaroxaban à dose curative et d'autres anticoagulants oraux directs doit être évitée chez ces patients en l'absence d'indication fondée sur des preuves pour l'anticoagulation orale.

Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention (HOST-EXAM): an investigator-initiated, prospective, randomised, open-label, multicentre trial.
Koo BK, Kang J, Park KW, Rhee TM, Yang HM, Won KB, Rha SW, Bae JW, Lee NH, Hur SH, Yoon J, Park TH, Kim BS, Lim SW, Cho YH, Jeon DW, Kim SH, Han JK, Shin ES, Kim HS; HOST-EXAM investigators. | Lancet. 2021 Jun 26;397(10293):2487-2496
DOI: https://doi.org/10.1016/s0140-6736(21)01063-1
Keywords: ChongKunDang, SamJin, HanMi, DaeWoong, and the South Korea Ministry of Health and Welfare.

ARTICLE

Introduction : Optimal antiplatelet monotherapy during the chronic maintenance period in patients who undergo coronary stenting is unknown. We aimed to compare head to head the efficacy and safety of aspirin and clopidogrel monotherapy in this population.

Méthode : We did an investigator-initiated, prospective, randomised, open-label, multicentre trial at 37 study sites in South Korea. We enrolled patients aged at least 20 years who maintained dual antiplatelet therapy without clinical events for 6-18 months after percutaneous coronary intervention with drug-eluting stents (DES). We excluded patients with any ischaemic and major bleeding complications. Patients were randomly assigned (1:1) to receive a monotherapy agent of clopidogrel 75 mg once daily or aspirin 100 mg once daily for 24 months. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium (BARC) bleeding type 3 or greater, in the intention-to-treat population.

Résultats : Between March 26, 2014, and May 29, 2018, we enrolled 5530 patients. 5438 (98·3%) patients were randomly assigned to either the clopidogrel group (2710 [49·8%]) or to the aspirin group (2728 [50·2%]). Ascertainment of the primary endpoint was completed in 5338 (98·2%) patients. During 24-month follow-up, the primary outcome occurred in 152 (5·7%) patients in the clopidogrel group and 207 (7·7%) in the aspirin group (hazard ratio 0·73 [95% CI 0·59-0·90]; p=0·0035).

Conclusion : Clopidogrel monotherapy, compared with aspirin monotherapy during the chronic maintenance period after percutaneous coronary intervention with DES significantly reduced the risk of the composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and BARC bleeding type 3 or greater. In patients requiring indefinite antiplatelet monotherapy after percutaneous coronary intervention, clopidogrel monotherapy was superior to aspirin monotherapy in preventing future adverse clinical events.

Conclusion (proposition de traduction) : Le clopidogrel en monothérapie, par rapport à l'aspirine en monothérapie pendant la période d'entretien au long court après une intervention coronarienne percutanée avec stents actifs, a significativement réduit le risque composite de décès toutes causes confondues, d'infarctus du myocarde non mortel, d'accident vasculaire cérébral, de réadmission en raison d'un syndrome coronarien aigu, et de saignement de type 3 ou plus du Saignement Academic Research Consortium (BARC). Chez les patients nécessitant une monothérapie antiplaquettaire indéfinie après une intervention coronarienne percutanée, le clopidogrel en monothérapie était supérieur à l'aspirine en monothérapie pour prévenir de futurs événements cliniques indésirables.

A point-of-care thoracic ultrasound protocol for hospital medical emergency teams (METUS) improves diagnostic accuracy.
Blans MJ, Bousie E, van der Hoeven JG, Bosch FH. | Ultrasound J. 2021 Jun 4;13(1):29
DOI: https://doi.org/10.1186/s13089-021-00229-3  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Point-of-care ultrasound (POCUS) has proven itself in many clinical situations. Few data on the use of POCUS during Medical Emergency Team (MET) calls exist. In this study, we hypothesized that the use of POCUS would increase the number of correct diagnosis made by the MET and increase MET’s certainty.

Méthode : Single-center prospective observational study on adult patients in need for MET assistance. Patients were included in blocks (weeks). During even weeks, the MET physician performed a clinical assessment and registered an initial diagnosis. Subsequently, the POCUS protocol was performed and a second diagnosis was registered (US+). During uneven weeks, no POCUS was performed (US−). A blinded expert reviewed the charts for a final diagnosis. The number of correct diagnoses was compared to the final diagnosis between both groups. Physician’s certainty, mortality and possible differences in first treatment were also evaluated.

Résultats : We included 100 patients: 52 in the US + and 48 in the US− group. There were significantly more correct diagnoses in the US+ group compared to the US− group: 78 vs 51% (P = 0.006). Certainty improved significantly with POCUS (P < 0.001). No differences in 28-day mortality and first treatment were found.

Conclusion : The use of thoracic POCUS during MET calls leads to better diagnosis and increases certainty.

Conclusion (proposition de traduction) : L'utilisation de l'échographie thoracique au point d'intervention lors des appels de l'équipe d'urgence médicale conduit à un meilleur diagnostic et augmente la certitude.

Commentaire : Erratum in: Ultrasound J. 2021 Jun 16;13(1):31  .