Bibliographie de Médecine d'Urgence

Mois d'août 2021


Academic Emergency Medicine Education and Training

Sex-related differences in D-dimer levels for venous thromboembolism screening.
Reagh JJ, Zheng H, Stolz U, Parry BA, Chang AM, House SL, Giordano NJ, Cohen J, Singer AJ, Francis S, Prochaska JH, Zeserson E, Wild PS, Limkakeng AT Jr, Walters EL, LoVecchio F, Theodoro D, Hollander JE, Kabrhel C, Fermann GJ. | Acad Emerg Med. 2021 Aug;28(8):873-881
DOI: https://doi.org/10.1111/acem.14220
Keywords: D-dimer; age-adjusted; deep vein thrombosis; diagnostic testing; logistic regression; pulmonary embolism; receiver operating characteristic; sex-adjusted; venous thromboembolism.

ORIGINAL CONTRIBUTION

Introduction : D-dimer is generally considered positive above 0.5 mg/L irrespective of sex. However, women have been shown to be more likely to have a positive D-dimer after controlling for other factors. Thus, differences may exist between males and females for using D-dimer as a marker of venous thromboembolic (VTE) disease. We hypothesized that the accuracy of D-dimer tests may be enhanced by using appropriate cutoff values that reflect sex-related differences in D-dimer levels.

Méthode : This research is a secondary analysis of a multicenter, international, prospective, observational study of adult (18+ years) patients suspected of VTE, with low-to-intermediate pretest probability based on Wells criteria ≤ 6 for pulmonary embolism (PE) and ≤ 2 for deep vein thrombosis (DVT). VTE diagnoses were based on computed tomography, ventilation perfusion scanning, or venous ultrasound. D-dimer levels were tested for statistical difference across groups stratified by sex and diagnosis. Multivariable regression was used to investigate sex as a predictor of diagnosis. Sex-specific optimal D-dimer thresholds for PE and DVT were calculated from receiver operating characteristic analyses. A Youden threshold (D-dimer level coinciding with the maximum of sensitivity plus specificity) and a cutoff corresponding to 95% sensitivity were calculated. Statistical difference for cutoffs was tested via 95% confidence intervals from 2,000 bootstrapped samples.

Résultats : We included 3,586 subjects for analysis, of whom 61% were female. Race demographics were 63% White, 27% Black/African American, and 6% Hispanic. In the suspected PE cohort, 6% were diagnosed with PE, while in the suspected DVT cohort, 11% were diagnosed with DVT. D-dimer levels were significantly higher in males than females for the PE-positive group and the DVT-negative group, but males had significantly lower D-dimer levels than females in the PE-negative group. Regression models showed male sex as a significant positive predictor of DVT diagnosis, controlling for D-dimer levels. The Youden thresholds for PE patients were 0.97 (95% CI = 0.64 to 1.79) mg/L and 1.45 (95% CI = 1.36 to 1.95) mg/L for females and males, respectively; 95% sensitivity cutoffs for this group were 0.64 (95% CI = 0.20 to 0.89) and 0.55 (95% CI = 0.29 to 1.61). For DVT, the Youden thresholds were 0.98 (95% CI = 0.84 to 1.56) mg/L for females and 1.25 (95% CI = 0.65 to 3.33) mg/L for males with 95% sensitivity cutoffs of 0.33 (95% CI = 0.2 to 0.61) and 0.32 (95% CI = 0.18 to 0.7), respectively.

Conclusion : Differences in D-dimer levels between males and females are diagnosis specific; however, there was no significant difference in optimal cutoff values for excluding PE and DVT between the sexes.

Conclusion (proposition de traduction) : Les différences de taux de D-dimères entre les hommes et les femmes sont spécifiques au diagnostic ; cependant, il n'y avait pas de différence significative dans les valeurs seuil optimales pour exclure une embolie pulmonaire et une thrombose veineuse profonde entre les sexes.

Anaesthesia, Critical Care & Pain Medicine

Non-invasive oxygenation strategies for respiratory failure with COVID-19: A concise narrative review of literature in pre and mid-COVID-19 era.
Ogawa K, Asano K, Ikeda J, Fujii T. | Anaesth Crit Care Pain Med. 2021 Aug;40(4):100897
DOI: https://doi.org/10.1016/j.accpm.2021.100897
Keywords: Acute respiratory failure; Awake proning; COVID-19; High-flow oxygen; Non-invasive ventilation; SARS-CoV-2.

Review

Editorial : The coronavirus disease 2019 (COVID-19) has spread globally and can cause a shortage of medical resources, in particular, mechanical ventilators. High-flow nasal cannula oxygen therapy (HFNC) and non-invasive positive pressure ventilation (NPPV) are frequently used for acute respiratory failure patients as alternatives to invasive mechanical ventilation. They are drawing attention because of a potential role to save mechanical ventilators. However, their effectiveness and risk of viral spread are unclear. The latest network meta-analysis of pre-COVID-19 trials reported that treatment with non-invasive oxygenation strategies was associated with improved survival when compared with conventional oxygen therapy. During the COVID-19 pandemic, a lot of clinical research on COVID-19 related acute respiratory failure has been reported. Several observational studies and small trials have suggested HFNC or NPPV as an alternative of standard oxygen therapy to manage COVID-19 related acute respiratory failure, provided that appropriate infection prevention is applied by health care workers to avoid risks of the virus transmission. Awake proning is an emerging strategy to optimise the management of patients with COVID-19 acute respiratory failure. However, the benefits of awake proning have yet to be assessed in properly designed clinical research. Although HFNC and NPPV are probably effective for acute respiratory failure, the safety data are mostly based on observational and experimental reports. As such, they should be implemented carefully if adequate personal protective equipment and negative pressure rooms are available.

Conclusion : HFNC and NPPV for moderate ARF were suggested to be beneficial to avoid intubation and improve mortality from the meta-analysis of pre- COVID RCTs. A number of observational studies reported possible benefits of HFNC or NPPV for COVID-19 ARF. In particular, HFNC or NPPV may be considered for patients with a DNI order. Despite that conducting proper RCTs amid pandemic is challenging, many trials are reported to be completed. Findings from the trials should be reported with transparency to provide minimally biased information. Also, strong interest should focus on the safety of HFNC and NPPV for HCWs when the positive pressure ventilation devices are applied to COVID-19 patients. From the currently available epidemiological data, the risks of virus spread and transmission to HCWs appear low when HCWs wear appropriate PPE with N95/ FFP2 mask in a negative pressure room. The safety of HCWs is of top priority, as such any RCTs or observational studies on the clinical impact of HFNC and NPPV should assess the possible risk of COVID-19 transmission to HCWs to provide precise and reliable data. Finally, awake proning should not be implemented into clinical practice until further research provides high-quality data of benefits and safety for patients with ARF.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit et la ventilation non invasive dans l'insuffisance respiratoire aiguë modérée ont été suggérées comme bénéfiques pour éviter l'intubation et améliorer la mortalité à partir de la méta-analyse des essais contrôlés randomisés pré-COVID. Un certain nombre d'études observationnelles ont signalé les avantages possibles de l'oxygénothérapie nasale à haut débit ou de la ventilation non invasive pour l'insuffisance respiratoire aiguë COVID-19. En particulier, l'oxygénothérapie nasale à haut débit ou la ventilation non invasive peuvent être envisagées pour les patients considéré comme à « Ne pas intuber ». Bien qu'il soit difficile de mener des essais contrôlés randomisés appropriés en période de pandémie, de nombreux essais seraient terminés. Les résultats des essais doivent être rapportés avec transparence afin de fournir des informations peu biaisées. En outre, un vif intérêt devrait se concentrer sur la sécurité de l'oxygénothérapie nasale à haut débit et de la ventilation non invasive pour les travailleurs de la santé lorsque les dispositifs de ventilation à pression positive sont appliqués aux patients COVID-19. D'après les données épidémiologiques actuellement disponibles, les risques de propagation et de transmission du virus aux agents de santé semblent faibles lorsque les agents de santé portent un équipement de protection individuelle approprié avec un masque N95/FFP2 dans une salle à pression négative. La sécurité des travailleurs de la santé est une priorité absolue, en tant que tel, tout travailleur de la santé ou toute étude d'observation sur l'impact clinique de l'oxygénothérapie nasale à haut débit et de la ventilation non invasive devrait évaluer le risque possible de transmission de la COVID-19 aux travailleurs de la santé pour fournir des données précises et fiables. Enfin, le décubitus ventral chez le patient non sédaté ne devrait pas être mise en œuvre dans la pratique clinique jusqu'à ce que d'autres recherches fournissent des données de haute qualité sur les avantages et la sécurité pour les patients souffrant d'insuffisance respiratoire aiguë.

Prevention of venous thromboembolism and haemostasis monitoring in patients with COVID-19: Updated proposals (April 2021): From the French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT), in collaboration with the French society of anaesthesia and intensive care (SFAR).
Godon A, Tacquard CA, Mansour A, Garrigue D, Nguyen P, Lasne D, Testa S, Levy JH, Albaladejo P, Gruel Y, Susen S, Godier A; Gihp, the GFHT. | Anaesth Crit Care Pain Med. 2021 Aug;40(4):100919
DOI: https://doi.org/10.1016/j.accpm.2021.100919  | Télécharger l'article au format  
Keywords: COVID-19AnticoagulationThromboprophylaxisVenous thromboembolismThrombotic riskBleeding risk

Guideline

Editorial : Among outpatients, the French Society of Vascular Medicine suggests a standard dose thromboprophylaxis (with low-molecular-weight heparin or fondaparinux) if risk factors are present, during 7–14 days. Risk factors include, in addition to a significant reduction in mobility: BMI > 30 kg/m2, age >70 years, active cancer, personal history of VTE, and major surgery within the last three months.
Among severe patients, we suggest a total duration of increased-dose prophylactic anticoagulation (either intermediate or therapeutic) of 7–10 days, according to the described course of the disease.
In patients with a very high thrombotic risk, on therapeutic dose prophylactic anticoagulation, we suggest systematic screening for thrombosis before de-escalation at days 7–10. These patients are suspected of having thrombosis until proven otherwise. Systematic screening may include CT pulmonary angiography, compression ultrasonography, or other diagnostic imaging available. In the absence of diagnosed thrombosis, a standard-dose, weight-adapted thromboprophylaxis would limit thrombotic complications until discharge. If a thrombotic complication is diagnosed, appropriate antithrombotic treatment can be initiated according to its localisation and severity. In this subgroup of patients, appropriate diagnostic testing could occur before day 7 if clinical suspicion of thrombosis is present.
In all other cases of hospitalised patients, standard dose thromboprophylaxis is indicated until discharge.
After hospital discharge, a prolonged thromboprophylaxis should be decided on a case-by-case basis. The risk of post-discharge venous thromboembolism appears to be similar to other acute medical illnesses. Age over 75 and prior history of venous thromboembolism are strongly associated with post-discharge thrombotic complications.

Commentaire :  Anticoagulation prophylactique pour les patients COVID-19.

Association between time to advanced airway management and neurologically favourable survival during out-of-hospital cardiac arrest.
Fukuda T, Ohashi-Fukuda N, Inokuchi R, Kondo Y, Sekiguchi H, Taira T, Kukita I. | Anaesth Crit Care Pain Med. 2021 Aug;40(4):100906
DOI: https://doi.org/10.1016/j.accpm.2021.100906
Keywords: Advanced airway management; Cardiopulmonary resuscitation; Endotracheal intubation; Out-of-hospital cardiac arrest; Supraglottic airway device.

Original article

Introduction : Advanced airway management (AAM) is commonly performed as part of advanced life support. However, there is controversy about the association between the timing of AAM and outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to determine whether time to AAM is associated with outcomes after OHCA.

Méthode : This was a nationwide population-based observational study using the Japanese government-led registry of OHCA. Adults who experienced OHCA and received AAM by EMS personnel in the prehospital setting from 2014 to 2017 were included. Multivariable logistic regression models were used to assess the associations between time to AAM (defined as time in minutes from emergency call to the first successful AAM) and outcomes after OHCA. Then, associations between early (≤ 20 min) vs. delayed (> 20 min) AAM and outcomes after OHCA were examined using propensity score-matched analyses. The primary outcome was one-month neurologically favourable survival.

Résultats : A total of 164,223 patients (median [IQR] age, 80 [69-86] years; 57.7% male) were included. The median time to AAM was 17 min (IQR, 14-22). Longer time to AAM was significantly associated with a decreased chance of one-month neurologically favourable survival (multivariable adjusted OR per minute delay, 0.90 [95% CI, 0.90-0.91]). In the propensity score-matched cohort, compared with early AAM, delayed AAM was associated with a decreased chance of one-month neurologically favourable survival (516 of 50,997 [1.0%] vs. 226 of 50,997 [0.4%]; RR, 0.44; 95% CI, 0.37-0.51; NNT, 176).

Conclusion : Delay in AAM was associated with a decreased chance of one-month neurologically favourable survival among patients with OHCA.

Conclusion (proposition de traduction) : Le retard dans la gestion avancée des voies aériennes était associé à une diminution des chances de survie neurologiquement favorable à un mois chez les patients ayant subi un arrêt cardiaque en dehors de l'hôpital.

Guidelines for the acute care of severe limb trauma patients.
Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. | Anaesth Crit Care Pain Med. 2021 Aug;40(4):100862
DOI: https://doi.org/10.1016/j.accpm.2021.100862
Keywords: Compartment syndrome; Damage control; Fat embolism syndrome; Guidelines; Rhabdomyolysis; Severe limb trauma patient; Tourniquet.

Guideline

Introduction : To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre.
Design: A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded.

Méthode : The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

Résultats : The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

Conclusion : There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.

Conclusion (proposition de traduction) : Il y avait un accord significatif parmi les experts sur des recommandations fortes pour améliorer les pratiques pour les patients souffrant de traumatismes sévères des membres.

Commentaire : Voir la publication en français de décembre 2020 : RFE commune SFAR-SFMU. J. Pottecher, H. Lefort, P. Adam, O et al. Prise en charge des patients présentant un traumatisme sévère de membre(s). Version pdf  

Anesthesia & Analgesia

The Bitter and the Sweet: Relationship of Lactate, Glucose, and Mortality After Severe Blunt Trauma.
Richards JE, Mazzeffi MA, Massey MS, Rock P, Galvagno SM, Scalea TM. | Anesth Analg. 2021 Aug 1;133(2):455-461
DOI: https://doi.org/10.1213/ane.0000000000005335
Keywords: Aucun

Original Clinical Research Report

Introduction : Hyperglycemia is associated with mortality after trauma; however, few studies have simultaneously investigated the association of depth of shock and acute hyperglycemia. We evaluated lactate, as a surrogate measure for depth of shock, and glucose levels on mortality following severe blunt trauma. We hypothesize that measurements of both lactate and glucose are associated with mortality when considered simultaneously.

Méthode : This is a retrospective cohort study at a single academic trauma center. Inclusion criteria are age 18-89 years, blunt trauma, injury severity score (ISS) ≥15, and transferred from the scene of injury. All serum blood glucose and lactate values were analyzed within the first 24 hours of admission. Multiple metrics of glucose and lactate were calculated: first glucose (Glucadm) and lactate (Lacadm) at hospital admission, mean 24-hour after hospital admission glucose (Gluc24-hMean) and lactate (Lac24-hMean), maximum 24-hour after hospital admission glucose (Gluc24-hMax) and lactate (Lac24-hMax), and time-weighted 24-hour after hospital admission glucose (Gluc24-hTW) and lactate (Lac24-hTW). Primary outcome was in-hospital mortality. Multivariable logistic regression modeling assessed the odds ratio (OR) of mortality, after adjusting for confounding variables.

Résultats : A total of 1439 trauma patients were included. When metrics of both glucose and lactate were analyzed, after adjusting for age, ISS, and admission shock index, only lactate remained significantly associated with mortality: Lacadm (OR, 1.28; 95% confidence interval [CI], 1.13-1.44); Lac24-hMean (OR, 1.86; 95% CI, 1.52-2.28); Lac24-hMax (OR, 1.39; 95% CI, 1.23-1.56); and Lac24-hTW (OR, 1.86; 95% CI, 1.53-2.26).

Conclusion : Lactate is associated with mortality in severely injured blunt trauma patients, after adjusting for injury severity, age, and shock index. However, we did not find evidence for an association of glucose with mortality after adjusting for lactate.

Conclusion (proposition de traduction) : Le lactate est associé à la mortalité chez les patients ayant subi un traumatisme sévère fermé, après ajustement en fonction de la gravité de la blessure, de l'âge et du shock index. Cependant, nous n'avons trouvé aucune preuve d'une association du glucose avec la mortalité après ajustement pour le lactate.

Effect of Paratracheal Pressure on the Glottic View During Direct Laryngoscopy: A Randomized Double-Blind, Noninferiority Trial.
Won D, Kim H, Chang JE, Lee JM, Min SW, Ma S, Kim C, Hwang JY, Kim TK. | Anesth Analg. 2021 Aug 1;133(2):491-499
DOI: https://doi.org/10.1213/ane.0000000000005620
Keywords: Aucun

Original Clinical Research Report

Introduction : Cricoid pressure has been used as a component of the rapid sequence induction and intubation technique. However, concerns have been raised regarding the effectiveness and safety of cricoid pressure. Paratracheal pressure, a potential alternative to cricoid pressure to prevent regurgitation of gastric contents or aspiration, has been studied to be more effective to cricoid pressure in preventing gastric insufflation during positive pressure ventilation. However, to adopt paratracheal compression into our practice, adverse effects including its effect on the glottic view during direct laryngoscopy should be studied. We conducted a randomized, double-blind, noninferiority trial comparing paratracheal and cricoid pressures for any adverse effects on the view during direct laryngoscopy, together with other secondary outcome measures.

Méthode : In total, 140 adult patients undergoing general anesthesia randomly received paratracheal pressure (paratracheal group) or cricoid pressure (cricoid group) during anesthesia induction. The primary end point was the incidence of deteriorated laryngoscopic view, evaluated by modified Cormack-Lehane grade with a predefined noninferiority margin of 15%. Secondary end points included percentage of glottic opening score, ease of mask ventilation, change in ventilation volume and peak inspiratory pressure during mechanical mask ventilation, ease of tracheal intubation, and resistance encountered while advancing the tube into the glottis. The position of the esophagus was assessed by ultrasound in both groups to determine whether pressure applied to the respective area would be likely to result in esophageal compression. All secondary outcomes were tested for superiority, except percentage of glottic opening score, which was tested for noninferiority.

Résultats : Paratracheal pressure was noninferior to cricoid pressure regarding the incidence of deterioration of modified Cormack-Lehane grade (0% vs 2.9%; absolute risk difference, -2.9%; 95% confidence interval, -9.9 to 2.6, P <.0001). Mask ventilation, measured on an ordinal scale, was found to be easier (ie, more likely to have a lower score) with paratracheal pressure than with cricoid pressure (OR, 0.41; 95% confidence interval, 0.21-0.79; P = .008). The increase in peak inspiratory pressure was significantly less in the paratracheal group than in the cricoid group during mechanical mask ventilation (median [min, max], 0 [-1, 1] vs 0 [-1, 23]; P = .001). The differences in other secondary outcomes were nonsignificant between the groups. The anatomical position of the esophagus was more suitable for compression in the paratracheal region, compared to the cricoid cartilage region.

Conclusion : Paratracheal pressure was noninferior to cricoid pressure with respect to the effect on glottic view during direct laryngoscopy.

Conclusion (proposition de traduction) : La pression paratrachéale n'était pas inférieure à la pression cricoïde en ce qui concerne l'effet sur la vision glottique pendant la laryngoscopie directe.

Commentaire :  Schéma montrant les pressions paratrachéales et cricoïdes. A, Pression paratrachéale. B, pression cricoïde.

Annals of Emergency Medicine

Impact of Atrial Fibrillation Case Volume in the Emergency Department on Early and Late Outcomes of Patients With New Atrial Fibrillation.
Hawkins NM, Youngson E, Sandhu RK, Scheuermeyer FX, Ezekowitz JA, Kaul P, McAlister FA. | Ann Emerg Med. 2021 Aug;78(2):242-252
DOI: https://doi.org/10.1016/j.annemergmed.2021.03.014
Keywords: Aucun

Cardiology

Introduction : To define the association between atrial fibrillation case volume in the emergency department and death or all-cause hospitalization at 30 days and 1 year in patients with new atrial fibrillation. Secondary objectives examined repeat ED visits and the management of atrial fibrillation within 90 days.

Méthode : We identified all adults presenting to an ED in Alberta, Canada, with a new primary diagnosis of atrial fibrillation/flutter between 2009 and 2015 using International Classification of Diseases, 10th Revision code I48. Volume was classified in tertiles weighted by annual ED number of atrial fibrillation cases. The association between volume and outcomes was evaluated using generalized linear mixed models, adjusting for prognostically important covariates as fixed effects and ED as a random effect to account for potential clustering within EDs.

Résultats : The tertiles consisted of 4 high, 9 medium, and 68 low atrial fibrillation volume EDs, with 4,217, 4,193, and 4,112 patients, respectively. Volume was not independently associated with the primary outcome or individual components. However, medium- and high-volume EDs had fewer repeat ED visits at 30 days (respective adjusted odds ratio [aOR] 0.75 [95% confidence interval {CI} 0.66 to 0.87] and 0.64 [0.52 to 0.79]) and 1 year (respective aOR 0.77 [95% CI 0.67 to 0.90] and 0.71 [0.56 to 0.90]). Fewer patients were admitted from medium- (37.1%) and high- (32.0%) compared with low-volume (39.5%) EDs. Patients attending medium- and high-volume EDs were more likely to be cardioverted (aOR 3.28 [95% CI 1.94 to 5.53] and 3.81 [1.39 to 10.48] for medium- and high-volume EDs, respectively).

Conclusion : Treatment in higher volume EDs was associated with significantly lower admission rates and repeat ED visits but no difference in survival.

Conclusion (proposition de traduction) : Le traitement dans les services d'urgence à volume plus élevé était associé à des taux d'admissions significativement plus faibles et à des visites répétées aux services d'urgence, mais aucune différence sur la survie.

What Is the Optimal Resuscitation Fluid for Patients With Sepsis, Trauma, or Traumatic Brain Injury?.
Yoo MJ, Bridwell RE, Long B. | Ann Emerg Med. 2021 Aug;78(2):303-305
DOI: https://doi.org/10.1016/j.annemergmed.2021.02.012  | Télécharger l'article au format  
Keywords: Aucun

General Medicine

Méthode : Network meta-analysis authors searched PubMed, EMBASE, and Cochrane Central for studies registered from the time of database inception to January 2020.
The authors’ search strategies combined patient conditions, outcomes, and fluid types.
Study selection
The authors included all randomized controlled trials that evaluated critically ill adult (age > 18 years) patients with systemic hypoperfusion requiring fluid resuscitation. The authors excluded studies that evaluated children with dengue fever or burn injuries and mixed populations without reported subgroup data.

Résultats : Two authors independently screened and extracted data from the selected studies, with a third author resolving disagreements. Study outcomes included all-cause mortality, target resuscitation volume reversing organ hypoperfusion, acute kidney injury (AKI) characterized by the risk, injury, failure, loss, and end-stage renal failure criteria, blood transfusion volume, and allergic reaction rate. The direct and indirect evidence between treatment groups were analyzed using an odds ratio with 95% confidence intervals and visualized with network mapping. The strength of the evidence was assessed using the confidence in network meta-analysis web application. The authors further evaluated the surface under the cumulative ranking (SUCRA) probabilities for each condition, which is a framework that compares the safety of each intervention to a hypothetical best treatment. Additionally, in order to adjust for the various statistical tests between network metaanalyses, the author performed sequential network meta-analysis testing. Risk of bias was determined using the revised Cochrane risk of bias tool.

Conclusion : The use of balanced crystalloids instead of isotonic saline or starch for sepsis and the use of isotonic saline instead of iso-oncotic albumin for traumatic brain injury may be associated with reduced mortality. However, balanced crystalloids and isotonic saline are associated with increased resuscitation volumes compared with iso-oncotic albumin in patients with sepsis. No mortality benefit The use of balanced crystalloids instead of isotonic saline or starch for sepsis and the use of isotonic saline instead of iso-oncotic albumin for traumatic brain injury may be associated with reduced mortality. However, balanced crystalloids and isotonic saline are associated with increased resuscitation volumes compared with iso-oncotic albumin in patients with sepsis. No mortality benefit has been demonstrated for any fluid in patients with non-traumatic brain injury trauma.

Conclusion (proposition de traduction) : L'utilisation d'un cristalloïde balancé au lieu d'une solution saline isotonique ou d'amidon dans le sepsis et l'utilisation d'une solution saline isotonique au lieu d'albumine iso-oncotique dans les lésions cérébrales traumatiques peuvent être associées à une réduction de la mortalité.
Cependant, les cristalloïdes balancés et la solution saline isotonique sont associés à des volumes de remplissage accrus par rapport à l'albumine iso-oncotique chez les patients présentant un sepsis. Aucun bénéfice sur la mortalité n'a été démontré pour aucun liquide de remplissage chez les patients présentant un traumatisme crânien non traumatique.

Commentaire : Les auteurs concluent que les cristalloïdes balancés sont favorables dans le traitement du sepsis et que les solutions salines isotoniques sont favorables dans le traitement des lésions cérébrales traumatiques.

Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis.
Powell EC, Roskind CG, Schnadower D and al; Pediatric Emergency Research Canada and Pediatric Emergency Care Applies Research Networks. | Ann Emerg Med. 2021 Aug 11:S0196-0644(21)00478-9
DOI: https://doi.org/10.1016/j.annemergmed.2021.06.003
Keywords: Aucun

ORIGINAL RESEARCH

Introduction : This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice.

Méthode : This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit.

Résultats : In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ.

Conclusion : Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.

Conclusion (proposition de traduction) : Chez les enfants d'âge préscolaire présentant une gastro-entérite et nécessitant des soins aux urgences, l'administration d'ondansétron par voie orale était associée à une réduction des besoins en remplissage vasculaire lors des visites d'urgence de référence ; il n'y a pas eu besoin de recourir à l'administration de liquides intraveineux dans les 72 heures, à une hospitalisation ou n'a pas été associé à des vomissements et à une diarrhée dans les 24 heures suivant la sortie.

Annals of Intensive Care

Comparison of four channelled videolaryngoscopes to Macintosh laryngoscope for simulated intubation of critically ill patients: the randomized MACMAN2 trial.
Decamps P, Grillot N, Le Thuaut A, Brule N, Lejus-Bourdeau C, Reignier J, Lascarrou JB. | Ann Intensive Care. 2021 Aug 16;11(1):126
DOI: https://doi.org/10.1186/s13613-021-00916-3  | Télécharger l'article au format  
Keywords: Endotracheal intubation; High-fidelity simulation; Intensive care; Macintosh laryngoscope; Videolaryngoscope.

Research

Introduction : Videolaryngoscopes with an operating channel may improve the intubation success rate in critically ill patients. We aimed to compare four channelled videolaryngoscopes to the Macintosh laryngoscope used for intubation of a high-fidelity simulation mannikin, in a scenario that simulated critical illness due to acute respiratory failure.

Résultats : Of the 79 residents who participated, 54 were considered inexperienced with orotracheal intubation. Each participant used all five devices in random order. The first-pass success rate was 97.5% [95% CI 91.1-99.7] for Airtraq™, KingVision™, and Pentax AWS200™, 92.4% [95% CI 84.2-97.2] for VividTrac VT-A100™, and 70.9% [95% CI 59.6-80.6] for direct Macintosh laryngoscopy. The first-pass success rate was significantly lower with direct Macintosh laryngoscopy than with the videolaryngoscopes (p < 0.0001 for Airtraq™, KingVision™, Pentax AWS200™, and VividTrac VT-A100™).

Conclusion : The Airtraq™, KingVision™, and Pentax AWS200™ channelled videolaryngoscopes produced high first-pass success rates with a lower boundary of the 95% CI above 90%. A multicentre, randomised controlled clinical study comparing channelled videolaryngoscopy to direct laryngoscopy should include one of these three videolaryngoscopes.

Conclusion (proposition de traduction) : Les vidéolaryngoscopes avec canal opérateur Airtraq™, KingVision™ et Pentax AWS200™ ont donné des taux de réussite élevés au premier essai avec une limite inférieure de l'intervalle de confiance à 95 % supérieure à 90  %. Une étude clinique contrôlée randomisée multicentrique comparant la vidéolaryngoscopie avec canal opérateur à la laryngoscopie directe doit inclure l'un de ces trois vidéolaryngoscopes.

Commentaire :  Vidéolaryngoscopes utilisés dans l'essai MACMAN2

P/FP ratio: incorporation of PEEP into the PaO 2/FiO 2 ratio for prognostication and classification of acute respiratory distress syndrome.
Palanidurai S, Phua J, Chan YH, Mukhopadhyay A. | Ann Intensive Care. 2021 Aug 9;11(1):124
DOI: https://doi.org/10.1186/s13613-021-00908-3  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; Mortality; PaO2/FiO2 ratio; Positive end-expiratory pressure.

RESEARCH

Introduction : The current Berlin definition of acute respiratory distress syndrome (ARDS) uses the PaO2/FiO2 (P/F) ratio to classify severity. However, for the same P/F ratio, a patient on a higher positive end-expiratory pressure (PEEP) may have more severe lung injury than one on a lower PEEP.
Objectives: We designed a new formula, the P/FP ratio, incorporating PEEP into the P/F ratio and multiplying with a correction factor of 10 [(PaO2*10)/(FiO2*PEEP)], to evaluate if it better predicts hospital mortality compared to the P/F ratio post-intubation and to assess the resultant changes in severity classification of ARDS.

Méthode : We categorized patients from a dataset of seven ARDS network trials using the thresholds of ≤ 100 (severe), 101-200 (moderate), and 201-300 (mild) for both P/F (mmHg) and P/FP (mmHg/cmH2O) ratios and evaluated hospital mortality using areas under the receiver operating characteristic curves (AUC).

Résultats : Out of 3,442 patients, 1,057 (30.7%) died. The AUC for mortality was higher for the P/FP ratio than the P/F ratio for PEEP levels > 5 cmH2O: 0.710 (95% CI 0.691-0.730) versus 0.659 (95% CI 0.637-0.681), P < 0.001. Improved AUC was seen with increasing PEEP levels; for PEEP ≥ 18 cmH2O: 0.963 (95% CI 0.947-0.978) versus 0.828 (95% CI 0.765-0.891), P < 0.001. When the P/FP ratio was used instead of the P/F ratio, 12.5% and 15% of patients with moderate and mild ARDS, respectively, were moved to more severe categories, while 13.9% and 33.6% of patients with severe and moderate ARDS, respectively, were moved to milder categories. The median PEEP and FiO2 were 14 cmH2O and 0.70 for patients reclassified to severe ARDS, and 5 cmH2O and 0.40 for patients reclassified to mild ARDS.

Conclusion : The multifactorial P/FP ratio has a greater predictive validity for hospital mortality in ARDS than the P/F ratio. Changes in severity classification with the P/FP ratio reflect both true illness severity and the applied PEEP strategy.

Conclusion (proposition de traduction) : Le rapport multifactoriel P/FP a une plus grande validité prédictive pour la mortalité hospitalière dans le SDRA que le rapport P/F. Les changements dans la classification de la gravité avec le rapport P/FP reflètent à la fois la gravité réelle de la maladie et la stratégie de PEEP appliquée.

Commentaire : Pour mémoire :
Le syndrome de détresse respiratoire aiguë (SDRA), initialement décrit par Ashbaugh en 1967, a été redéfini à l’occasion du congrès de la Société Européenne de Soins Intensifs à Berlin en 2012.
Elle repose sur 4 critères :
1) insuffisance respiratoire aiguë évoluant depuis une semaine ou moins ;
2) opacités bilatérales sur l’imagerie thoracique ;
3) pas d’argument pour un œdème hydrostatique prédominant ;
4) hypoxémie avec rapport PaO2/FIO2 < 300 mmHg pour une pression expiratoire positive réglée à 5 cm H2O ou plus avec 3 stades de gravité définis en fonction de l’hypoxémie :
• SDRA léger (300 < P/F < 200 mmHg) ;
• SDRA modéré (200 < P/F < 100 mmHg) ;
• ou SDRA sévère (P/F < 100 mmHg).
Voir le texte de recommandation de la SFAR 2018 : Prise en charge du Syndrome de Détresse Respiratoire Aigüe (SDRA) de l’adulte à la phase initiale  .

Concernant l'article ci-dessus, voir l'étude de faisabilité : Sunitha P. The P/fp Ratio (pao2/fio2 X Peep) X 10: A Pilot Approach To Calculate The Severity Of Oxygenation/ards With Peep.Am J Respir Crit Care Med 2017;195:A3756  .

BMC Emergency Medicine

Prehospital assessment and management of postpartum haemorrhage- healthcare personnel's experiences and perspectives.
Leonardsen AL, Helgesen AK, Ulvøy L, Grøndahl VA. | BMC Emerg Med. 2021 Aug 28;21(1):98
DOI: https://doi.org/10.1186/s12873-021-00490-8  | Télécharger l'article au format  
Keywords: Ambulance; Collective efficacy; Delphi technique; Manual aortic compression; Postpartum hemorrhage; Prehospital; Questionnaire; Self-efficacy.

Research article

Introduction : Postpartum hemorrhage (PPH) is a serious obstetric emergency, and one of the top five causes of maternal mortality globally. The most common causes of PPH include uterine atony, placental disorders, birth trauma and coagulation defects. Timely diagnosis and early management are critical to reduce morbidity, the need for blood transfusion or even mortality. External, manual aortic compression (AC) has been suggested as an intervention that reduce PPH and extend time for control of bleeding or resuscitation. This procedure is not commonly utilized by healthcare personnel. The incidence of home-births is increasing, and competence in PPH assessment and management is essential in prehospital personnel. The objective was to explore prehospital personnel's competence in PPH and AC, utilizing different tools.

Méthode : The study was conducted in a county in South-eastern Norway, including five ambulance stations. All prehospital personnel (n = 250) were invited to participate in a questionnaire study. The questionnaire included the PPH self-efficacy (PPHSE) and PPH collective efficacy (PPHCE) tools, as well as tool developed utilizing the Delphi technique. Descriptive statistics were used to analyze the quantitative data, while quantitative content analysis was used to analyse free-text responses.

Résultats : A total of 87 prehospital personnel responded to the questionnaire, 57.5% male, mean age 37.9 years. In total, 80.4% were ambulance workers and/or paramedics, and 96.6 and 97.7% respectively reported to need more education or training in PPH. Moreover, 82.8% reported having managed patient(s) with PPH, but only 2.9% had performed AC. Prehospital personnels' responses varied extensively regarding knowledge about what PPH is, how to estimate and handle PPH, and how to perform AC. Mean self-efficacy varied from 3.3 to 5.6, while collective efficacy varied from 1.9 to 3.8.

Conclusion : This study indicates that prehospital personnel lack knowledge about PPH and AC, due to various responses to the developed questionnaire. Even though AC is an acknowledged intervention in PPH, few participants reported that this was utilized. Our findings emphasize the need for education and training in PPH and PPH handling generally, and in AC specifically.

Conclusion (proposition de traduction) : Cette étude indique que le personnel préhospitalier manque de connaissances sur l'hémorragie du post-partum et la compression aortique, en raison des diverses réponses au questionnaire élaboré. Même si la compression aortique est une intervention reconnue dans l'hémorragie du post-partum, peu de participants ont signalé qu'elle était utilisée. Nos résultats soulignent le besoin d'éducation et de formation sur l'hémorragie du post-partum et la gestion de l'hémorragie du post-partum en général, et sur la compression aortique en particulier.

Commentaire : Compression de l'aorte abdominale :
Compression juste au-dessus de l'ombilic, jusqu'à ce que le pouls fémoral ne soit plus perçu, le temps par exemple d’insérer un ballon intra-utérin ou de débuter la laparotomie.

Impact of video quality when evaluating video-assisted cardiopulmonary resuscitation: a randomized, controlled simulation trial.
Plata C, Nellessen M, Roth R, Ecker H, Böttiger BW, Löser J, Wetsch WA. | BMC Emerg Med. 2021 Aug 21;21(1):96
DOI: https://doi.org/10.1186/s12873-021-00486-4  | Télécharger l'article au format  
Keywords: CPR; Cardiopulmonary resuscitation; OHCA; V-CPR; Video-assisted CPR.

Research article

Introduction : Although not routinely established during cardiopulmonary resuscitation (CPR), video-assisted CPR has been described as beneficial in the communication with emergency medical service (EMS) authorities in out-of-hospital cardiac arrest scenarios. Since the influence of video quality has not been investigated systematically and due to variation of quality of a live-stream video during video-assisted CPR, we investigated the influence of different video quality levels during the evaluation of CPR performance in video sequences.

Méthode : Seven video sequences of CPR performance were recorded in high quality and artificially reduced to medium and low quality afterwards. Video sequences showed either correct CPR performance or one of six typical errors: too low and too high compression rate, superficial and increased compression depth, wrong hand position and incomplete release. Video sequences were randomly assigned to the different quality levels. During the randomised and double-blinded evaluation process, 46 paramedics and 47 emergency physicians evaluated seven video sequences of CPR performance in different quality levels (high, medium and low resolution).

Résultats : Of 650 video sequences, CPR performance was evaluable in 98.2%. CPR performance was correctly evaluated in 71.5% at low quality, in 76.8% at medium quality, and in 77.3% at high quality level, showing no significant differences depending on video quality (p = 0.306). In the subgroup analysis, correct classification of increased compression depth showed significant differences depending on video quality (p = 0.006). Further, there were significant differences in correct CPR classification depending on the presented error (p < 0.001). Allegedly errors, that were not shown in the video sequence, were classified in 28.3%, insignificantly depending on video quality. Correct evaluation did not show significant interprofessional differences (p = 0.468).

Conclusion : Video quality has no significant impact on the evaluation of CPR in a video sequence. Even low video quality leads to an acceptable rate of correct evaluation of CPR performance. There is a significant difference in evaluation of CPR performance depending on the presented error in a video sequence.

Conclusion (proposition de traduction) : La qualité de la vidéo n'a pas d'impact significatif sur l'évaluation de la RCP dans une séquence vidéo. Même une qualité vidéo faible conduit à un taux acceptable d'évaluation correcte des performances de RCP. Il existe une différence significative dans l'évaluation des performances de RCP en fonction de l'erreur présentée dans une séquence vidéo.

Chest

The Usefulness of Chest CT Imaging in Patients With Suspected or Diagnosed COVID-19: A Review of Literature.
Machnicki S, Patel D, Singh A, Talwar A, Mina B, Oks M, Makkar P, Naidich D, Mehta A, Hill NS, Brown KK, Raoof S. | Chest. 2021 Aug;160(2):652-670
DOI: https://doi.org/10.1016/j.chest.2021.04.004  | Télécharger l'article au format  
Keywords: Chest CT scans; COVID-19; COVID-19 pneumonia; SARS-COV-2

CHEST Reviews

Editorial : The COVID-19 pandemic has had devastating medical and economic consequences globally.The severity of COVID-19 is related, in a large measure, to the extent of pulmonary involve-ment. The role of chest CT imaging in the management of patients with COVID-19 has evolvedsince the onset of the pandemic. Specifically, the description of CT scanfindings, use of chest CTimaging in various acute and subacute settings, and its usefulness in predicting chronic diseasehave been defined better. We performed a review of published data on CT scans in patients withCOVID-19. A summary of the range of imagingfindings, from typical to less common abnor-malities, is provided. Familiarity with thesefindings may facilitate the diagnosis and manage-ment of this disease. A comparison of sensitivity and specificity of chest CT imaging withreverse-transcriptase polymerase chain reaction testing highlights the potential role of CTimaging in difficult-to-diagnose cases of COVID-19. The usefulness of CT imaging to assessprognosis, to guide management, and to identify acute pulmonary complications associatedwith SARS-CoV-2 infection is highlighted. Beyond the acute stage, it is important for cliniciansto recognize pulmonary parenchymal abnormalities, progressivefibrotic lung disease, andvascular changes that may be responsible for persistent respiratory symptoms. A largecollection of multi-institutional images were included to elucidate the CT scanfindingsdescribed.

Conclusion : Since the onset of the pandemic, the role of chestimaging has evolved considerably. The purpose of thisreview, therefore, has been to examine all available,pertinent reports from 2020, assessing both current andpotential indications for CT imaging. In particular, thisincludes evaluating the sensitivity and specificity of CTimaging compared with other testing methods, as well asin the specific settings of acute vs subacute and chronicdisease.

Conclusion (proposition de traduction) : Depuis le début de la pandémie, le rôle du scanner thoracique a considérablement évolué. Le but de cet article a donc été d'examiner tous les rapports disponibles et pertinents à partir de 2020, évaluant les indications actuelles et potentielles du scanner. En particulier, cela comprend l'évaluation de la sensibilité et de la spécificité du scanner par rapport à d'autres méthodes de test, ainsi que dans les contextes spécifiques des maladies aiguës vs subaiguës et chroniques.

Cochrane Database of Systematic Reviews

Colchicine for acute gout.
McKenzie BJ, Wechalekar MD, Johnston RV, Schlesinger N, Buchbinder R. | Cochrane Database Syst Rev.  2021 Aug 26;8(8):CD006190
DOI: https://doi.org/10.1002/14651858.cd006190.pub3
Keywords: Aucun

Intervention

Introduction : This is an updated Cochrane Review, first published in 2006 and updated in 2014. Gout is one of the most common rheumatic diseases worldwide. Despite the use of colchicine as one of the first-line therapies for the treatment of acute gout, evidence for its benefits and harms is relatively limited.
Objectives : To update the available evidence of the benefits and harms of colchicine for the treatment of acute gout.

Méthode : We updated the search of CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICTRP registries to 28 August 2020. We did not impose any date or language restrictions in the search.
Selection criteria: We considered published randomised controlled trials (RCTs) and quasi-randomised controlled trials (quasi-RCTs) evaluating colchicine therapy compared with another therapy (placebo or active) in acute gout; low-dose colchicine at clinically relevant doses compared with placebo was the primary comparison. The major outcomes were pain, participant global assessment of treatment success (proportion with 50% or greater decrease in pain from baseline up to 32 to 36 hours), reduction of inflammation, function of target joint, serious adverse events, total adverse events and withdrawals due to adverse events.
Data collection and analysis: We used standard methodological procedures as expected by Cochrane in this review update.

Résultats : We included four trials (803 randomised participants), including two new trials, in this updated review. One three-arm trial compared high-dose colchicine (52 participants), low-dose colchicine (74 participants) and placebo (59 participants); one trial compared high-dose colchicine with placebo (43 participants); one trial compared low-dose colchicine with non-steroidal anti-inflammatory drugs (NSAIDs) (399 participants); and one trial compared low-dose colchicine with Chuanhu anti-gout mixture (traditional Chinese Medicine compound) (176 participants). We did not identify any trials comparing colchicine to glucocorticoids (by any route). The mean age of participants ranged from 51.2 to 70 years, and trial duration from 48 hours to 12 weeks. Two trials were at low risk of bias, one was possibly susceptible to selection bias (random sequence generation), reporting bias and other bias, and one open-label trial was at high risk of performance and detection bias. For the primary comparison, low-quality evidence from one trial (103 participants, downgraded for imprecision and bias) suggests low-dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events. The number of people who reported treatment success (50% or greater pain reduction) at 32 to 36 hours was slightly larger with low-dose colchicine (418 per 1000) compared with placebo (172 per 1000; risk ratio (RR) 2.43, 95% confidence interval (CI) 1.05 to 5.64; absolute improvement 25% more reported success (7% more to 42% more, the 95% CIs include both a clinically important and unimportant benefit); relative change of 143% more people reported treatment success (5% more to 464% more). The incidence of total adverse events was 364 per 1000 with low-dose colchicine compared with 276 per 1000 with placebo: RR 1.32, 95% CI 0.68 to 2.56; absolute difference 9% more events with low-dose colchicine (9% fewer to 43% more, the 95% CIs include both a clinically important effect and no effect); relative change of 32% more events (32% fewer to 156% more). No participants withdrew due to adverse events or reported any serious adverse events. Pain, inflammation and function were not reported. Low-quality evidence (downgraded for imprecision and bias) from two trials (124 participants) suggests that high-dose colchicine compared to placebo may improve symptoms, but with increased risk of harms…

Conclusion : We found low-quality evidence that low-dose colchicine may be an effective treatment for acute gout when compared to placebo and low-quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high- and low-dose colchicine improve pain when compared to placebo, low-quality evidence suggests that high-dose (but not low-dose) colchicine may increase the number of adverse events compared to placebo, while low-quality evidence indicates that the number of adverse events may be similar with low-dose colchicine and NSAIDs.
Further trials comparing colchicine to placebo or other treatment will likely have an important impact on our confidence in the effect estimates and may change the conclusions of this review. There are no trials reporting the effect of colchicine in populations with comorbidities or in comparison with other commonly used treatments, such as glucocorticoids.

Conclusion (proposition de traduction) : Nous avons trouvé des données probantes de faible qualité indiquant que la colchicine à faible dose pourrait être un traitement efficace de la goutte aiguë par rapport au placebo et des données probantes de faible qualité indiquant que ses bénéfices pourraient être similaires à ceux des AINS. Nous avons déclassé les données probantes pour cause de biais et d'imprécision. Bien que la colchicine à forte et à faible dose améliore la douleur par rapport au placebo, des données probantes de faible qualité suggèrent que la colchicine à forte dose (mais pas à faible dose) pourrait augmenter le nombre d'effets indésirables par rapport au placebo, tandis que des données probantes de faible qualité indiquent que le nombre d'effets indésirables pourrait être similaire avec la colchicine à faible dose et les AINS.
D'autres essais comparant la colchicine à un placebo ou à un autre traitement auront probablement un impact important sur notre confiance dans les estimations de l'effet et pourraient modifier les conclusions de cette revue. Il n'existe pas d'essais rapportant l'effet de la colchicine dans des populations présentant des comorbidités ou en comparaison avec d'autres traitements couramment utilisés, tels que les glucocorticoïdes.

Commentaire : Voir la traduction en français sur :
Colchicine dans le traitement des poussées aiguës de goutte  .

Preoperative hair removal to reduce surgical site infection.
Tanner J, Melen K. | Cochrane Database Syst Rev. 2021 Aug 26;8(8):CD004122
DOI: https://doi.org/10.1002/14651858.cd004122.pub5
Keywords: Aucun

Intervention

Introduction : Hair has traditionally been removed from the surgical site before surgery; however, some studies claim that this increases surgical site infections (SSIs) and should be avoided. This is the second update of a review published in 2006 and first updated in 2011.
Objectives : To determine whether routine preoperative hair removal (compared with no removal) and the method, timing, or setting of hair removal effect SSI rates.

Méthode : In November 2019, for this second update we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and scanned the reference lists of included studies plus reviews to identify additional studies. We applied no date or language restrictions.
Selection criteria: We included randomised controlled trials or quasi-randomised trials that compared: · hair removal with no hair removal; · different methods of hair removal; and · hair removal at different times before surgery.
Data collection and analysis: Two review authors independently assessed the relevance of each study. Data were extracted independently by both review authors and cross-checked. We carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool and assessed the certainty of evidence according to GRADE. Sensitivity analyses excluding studies at high risk of bias were conducted.

Résultats : We included 11 new studies in this update resulting in a total of 19 randomised and 6 quasi-randomised trials (8919 participants). Clipping compared with no hair removal Low certainty evidence suggests there may be little difference in risk of SSI when no hair removal is compared with hair removal using clippers (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.65 to 1.39; three studies with 1733 participants). Shaving with a razor compared with no hair removal Moderate certainty evidence suggests the risk of SSI is probably increased in participants who have hair removal with a razor compared with no removal (RR 1.82, 95% CI 1.05 to 3.14; seven studies with 1706 participants). In terms of absolute risk this represents 17 more SSIs per 1000 in the razor group compared with the no hair removal group (95% CI 1 more to 45 more SSI in the razor group). Based on low-certainty evidence, it is unclear whether there is a difference in stitch abscesses between hair removal with a razor and no hair removal (1 trial with 80 participants; RR 1.00, 95% CI 0.21 to 4.66). Based on narrative data from one trial with 136 participants, there may be little difference in length of hospital stay between participants having hair removed with a razor compared with those having no hair removal (low-certainty evidence). Based on narrative data from one trial with 278 participants, it is uncertain whether there is a difference in cost between participants having hair removed by shaving with a razor compared with no hair removal (very low certainty evidence). Depilatory cream compared with no hair removal Low certainty evidence suggests there may be little difference in SSI risk between depilatory cream or no hair removal, although there are were wide confidence intervals around the point estimate that included benefit and harm (RR 1.02, 95% CI 0.45 to 2.31; low-certainty evidence; 1 trial with 267 participants). Based on narrative data from one trial with 267 participants, it is uncertain whether there is a difference in cost between participants having hair removed with depilatory cream compared with no hair removal (very low certainty evidence). Shaving with a razor compared with clipping Moderate-certainty evidence from 7 studies with 3723 participants suggests the risk of SSI is probably increased by shaving with a razor compared with clipping (RR 1.64, 95% CI 1.16 to 2.33)…

Conclusion : Compared with no hair removal, there may be little difference in risk of SSI when clippers or depilatory cream are used (low-certainty evidence). However, there are probably fewer SSIs when hair is not removed compared with shaving with a razor (moderate-certainty evidence). If hair has to be removed, moderate-certainty evidence suggests using clippers or depilatory cream probably results in fewer SSIs and other complications compared with shaving using a razor. There may be a small reduction in SSIs when hair is removed on the day of, rather than the day before, surgery.

Conclusion (proposition de traduction) : Par rapport à l'absence d'épilation, il peut y avoir peu de différence dans le risque d'infection du site opératoire lorsque des tondeuses ou une crème dépilatoire sont utilisées (preuves de faible certitude). Cependant, il y a probablement moins d'infections du site opératoire lorsque les poils ne sont pas épilés par rapport au rasage avec un rasoir (preuves de certitude modérée). Si les poils doivent être épilés, des preuves de certitude modérée suggèrent que l'utilisation d'une tondeuse ou d'une crème dépilatoire entraîne probablement moins d'infections du site opératoire et d'autres complications par rapport au rasage à l'aide d'un rasoir. Il peut y avoir une petite réduction des infections du site opératoire lorsque les poils sont épilés le jour de la chirurgie plutôt que la veille.

Critical Care

The impact of prehospital tranexamic acid on mortality and transfusion requirements: match-pair analysis from the nationwide German TraumaRegister DGU®.
Imach S, Wafaisade A, Lefering R, Böhmer A, Schieren M, Suárez V, Fröhlich M; TraumaRegister DGU. | Crit Care. 2021 Aug 4;25(1):277
DOI: https://doi.org/10.1186/s13054-021-03701-7  | Télécharger l'article au format  
Keywords: Bleeding; Coagulopathy; Hemostatic disorders; Mass transfusion; TXA; Tranexamic acid; Trauma; Trauma care.

Research

Introduction : Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany.

Méthode : The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included.

Résultats : The matching yielded two comparable cohorts (n = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group (p = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused (p = 0.022), but needed significantly less packed red blood cells (p ≤ 0.001) and fresh frozen plasma (p = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p = 0.015). Mortality was similar except for early mortality after 6 h (p = 0.004) and 12 h (p = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p = 0.080).

Conclusion : This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.

Conclusion (proposition de traduction) : Il s'agit de la plus grande étude civile dans laquelle l'effet de l'utilisation préhospitalière d'acide tranexamique dans un trauma system mature a été examiné. L'utilisation d'acide tranexamique chez les patients de réanimation était associée à un risque significativement plus faible de transfusion massive et à une mortalité plus faible au début de la période de traitement à l'hôpital. En raison de l'administration répétée, un effet dose-dépendant de l'acide tranexamique doit être discuté.

Commentaire : Olldashi F, Kerçi M, Zhurda T et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomised controlled trial. Lancet [Internet]. 2011;377(9771):1096–101, 1101.e1-1101.e2  .
Collaborators TC-3 trial. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet (London, England) [Internet]. 2019/10/14. 2019 Nov 9;394(10210):1713–23  .

Current Opinion in Critical Care

Managing the first 120 min of cardiogenic shock: from resuscitation to diagnosis.
Jentzer JC, Tabi M, Burstein B. | Curr Opin Crit Care. 2021 Aug 1;27(4):416-425
DOI: https://doi.org/10.1097/mcc.0000000000000839
Keywords: Aucun

CARDIOGENIC SHOCK

Introduction : Cardiogenic shock continues to carry a high mortality, and recent randomized trials have not identified novel therapies that improve survival. Early optimization of patients with confirmed or suspected cardiogenic shock is crucial, as patients can quickly transition from a hemodynamic shock state to a treatment-resistant hemometabolic shock state, where accumulated metabolic derangements trigger a self-perpetuating cycle of worsening shock.

Résultats : We describe a structured ABCDE approach involving stabilization of the airway, breathing and circulation, followed by damage control and etiologic assessment. Respiratory failure is common and many cardiogenic shock patients require invasive mechanical ventilation. Norepinephrine is titrated to restore mean arterial pressure and dobutamine is titrated to restore cardiac output and organ perfusion. Echocardiography is essential to identify potential causes and characterize the phenotype of cardiogenic shock. Coronary angiography is usually indicated, particularly when acute myocardial ischemia is suspected, followed by culprit-vessel revascularization if indicated. An invasive hemodynamic assessment can clarify whether temporary mechanical circulatory support is necessary.

Conclusion : Early stabilization of hemodynamics and end-organ function is necessary to achieve best outcomes in cardiogenic shock. Using a structured approach tailored to initial cardiogenic shock resuscitation may help to demonstrate benefit from novel therapies in the future.

Conclusion (proposition de traduction) : Une stabilisation précoce de l'hémodynamique et de la fonction des organes cibles est nécessaire pour obtenir les meilleurs résultats en cas de choc cardiogénique. L'utilisation d'une approche structurée adaptée à la réanimation initiale du choc cardiogénique peut aider à démontrer les avantages des nouvelles thérapeutiques à l'avenir.

Commentaire :  Approche initiale suggérée pour la stabilisation hémodynamique chez les patients présentant un choc cardiogénique. L'objectif principal est de restaurer une pression artérielle moyenne adéquate pour permettre l'autorégulation du débit sanguin dans les organes, suivie par la restauration d'un débit cardiaque et d'une perfusion normaux (à l'aide de marqueurs de substitution tels que la PAS ou la saturation en oxygène veineux central/mixte si le débit cardiaque ne peut pas être mesuré directement). Les vasopresseurs (c'est-à-dire la noradrénaline) doivent être titrés pour atteindre la pression artérielle moyenne cible, tandis que les inotropes bêta-adrénergiques doivent être titrés séparément pour obtenir un débit cardiaque adéquat. L'évaluation de la réactivité liquidienne est souvent difficile, et un défi hydrique empirique à faible volume peut être envisagé s'il n'y a aucune preuve de surcharge volumique.

The medical treatment of cardiogenic shock: cardiovascular drugs.
De Backer D, Arias Ortiz J, Levy B. | Curr Opin Crit Care. 2021 Aug 1;27(4):426-432
DOI: https://doi.org/10.1097/mcc.0000000000000822
Keywords: Aucun

CARDIOGENIC SHOCK

Introduction : To discuss the use of vasopressors and inotropes in cardiogenic shock.

Résultats : The classic form or cardiogenic shock requires administration of inotropic and/or vasopressor agents to try to improve the impaired tissue perfusion. Among vasopressors various alpha-adrenergic agents, vasopressin derivatives and angiotensin can be used. The first-line therapy remains norepinephrine as it is associated with minimal adverse effects and appears to be associated by the best outcome in network meta-analyses. On the contrary, epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death. Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension. Concerning inotropic agents, dobutamine is the first-line agent but levosimendan is an excellent alternative or additional agent in cases not responding to dobutamine. The impact on outcome of inotropic agents remains controversial.

Conclusion : Recent studies have refined the position of the various vasopressor and inotropic agents. Norepinephrine is recommended as first-line vasopressor agent by various guidelines. Among inotropic agents, selection between the agents should be individualized and based on the hemodynamic response.

Conclusion (proposition de traduction) : Des études récentes ont affiné la position des différents agents vasopresseurs et inotropes. La norépinéphrine est recommandée comme agent vasopresseur de première intention par diverses recommandations. Parmi les agents inotropes, la sélection entre les agents doit être individualisée et basée sur la réponse hémodynamique.

Commentaire : POINTS CLÉS
• La noradrénaline est l'agent vasopresseur de première intention car elle augmente la pression artérielle et est associée à des effets indésirables minimes.
• L'adrénalmine est associée à une tachycardie excessive et peut favoriser les arythmies et le choc réfractaire.
• La vasopressine peut être une alternative à la norépinéphrine (ndlr : également appelée noradrénaline) chez les patients souffrant de tachycardie ou d'hypertension pulmonaire.
• Parmi les agents inotropes, la dobutamine reste l'agent de première intention. Les inhibiteurs de la phosphodiestérase et le lévosimendan peuvent être d'excellentes alternatives dans certains cas.

Mechanical ventilation in cardiogenic shock.
Tavazzi G | Curr Opin Crit Care. 2021 Aug 1;27(4):447-453
DOI: https://doi.org/10.1097/mcc.0000000000000836
Keywords: Aucun

CARDIOGENIC SHOCK

Introduction : Mechanical ventilation is frequently needed in patients with cardiogenic shock. The aim of this review is to summarize and discuss the current evidence and the pathophysiological mechanism that a clinician should consider while setting the ventilator.

Résultats : Little attention has been placed specifically to ventilatory strategies in patients with cardiogenic shock undertaking mechanical ventilation. Lung failure in patients with cardiogenic shock is associated with worsening outcome as well as a delay in mechanical ventilation institution. The hemodynamic profile and cardiogenic shock cause, considering the preload dependency of the failing heart, must be defined to adjust ventilatory setting.

Conclusion : Evidence is growing regarding the role of lung failure as adverse prognostic factor and beneficial effect of positive pressure ventilation as part of first-line treatment in patients with cardiogenic failure.

Conclusion (proposition de traduction) : Les preuves se multiplient concernant le rôle de l'insuffisance pulmonaire en tant que facteur pronostique défavorable et effet bénéfique de la ventilation à pression positive dans le cadre du traitement de première intention chez les patients atteints d'insuffisance cardiogénique.

Commentaire : POINTS CLÉS
• L'insuffisance respiratoire nécessitant une ventilation mécanique chez les patients présentant un choc cardiogénique est fréquente.
• La ventilation à pression positive peut inverser l'hypoxémie et réduire la pression transmurale, favorisant la perfusion du myocarde et des organes cibles et réduisant la postcharge ventriculaire gauche.
• Le réglage de la ventilation mécanique doit être adapté à l'étiologie du choc cardiogénique avec une prudence particulière en cas d'insuffisance ventriculaire droite et/ou de forte dépendance à la précharge.
• Il existe une lacune dans les données probantes concernant la meilleure stratégie de ventilation chez les patients présentant un choc cardiogénique.

Évaluations suggérées chez les patients nécessitant une ventilation mécanique.
MV, ventilation mécanique ; NIV, ventilation non invasive (VNI).

Hemodynamic monitoring in cardiogenic shock.
VanDyck TJ, Pinsky MR. | Curr Opin Crit Care. 2021 Aug 1;27(4):454-459
DOI: https://doi.org/10.1097/mcc.0000000000000838
Keywords: Aucun

CARDIOGENIC SHOCK

Introduction : Cardiogenic shock remains a major cause of mortality today. With recent advancements in invasive mechanical support strategies, reperfusion practice, and a new classification scheme is proposed for cardiogenic shock, an updated review of the latest hemodynamic monitoring techniques is important.

Résultats : Multiple recent studies have emerged supporting the use of pulmonary artery catheters in the cardiogenic shock population. Data likewise continues to emerge on the use of echocardiography and biomarker measurement in the care of these patients.

Conclusion : The integration of multiple forms of hemodynamic monitoring, spanning noninvasive and invasive modalities, is important in the diagnosis, staging, initial treatment, and subsequent management of the cardiogenic shock patient.

Conclusion (proposition de traduction) : L'intégration de plusieurs formes de surveillance hémodynamique, couvrant les modalités non invasives et invasives, est importante dans le diagnostic, la stadification, le traitement initial et la prise en charge ultérieure du patient en choc cardiogénique.

Commentaire : POINTS CLÉS
• La surveillance hémodynamique répétée est primordiale pour le diagnostic, le traitement initial et la gestion ultérieure du choc cardiogénique.
• Tous les patients présentant un choc cardiogénique doivent bénéficier d'un cathéter artériel placé pour la surveillance de la pression artérielle et la titration des perfusions vasoactives.
• Une surveillance invasive avec un cathéter artériel pulmonaire doit être envisagée, en particulier chez les patients dont le diagnostic est incertain ou chez les patients qui ne répondent pas au traitement initial.
• L'échocardiographie doit être utilisée tôt dans le diagnostic du choc cardiogénique et des évaluations répétée peuvent faciliter la prise en charge.

Emergency Radiology

The role of imaging in the management of non-traumatic subarachnoid hemorrhage: a practical review.
Khatri GD, Sarikaya B, Cross NM, Medverd JR. | Emerg Radiol. 2021 Aug;28(4):797-808
DOI: https://doi.org/10.1007/s10140-021-01900-x
Keywords: Aneurysmal subarachnoid hemorrhage; Angiography; CT scans spiral; Digital subtraction; Lumbar puncture; MRI scan.

Review Article

Editorial : The purpose of this review is to understand the role of imaging in the diagnosis and management of non-traumatic subarachnoid hemorrhage (SAH). SAH is a life-threatening emergency and a relatively common entity, the most common etiology being ruptured aneurysms. Multiple conundrums exist in literature at various steps of its imaging workup: diagnosis, management, and follow-up. We target our review to highlight the most effective practice and suggest efficient workup plans based on literature search, and describe in detail the clinical diagnostic and prognostic scales, role of CT scan, lumbar puncture, and MR, including angiography in the diagnosis and workup of SAH and its complications, and try to simplify the conundrums. Practical knowledge of imaging workup of SAH can help guide correct management of these patients, so as to reduce morbidity and mortality without resource overutilization.

Conclusion : Non-traumatic SAH can result from a wide array of clinical entities and represents a medical emergency due to its high immediate and near-term mortality and morbidity. NCCT head scan performed within 6 h of symptom initiation is the undisputed appropriate initial test for diagnosis. Lumbar puncture is highly sensitive and represents the traditional approach for detection of SAH in cases of suspected false negative NCCT head and subacute SAH, but it is invasive and evidence to substitute MRI in diagnostic algorithms is compelling. Modern catheter angiography, employing digital subtraction and 3D rotational angiography techniques, is still the gold standard for differentiation and treatment planning. Particularly as health systems increasingly attempt to direct SAH patients to centers of excellence, angiography can be performed safely within algorithms leading to confident diagnosis, treatment planning, and disposition.

Conclusion (proposition de traduction) : L’hémorragie sous-arachnoïde non traumatique peut être causée par un large éventail d’entités cliniques et constitue une urgence médicale en raison de sa forte mortalité et morbidité immédiates et à court terme. La tomodensitométrie sans injection réalisée dans les 6 heures suivant l’apparition des symptômes est l'examen initial approprié incontesté pour le diagnostic. La ponction lombaire est très sensible et représente l'approche traditionnelle pour la détection d'une hémorragie sous-arachnoïdienne en cas de suspicion de faux négatif de la tomodensitométrie cérébrale sans injection et d'hémorragie sous-arachnoïdienne subaiguë, mais elle est invasive et les preuves pour substituer l'IRM dans les algorithmes de diagnostic sont probantes. L'angiographie moderne par cathéter, utilisant des techniques de soustraction numérique et d'angiographie rotationnelle 3D, est toujours la référence en matière de différenciation et de planification du traitement. D'autant plus que les systèmes de santé tentent de plus en plus d'orienter les patients atteints d'hémorragie sous-arachnoïdienne vers des centres d'excellence, l'angiographie peut être réalisée en toute sécurité dans le cadre d'algorithmes permettant un diagnostic de certitude, une planification du traitement et l'élimination du diagnostic.

Imaging of drug mules.
Malhotra R, Singh A. | Emerg Radiol. 2021 Aug;28(4):809-814
DOI: https://doi.org/10.1007/s10140-021-01924-3
Keywords: Body packer; Drug mule; Drug pusher.

Review Article

Editorial : Cocaine, heroin, methamphetamine, and hashish are the primary drugs transported by a body packer, who swallows such packages. A body pusher or stuffer transports drug packages in rectum or vagina. Plain radiography is the primary imaging modality used in the evaluation of concealed drugs and has sensitivity of 85-90%. The imaging features include well-defined opacities in the bowel with crescents of air near ovoid opacities. The imaging signs include double condom sign, halo sign, parallelism sign, and tic tac sign. A low-dose CT is an efficient noninvasive and accurate technique of locating packages internally for all types of concealment.

Conclusion : Drug smuggling is an increasingly prevalent patient problem and radiological awareness of the features of body packing is critical for physicians to provide accurate treatment and prevent complications. For identification of body packers, abdominal radiography remains the most widespread initial imaging technique; however, false-negative and false-positive diagnoses are possible due to improved smuggling methods. Although a single abdominal radiograph is insufficiently sensitive to rule out abdominal drug carriage, its specificity is high. While plain abdominal film is most commonly used, a multimodal approach involving CT is typically used for accurate identification and treatment.

Conclusion (proposition de traduction) : La contrebande de drogue est un problème de plus en plus répandu chez les patients et la connaissance radiologique des caractéristiques de l’empaquetage des drogues transportées est essentielle pour que les médecins puissent fournir un traitement précis et prévenir les complications. Pour l'identification des drogues transportées, la radiographie abdominale reste la technique d'imagerie initiale la plus répandue ; cependant, des faux négatifs et faux positifs sont possibles à cause de l'amélioration des méthodes de contrebande. Bien qu'une seule radiographie abdominale soit insuffisamment sensible pour exclure le portage abdominal de drogue, sa spécificité est élevée. Alors que le cliché abdominal simple est le plus couramment utilisé, une approche multimodale incluant un scanner est généralement utilisée pour une identification précise et le traitement.

European Journal of Emergency Medicine

Association between mean arterial pressure and survival in patients after cardiac arrest with vasopressor support: a retrospective study.
Li Z, Zhou D, Zhang S, Wu L, Shi G. | Eur J Emerg Med. 2021 Aug 1;28(4):277-284
DOI: https://doi.org/10.1097/mej.0000000000000787
Keywords: Aucun

Original Article

Introduction : Mortality among patients admitted to the ICU after cardiac arrest is high. Hemodynamic management in the phase of postresuscitation care is recommended by international guidelines, but the optimal mean arterial pressure (MAP) range in postcardiac arrest patients with vasopressor support is still unclear.
Objective: The purpose of the article is to investigate the association between the time spent in different MAP categories and ICU mortality in postcardiac arrest patients admitted to the ICU surviving ≥24 h with vasopressor support.

Méthode : This retrospective observational study analysis on the basis of the multicenter ICU database (eICU database, eicu-crd.mit.edu) with high granularity data for 200 859 admissions admitted between 2014 and 2015 to one of 335 units at 208 hospitals located across the USA. Postcardiac arrest patients surviving ≥24 h with vasopressor support during the first 24 h were included.
Exposure: The main exposure was time spent in different MAP categories during the first 24 h after ICU admission.
Outcome measures and analysis: The primary outcome was ICU mortality. Associations between time spent in different MAP categories and ICU mortality were evaluated using 10 MAP thresholds: ≤100, ≤95, ≤90, ≤85, ≤80, ≤75, ≤70, ≤65, ≤60 and ≤55 mmHg. Multivariable logistic regression analyses were used to test the association between time spent in different MAP categories and ICU mortality.

Résultats : The study included 1018 eligible subjects in ICUs from 156 hospitals. The ICU mortality rate was 44.5%. After adjusting for confounders, MAP thresholds of ≤60 mmHg (OR, 1.13; 95% CI, 1.02-1.24; P = 0.014) and ≤55 mmHg (OR, 1.25; 95% CI, 1.09-1.45; P = 0.002) were significantly associated with increased ICU mortality. MAP thresholds of 65 mmHg or above were not associated with ICU mortality.

Conclusion : This study suggests that maintaining a mean arterial pressure of equal or greater than 65 mmHg may be a reasonable target in postcardiac arrest patients admitted to the ICU with vasopressor support. However, further prospective randomized trials are needed to determine the optimal mean arterial pressure targets in this patient population.

Conclusion (proposition de traduction) : Cette étude suggère que le maintien d'une pression artérielle moyenne égale ou supérieure à 65 mmHg pourrait être une cible raisonnable chez les patients après un arrêt cardiaque admis en USI avec un traitement par vasopresseur. Cependant, d'autres essais prospectifs randomisés sont nécessaires pour déterminer les cibles optimales de pression artérielle moyenne dans cette population de patients.

Intensive Care Medicine

Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS.
Grieco DL, Maggiore SM, Roca O, Spinelli E, Patel BK, Thille AW, Barbas CSV, de Acilu MG, Cutuli SL, Bongiovanni F, Amato M, Frat JP, Mauri T, Kress JP, Mancebo J, Antonelli M. | Intensive Care Med. 2021 Aug;47(8):851-866
DOI: https://doi.org/10.1007/s00134-021-06459-2  | Télécharger l'article au format  
Keywords: Acute hypoxemic respiratory failure (AHRF); Acute respiratory distress syndrome (ARDS); Continuous positive airway pressure (CPAP); High-flow nasal oxygen (H-FNO); Inspiratory effort; Noninvasive ventilation (NIV); Patient self-inflicted lung injury (P-SILI); Pressure support ventilation (PSV); Transpulmonary pressure.

Narrative Review

Editorial : The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO2/FiO2 > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO2/FiO2 ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.

Conclusion : Because of its simplicity of use, physiological and clinical effects recent clinical guidelines suggest HFNO as the optimal first-line intervention in AHRF. Early treatment with high-PEEP helmet PSV-NIV may represent a tool to further optimize the non-invasive treatment in most severe patients, but further adequately powered randomized studies are warranted to provide conclusive evidence.The optimal interface for non-invasive support of AHRF/ARDS remains a debated topic. Personalized treatments based on patients phenotypes, clinicians’ expertise, optimized interface, control of respiratory drive and strict physiological monitoring to promptly detect treatment failure represent the wisest approach for a safe clinical management.

Conclusion (proposition de traduction) : En raison de sa simplicité d'utilisation, de ses effets physiologiques et cliniques, les recommandations cliniques récentes suggèrent que l'utilisation de l'oxygénothérapie nasale à haut débit (OptiFlow) est l’intervention optimale de première intention dans l'insuffisance respiratoire hypoxémique aiguë. Un traitement précoce avec une ventilation non invasive utilisant un casque à PEEP élevé peut représenter un outil pour optimiser davantage le traitement non invasif chez les patients les plus sévères, mais d'autres études randomisées suffisamment puissantes sont nécessaires pour fournir des preuves concluantes.
L'interface optimale pour la prise en charge non invasive de « Insuffisance respiratoire hypoxémique aiguë »/« Syndrome de détresse respiratoire aiguë » reste un sujet débattu. Des traitements personnalisés basés sur les phénotypes des patients, l'expertise des cliniciens, une interface optimisée, la maîtrise de la commande respiratoire et une surveillance physiologique stricte pour détecter rapidement les échecs thérapeutiques représentent l'approche la plus judicieuse pour une prise en charge clinique sûre.

Commentaire : 

Internal and Emergency Medicine

Optimal timing of endoscopy for acute upper gastrointestinal bleeding: a systematic review and meta-analysis.
Merola E, Michielan A, de Pretis G. | Intern Emerg Med. 2021 Aug;16(5):1331-1340
DOI: https://doi.org/10.1007/s11739-020-02563-1
Keywords: Meta-analysis; Systematic review; Timing of endoscopy; Upper gastrointestinal bleeding; Very early endoscopy.

CE-Systematic reviews and meta-analysis

Editorial : Acute upper gastrointestinal bleeding (UGIB) is the most common indication for urgent endoscopy, but the correct timing of endoscopy in these patients is still debated. Our systematic review with meta-analysis was aimed at investigating the potential clinical benefit of very early endoscopy for UGIB patients. We performed an electronic literature search of PubMed, Scopus, Web of Science and the Cochrane Library up to 23rd May 2020 and considered only randomised controlled trials (RCTs) comparing management of UGIB patients by very early vs early endoscopy. Only five RCTs were considered eligible for quantitative analysis, with a total population of 926 cases (468 in the very early endoscopy arm and 458 in the early). The meta-analysis showed no statistically significant benefit for very early endoscopy compared to early endoscopy in terms of risk of rebleeding, mortality, ICU admission, blood transfusion, surgery and length of hospital stay. However, our results showed a significantly higher need for haemostatic treatment when very early endoscopy was performed (RR 1.23, 95% CI 1.06-1.42, p < 0.01) in comparison to early endoscopy.

Conclusion : Our systematic review with meta-analysis confirmed that very early endoscopy provides no significant clinical benefit in the management of UGIB than early endoscopy, but rather a higher need for haemostatic treatment. Although current guidelines recommend very early endoscopy in high-risk UGIB, data from RCTs regarding these cases are still lim- ited, and further publications are needed to draw definitive conclusions regarding this subgroup of patients.

Conclusion (proposition de traduction) : Notre revue systématique avec méta-analyse a confirmé que l'endoscopie très précoce n'apporte aucun bénéfice clinique significatif dans la gestion des saignements gastro-intestinaux supérieurs par rapport à l'endoscopie précoce, mais plutôt un besoin plus élevé de traitement hémostatique. Bien que les recommandations actuelles recommandent une endoscopie très précoce dans les hémorragies gastro-intestinales supérieures à haut risque, les données d'essais contrôlés randomisés concernant ces cas sont encore limitées et d'autres publications sont nécessaires pour tirer des conclusions définitives concernant ce sous-groupe de patients.

A simple lung ultrasound protocol for the screening of COVID‐19 pneumonia in the emergency department.
Dacrema A, Silva M, Rovero L, Vertemati V, Losi G, Piepoli MF, Sacchi R, Mangiacotti M, Nazerian P, Pagani L, Tinelli V, Poggiali E, Bastoni D, Vercelli A, Magnacavallo A. | Intern Emerg Med. 2021 Aug;16(5):1297-1305
DOI: https://doi.org/10.1007/s11739-020-02596-6  | Télécharger l'article au format  
Keywords: COVID-19; Emergency; Lung ultrasound; Outbreak; Pneumonia; Screening

M - ORIGINAL

Editorial : The most relevant manifestation of coronavirus disease 2019 (COVID-19) is interstitial pneumonia. Several lung ultrasound (US) protocols for pneumonia diagnosis are used in clinical practice, but none has been proposed for COVID-19 patients' screening in the emergency department. We adopted a simplified 6-scan lung US protocol for COVID-19 pneumonia diagnosis (LUSCOP) and compared its sensitivity with high resolution computed tomography (HRCT) in patients suspected for COVID-19, presenting to one Emergency Department from February 21st to March 15th, 2020, during the outbreak burst in northern Italy. Patients were retrospectively enrolled if both LUSCOP protocol and HRCT were performed in the Emergency Department. The sensitivity of LUSCOP protocol and HRCT were compared. COVID-19 pneumonia's final diagnosis was based on real-time reverse-transcription polymerase chain reaction from nasal-pharyngeal swab and on clinical data. Out of 150 suspected COVID-19 patients, 131 were included in the study, and 130 had a final diagnosis of COVID-19 pneumonia. The most frequent lung ultrasonographic features were: bilateral B-pattern in 101 patients (77%), B-pattern with subpleural consolidations in 26 (19.8%) and lung consolidations in 2 (1.5%). LUSCOP Protocol was consistent with HRCT in correctly screening 130 out of the 131 COVID-19 pneumonia cases (99.2%). In one case COVID-19 pneumonia was excluded by both HRCT and lung US. LUSCOP protocol showed optimal sensitivity and can be proposed as a simple screening tool for COVID-19 pneumonia diagnosis in the context of outbreak burst areas where prompt isolation of suspected patients is crucial for patients' and operators' safety.

Conclusion : In the context of COVID-19 outbreak burst, a novel, simple lung US protocol (LUSCOP protocol) showed to be a fea- sible, reliable, and sensitive screening tool for COVID-19 interstitial pneumonia diagnosis in patients with moderate/ severe manifestations of the disease.

Conclusion (proposition de traduction) : Dans le contexte de crise sanitaire COVID-19, un nouveau protocole simple d'échographie pulmonaire (protocole LUSCOP) s'est avéré être un outil de dépistage pratique, fiable et sensible pour le diagnostic de la pneumopathie interstitielle à COVID-19 chez les patients présentant des manifestations modérées/sévères de la maladie.

Lung ultrasound presentation of COVID-19 patients: phenotypes and correlations.
Secco G, Delorenzo M, Salinaro F, Zattera C, Barcella B, Resta F, Sabena A, Vezzoni G, Bonzano M, Briganti F, Cappa G, Zugnoni F, Demitry L, Mojoli F, Baldanti F, Bruno R, Perlini S; GERICO (Gruppo Esteso RIcerca COronarovirus) Lung US Pavia Study Group. | Intern Emerg Med. 2021 Aug;16(5):1317-1327
DOI: https://doi.org/10.1007/s11739-020-02620-9  | Télécharger l'article au format  
Keywords: COVID-19; Echographic phenotypes; Interstitial pneumonia; LUS score; Lung ultrasound.

EM - ORIGINAL

Editorial : Bedside lung ultrasound (LUS) can play a role in the setting of the SarsCoV2 pneumonia pandemic. To evaluate the clinical and LUS features of COVID-19 in the ED and their potential prognostic role, a cohort of laboratory-confirmed COVID-19 patients underwent LUS upon admission in the ED. LUS score was derived from 12 fields. A prevalent LUS pattern was assigned depending on the presence of interstitial syndrome only (Interstitial Pattern), or evidence of subpleural consolidations in at least two fields (Consolidation Pattern). The endpoint was 30-day mortality. The relationship between hemogasanalysis parameters and LUS score was also evaluated. Out of 312 patients, only 36 (11.5%) did not present lung involvment, as defined by LUS score < 1. The majority of patients were admitted either in a general ward (53.8%) or in intensive care unit (9.6%), whereas 106 patients (33.9%) were discharged from the ED. In-hospital mortality was 25.3%, and 30-day survival was 67.6%. A LUS score > 13 had a 77.2% sensitivity and a 71.5% specificity (AUC 0.814; p < 0.001) in predicting mortality. LUS alterations were more frequent (64%) in the posterior lower fields. LUS score was related with P/F (R2 0.68; p < 0.0001) and P/F at FiO2 = 21% (R2 0.59; p < 0.0001). The correlation between LUS score and P/F was not influenced by the prevalent ultrasound pattern. LUS represents an effective tool in both defining diagnosis and stratifying prognosis of COVID-19 pneumonia. The correlation between LUS and hemogasanalysis parameters underscores its role in evaluating lung structure and function.c

Conclusion : Bedside LUS represents an effective and fast tool for both the diagnosis definition and the prognostic stratification of COVID-19 pneumonia in the Emergency Department. LUS may be used in the ER to early identify COVID-19 worst patients and to correctly triage those patients with more extensive lung involvement who should be admitted to the General Ward or Intensive Care Unit (ICU). The study supports the primacy of LUS as the "go to" imaging modality for initial and ongoing management of COVID- 19 respiratory failure leaving the indication of chest CT scan as reserved only for the more complex cases. There- fore, LUS routine integration into the clinical management of this challenging disease is strongly suggested.

Conclusion (proposition de traduction) : L'échographie pulmonaire au lit du patient représente un outil efficace et rapide à la fois pour la définition du diagnostic et la stratification pronostique de la pneumopathie COVID-19 au service des urgences. L'échographie pulmonaire peut être utilisée aux urgences pour identifier rapidement les patients COVID-19 les plus atteints et pour trier correctement les patients présentant une atteinte pulmonaire plus étendue qui devraient être admis en médecine ou à l'unité de soins intensifs (USI). L'étude montre la primauté de l'échographie pulmonaire en tant que modalité d'imagerie « aller vers » pour la gestion initiale et continue de l'insuffisance respiratoire COVID-19, laissant l'indication de la tomodensitométrie thoracique comme réservée uniquement aux cas les plus complexes. Par conséquent, l'intégration de routine de l'échographie pulmonaire dans la gestion clinique de cette maladie difficile est fortement suggérée.

Journal of Critical Care

A systematic review and meta-analysis of propofol versus midazolam sedation in adult intensive care (ICU) patients.
Garcia R, Salluh JIF, Andrade TR, Farah D, da Silva PSL, Bastos DF, Fonseca MCM. | J Crit Care. 2021 Aug;64:91-99
DOI: https://doi.org/10.1016/j.jcrc.2021.04.001
Keywords: Adults; Intensive care unit; Meta-analysis; Midazolam; Propofol.

Systematic Reviews/Meta-Analysis

Introduction : Compare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam.

Méthode : We searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE. We separated patients into two groups: acute surgical patients (hospitalization up to 24 h) and critically-ill patients (hospitalization over 24 h and whose articles mostly mix surgical, medical and trauma patients).

Résultats : Globally, propofol was associated with a reduced MV time of 4.46 h (MD: -4.46 [95% CI -7.51 to -1.42] p = 0.004, I2 = 63%, 6 studies) and extubation time of 7.95 h (MD: -7.95 [95% CI -9.86 to -6.03] p < 0.00001, I2 = 98%, 16 studies). Acute surgical patients sedation with propofol compared to midazolam was associated with a reduced ICU stay of 5.07 h (MD: -5.07 [95% CI -8.68 to -1.45] p = 0.006, I2 = 41%, 5 studies), MV time of 4.28 h (MD: -4.28; [95% CI -4.62 to -3.94] p < 0.0001, I2 = 0%, 3 studies), extubation time of 1.92 h (MD: -1.92; [95% CI -2.71 to -1.13] p = 0.00001, I2 = 89%, 9 studies). In critically-ill patients sedation with propofol compared to midazolam was associated with a reduced extubation time of 32.68 h (MD: -32.68 [95% CI -48.37 to -16.98] p = 0.0001, I2 = 97%, 9 studies). GRADE was very low for all outcomes.

Conclusion : Sedation with propofol compared to midazolam is associated with improved clinical outcomes in ICU, with reduced ICU stay MV time and extubation time in acute surgical patients and reduced extubation time in critically-ill patients.

Conclusion (proposition de traduction) : La sédation par le propofol par rapport au midazolam est associée à de meilleurs résultats cliniques en USI, avec une réduction du temps de ventilation mécanique et d'extubation en USI chez les patients chirurgicaux aigus et une réduction du temps d'extubation chez les patients gravement malades.

Journal of Intensive Care

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020).
Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada TA, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda . | J Intensive Care. 2021 Aug 25;9(1):53
DOI: https://doi.org/10.1186/s40560-021-00555-7  | Télécharger l'article au format  
Keywords: Evidence-based medicine; GRADE; Guidelines; Sepsis; Septic shock; Systematic review.

Guideline

Editorial : The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Journal of Intensive Care Medicine

Vasopressor and Inotrope Therapy in Cardiac Critical Care.
Jentzer JC, Hollenberg SM. | J Intensive Care Med. 2021 Aug;36(8):843-856
DOI: https://doi.org/10.1177/0885066620917630
Keywords: CICU; dopamine; epinephrine; inotrope; norepinephrine; shock; vasopressor.

Analytic Review

Editorial : Patients admitted to the cardiac intensive care unit (CICU) are often in shock and require hemodynamic support. Identifying and addressing the pathophysiology mechanisms operating in an individual patient is crucial to achieving a successful outcome, while initiating circulatory support therapy to restore adequate tissue perfusion. Vasopressors and inotropes are the cornerstone of supportive medical therapy for shock, in addition to fluid resuscitation when indicated. Timely initiation of optimal vasopressor and inotrope therapy is essential for patients with shock, with the ultimate goals of restoring effective tissue perfusion in order to normalize cellular metabolism. Use of vasoactive agents for hemodynamic support of patients with shock should take both arterial pressure and tissue perfusion into account when choosing therapeutic interventions. For most patients with shock, including cardiogenic or septic shock, norepinephrine (NE) is an appropriate choice as a first-line vasopressor titrated to achieve an adequate arterial pressure due to a lower risk of adverse events than other catecholamine vasopressors. If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output to a sufficient level that meets tissue demand. Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events when used for vasopressor support and should be avoided. When NE alone is inadequate to achieve an adequate arterial pressure, addition of a noncatecholamine vasopressor such as vasopressin or angiotensin-II is reasonable, in addition to rescue therapies that may improve vasopressor responsiveness. In this review, we discuss the pharmacology and evidence-based use of vasopressor and inotrope drugs in critically ill patients, with a focus on the CICU population.

Conclusion : The ultimate goals of hemodynamic therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. Hemodynamics in CICU patients can be complex, involving right- and left-sided cardiac dysfunction and interactions of vascular and myocardial perturbation. The pathophysiology of organ dysfunction in shock is complex as well, and restoring hemodynamic stability after organ failure is established may not be adequate to ensure a good outcome.
Despite this complexity, the use of vasoactive agents for hemodynamic support of patients with shock can be guided by an underlying approach that takes both arterial pressure and tissue perfusion into account when choosing therapeutic interventions. The efficacy of hemodynamic therapy should be assessed by monitoring a combination of clinical and hemodynamic parameters and tailoring vasoactive therapy based on clinical response. Specific end points for therapy can vary in different clinical scenarios and in different patients and can evolve over time as the clinical course progresses. Nonetheless, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle.

Conclusion (proposition de traduction) : Les buts ultimes du traitement hémodynamique de l'état de choc sont de restaurer une perfusion tissulaire efficace et de normaliser le métabolisme cellulaire. L'hémodynamique chez les patients des unités de soins intensifs cardiaques peut être complexe, impliquant un dysfonctionnement cardiaque droit et gauche et des interactions de perturbation vasculaire et myocardique. La physiopathologie du dysfonctionnement d'un organe en cas de choc est également complexe, et la restauration de la stabilité hémodynamique une fois la défaillance d'un organe établie peut ne pas être suffisante pour garantir un bon résultat.
Malgré cette complexité, l'utilisation d'agents vasoactifs pour le soutien hémodynamique des patients en état de choc peut être guidée par une approche sous-jacente qui prend en compte à la fois la pression artérielle et la perfusion tissulaire lors du choix des interventions thérapeutiques. L'efficacité du traitement hémodynamique doit être évaluée en surveillant une combinaison de paramètres cliniques et hémodynamiques et en adaptant le traitement vasoactif en fonction de la réponse clinique. Les points finaux spécifiques du traitement peuvent varier selon les scénarios cliniques et les patients et peuvent évoluer au fil du temps à mesure que l'évolution clinique progresse. Néanmoins, l'idée que les cliniciens doivent définir des objectifs et des critères d'évaluation spécifiques, titrer les traitements en fonction de ces critères d'évaluation et évaluer les résultats de leurs interventions de manière continue reste un principe fondamental.

Commentaire :  Sélection de médicaments vasopresseurs et de traitements d'appoint en fonction de la sévérité du choc. Adapté de Jentzer JC and al. Management of Refractory Vasodilatory Shock. Chest. 2018 Aug;154(2):416-426  .
AKI = acute kidney injury; CRRT = continuous renal replacement therapy, CO = cardiac output; HR = heart rythm; NR = norepinephrine.

Standard Care Versus Awake Prone Position in Adult Nonintubated Patients With Acute Hypoxemic Respiratory Failure Secondary to COVID-19 Infection-A Multicenter Feasibility Randomized Controlled Trial.
Jayakumar D, Ramachandran Dnb P, Rabindrarajan Dnb E, Vijayaraghavan Md BKT, Ramakrishnan Ab N, Venkataraman Ab R. | J Intensive Care Med. 2021 Aug;36(8):918-924
DOI: https://doi.org/10.1177/08850666211014480  | Télécharger l'article au format  
Keywords: COVID-19; feasibility; hypoxia; prone; supine.

Original Research

Introduction : The feasibility and safety of awake prone positioning and its impact on outcomes in non-intubated patients with acute respiratory distress syndrome secondary to COVID-19 is unknown. Results of the observational studies published during this pandemic have been conflicting. In this context, we conducted a multi-center, parallel group, randomized controlled feasibility study on awake prone positioning in non-intubated patients with COVID-19 pneumonia requiring supplemental oxygen.

Méthode : 60 patients with acute hypoxic respiratory failure secondary to COVID-19 pneumonia requiring 4 or more liters of oxygen to maintain a saturation of ≥92% were recruited in this study. Thirty patients each were randomized to either standard care or awake prone group. Patients randomized to the prone group were encouraged to self-prone for at least 6 hours a day. The primary outcome was the proportion of patients adhering to the protocol in each group.

Résultats : In the prone group, 43% (13 out of 30) of patients were able to self-prone for 6 or more hours a day. In the supine group, 47% (14 out of 30) were completely supine and 53% spent some hours in the prone position, but none exceeded 6 hours. There was no significant difference in any of the secondary outcomes between the 2 groups and there were no adverse events.

Conclusion : Awake prone positioning in non-intubated patients with acute hypoxic respiratory failure is feasible and safe under clinical trial conditions. The results of our feasibility study will potentially help in the design of larger definitive trials to address this key knowledge gap.

Conclusion (proposition de traduction) : Le décubitus ventral sans sédation chez les patients non intubés présentant une insuffisance respiratoire hypoxique aiguë est faisable et sûr dans les conditions des essais cliniques. Les résultats de notre étude de faisabilité contribueront potentiellement à la conception d'essais définitifs plus importants pour combler cette lacune clé dans les connaissances.

Journal of the American Medical Association

Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial.
Zampieri FG, Machado FR, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Lovato WJ, Amêndola CP, Assunção MSC, Serpa-Neto A, Paranhos JLR, Andrade J, Godoy MMG, Romano E, Dal Pizzol F, Silva EB, Silva MML, Machado MCV, Malbouisson LMS, Manoel ALO, Thompson MM, Figueiredo LM, Soares RM, Miranda TA, de Lima LM, Santucci EV, Corrêa TD, Azevedo LCP, Kellum JA, Damiani LP, Silva NB, Cavalcanti AB; BaSICS investigators and the BRICNet members. | JAMA. 2021 Sep 7;326(9):830-838
DOI: https://doi.org/10.1001/jama.2021.11444
Keywords: Aucun

Original Investigation

Introduction : Slower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality.
Objective: To determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU).

Méthode : Unblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately).
Interventions : Patients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design.
Main outcomes and measures: The primary end point was 90-day survival.

Résultats : Of all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98).

Conclusion : Among patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate.

Conclusion (proposition de traduction) : Parmi les patients de l'unité de soins intensifs nécessitant un remplissage vasculaire, la perfusion à un rythme plus lent par rapport à un rythme plus rapide n'a pas réduit la mortalité à 90 jours. Ces résultats ne soutiennent pas l'utilisation d'un débit de perfusion plus lent.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Titre_de_l_article  . Rédigé par Aaron Lacy, le 16 septembre 2021.

Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial.
Zampieri FG, Machado FR, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Lovato WJ, Amêndola CP, Serpa-Neto A, Paranhos JLR, Guedes MAV, Lúcio EA, Oliveira-Júnior LC, Lisboa TC, Lacerda FH, Maia IS, Grion CMC, Assunção MSC, Manoel ALO, Silva-Junior JM, Duarte P, Soares RM, Miranda TA, de Lima LM, Gurgel RM, Paisani DM, Corrêa TD, Azevedo LCP, Kellum JA, Damiani LP, Brandão da Silva N, Cavalcanti AB; BaSICS investigators and the BRICNet members. | JAMA. 2021 Aug 10;326(9):1–12
DOI: https://doi.org/10.1001/jama.2021.11684
Keywords: Aucun

Original article

Introduction : Intravenous fluids are used for almost all intensive care unit (ICU) patients. Clinical and laboratory studies have questioned whether specific fluid types result in improved outcomes, including mortality and acute kidney injury.
Objective: To determine the effect of a balanced solution vs saline solution (0.9% sodium chloride) on 90-day survival in critically ill patients.

Méthode : Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil. Patients who were admitted to the ICU with at least 1 risk factor for worse outcomes, who required at least 1 fluid expansion, and who were expected to remain in the ICU for more than 24 hours were randomized between May 29, 2017, and March 2, 2020; follow-up concluded on October 29, 2020. Patients were randomized to 2 different fluid types (a balanced solution vs saline solution reported in this article) and 2 different infusion rates (reported separately).
Interventions: Patients were randomly assigned 1:1 to receive either a balanced solution (n = 5522) or 0.9% saline solution (n = 5530) for all intravenous fluids.
Main outcomes and measures: The primary outcome was 90-day survival.

Résultats : Among 11 052 patients who were randomized, 10 520 (95.2%) were available for the analysis (mean age, 61.1 [SD, 17] years; 44.2% were women). There was no significant interaction between the 2 interventions (fluid type and infusion speed; P = .98). Planned surgical admissions represented 48.4% of all patients. Of all the patients, 60.6% had hypotension or vasopressor use and 44.3% required mechanical ventilation at enrollment. Patients in both groups received a median of 1.5 L of fluid during the first day after enrollment. By day 90, 1381 of 5230 patients (26.4%) assigned to a balanced solution died vs 1439 of 5290 patients (27.2%) assigned to saline solution (adjusted hazard ratio, 0.97 [95% CI, 0.90-1.05]; P = .47). There were no unexpected treatment-related severe adverse events in either group.

Conclusion : Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution.

Conclusion (proposition de traduction) : Parmi les patients de réanimation nécessitant un remplissage vasculaire, l'utilisation d'un soluté balancé par rapport à une solution saline à 0,9 % n'a pas réduit de manière significative la mortalité à 90 jours. Les résultats ne soutiennent pas l'utilisation de ces solutés balancés.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Are Balanced Crystalloids Still Better? - The BaSICS RCT Part 2  . Rédigé par le Dr Aaron Lacy, le 17 septembre 2021.

• Brown RM, Wang L, Coston TD and al. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med. 2019 Dec 15;200(12):1487-1495  
• Self WH, Semler MW, Wanderer JPand al; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828  

Lancet Neurology

Fluid balance and outcome in critically ill patients with traumatic brain injury (CENTER-TBI and OzENTER-TBI): a prospective, multicentre, comparative effectiveness study.
Wiegers EJA, Lingsma HF, Huijben JA, Cooper DJ, Citerio G, Frisvold S, Helbok R, Maas AIR, Menon DK, Moore EM, Stocchetti N, Dippel DW, Steyerberg EW, van der Jagt M; CENTER-TBI; OzENTER-TBI Collaboration Groups. | Lancet Neurol. 2021 Aug;20(8):627-638
DOI: https://doi.org/10.1016/s1474-4422(21)00162-9
Keywords: Aucun

Article

Introduction : Fluid therapy-the administration of fluids to maintain adequate organ tissue perfusion and oxygenation-is essential in patients admitted to the intensive care unit (ICU) with traumatic brain injury. We aimed to quantify the variability in fluid management policies in patients with traumatic brain injury and to study the effect of this variability on patients' outcomes.

Méthode : We did a prospective, multicentre, comparative effectiveness study of two observational cohorts: CENTER-TBI in Europe and OzENTER-TBI in Australia. Patients from 55 hospitals in 18 countries, aged 16 years or older with traumatic brain injury requiring a head CT, and admitted to the ICU were included in this analysis. We extracted data on demographics, injury, and clinical and treatment characteristics, and calculated the mean daily fluid balance (difference between fluid input and loss) and mean daily fluid input during ICU stay per patient. We analysed the association of fluid balance and input with ICU mortality and functional outcome at 6 months, measured by the Glasgow Outcome Scale Extended (GOSE). Patient-level analyses relied on adjustment for key characteristics per patient, whereas centre-level analyses used the centre as the instrumental variable.

Résultats : 2125 patients enrolled in CENTER-TBI and OzENTER-TBI between Dec 19, 2014, and Dec 17, 2017, were eligible for inclusion in this analysis. The median age was 50 years (IQR 31 to 66) and 1566 (74%) of patients were male. The median of the mean daily fluid input ranged from 1·48 L (IQR 1·12 to 2·09) to 4·23 L (3·78 to 4·94) across centres. The median of the mean daily fluid balance ranged from -0·85 L (IQR -1·51 to -0·49) to 1·13 L (0·99 to 1·37) across centres. In patient-level analyses, a mean positive daily fluid balance was associated with higher ICU mortality (odds ratio [OR] 1·10 [95% CI 1·07 to 1·12] per 0·1 L increase) and worse functional outcome (1·04 [1·02 to 1·05] per 0·1 L increase); higher mean daily fluid input was also associated with higher ICU mortality (1·05 [1·03 to 1·06] per 0·1 L increase) and worse functional outcome (1·04 [1·03 to 1·04] per 1-point decrease of the GOSE per 0·1 L increase). Centre-level analyses showed similar associations of higher fluid balance with ICU mortality (OR 1·17 [95% CI 1·05 to 1·29]) and worse functional outcome (1·07 [1·02 to 1·13]), but higher fluid input was not associated with ICU mortality (OR 0·95 [0·90 to 1·00]) or worse functional outcome (1·01 [0·98 to 1·03]).

Conclusion : In critically ill patients with traumatic brain injury, there is significant variability in fluid management, with more positive fluid balances being associated with worse outcomes. These results, when added to previous evidence, suggest that aiming for neutral fluid balances, indicating a state of normovolaemia, contributes to improved outcome.

Conclusion (proposition de traduction) : Chez les patients de réanimation victimes d'un traumatisme crânien, il existe une variabilité significative dans l'équilibre hydrique, une surcharge hydrique étant associés à un moins bon pronostic. Ces résultats, ajoutés aux preuves précédentes, suggèrent que viser des équilibres hydriques neutres, indiquant un état de normovolémie, contribue à une amélioration des résultats.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Fluid Balance in TBI - Don't Drown the Brain  . Rédigé par Clay Smith, le 14 septembre 2021.

Pediatric Emergency Care

Tablet Computer as a Distraction Tool During Facial Laceration Repair: A Randomized Trial.
Bryl AW, Bonsu B, Johnson AL, Pommert KBJ, Hollenbach KA, Kanegaye JT. | Pediatr Emerg Care. 2021 Aug 1;37(8):e425-e430
DOI: https://doi.org/10.1097/pec.0000000000001626
Keywords: Aucun

Original article

Introduction : Child life interventions reduce the anxiety of medical procedures but are not always available in emergency departments. In this study, we determined the effect of parent-directed tablet computer use without child life direction on patient anxiety and on parent and suturing clinician experience during pediatric facial laceration repair.

Méthode : In a children's hospital emergency department, we enrolled children 2 to 12 years of age undergoing unsedated facial laceration repairs and randomized them to parent-directed tablet computer distraction or standard supportive care. We measured anxiety using the Observational Scale of Behavioral Distress-Revised (OSBD-R) for 5 procedure phases from videotaped laceration repairs. We compared OSBD-R scores for 5 phases and weighted averages between the tablet and standard care groups. Parents and suturing clinicians completed surveys about their experiences after the procedures.

Résultats : From April 2014 to July 2015, 77 patients (39 tablet, 38 standard) underwent repairs. Age, use of restraint, procedure duration, and number of sutures were similar between the 2 groups. The groups did not differ in procedure phase or weighted-average OSBD-R scores. Parents in the tablet group reported less personal anxiety compared with parents in the standard group (P = 0.01). In a post hoc subgroup analysis, subjects in the unrestrained tablet group had lower OSBD-R scores during the anesthetic injection phase than did subjects in the unrestrained standard group (P = 0.04). If restrained, subjects in the tablet group had higher OSBD-R scores during the anesthetic injection phase than did subjects in the standard group (P = 0.048).

Conclusion : Unrestrained children may benefit from parent-directed tablet computer distraction. Parents who operate the device are less anxious during their children's procedures.

Conclusion (proposition de traduction) : Les enfants qui ne bénéficient pas d'une contention physique pourraient bénéficier de la distraction avec une phablette dirigée par les parents. Les parents qui utilisent l'appareil sont moins anxieux pendant les procédures de leurs enfants.

Timing of Button Battery Removal From the Upper Gastrointestinal System in Children.
Al Lawati TT, Al Marhoobi RM. | Pediatr Emerg Care. 2021 Aug 1;37(8):e461-e463
DOI: https://doi.org/10.1097/pec.0000000000001697
Keywords: Aucun

Original article

Introduction : The aim of the study was to investigate the appropriate time of removal of button batteries (BB) from the esophagus and stomach in children.

Méthode : This is a retrospective descriptive single-center study reviewing the medical records of all children with BB ingestion seen in the Royal Hospital between January 1, 2011, and December 31, 2014. All children younger than 13 years with a history of BB ingestion were included. Biodemographic data including age and sex were obtained. In addition, time of ingestion of BB, location of BB, time of endoscopic removal, and any complications were recorded.

Résultats : Forty-six patients with BB ingestion were identified out of 385 who presented with foreign body ingestion (12%) during the study period. Twenty four (52%) were boys and 22 (48%) were girls. All children had BB of 20 mm in diameter. Two children had the BB in the esophagus, whereas 13 children had the BB in the stomach up on presentation. The mean time of presentation of children with BB in the esophagus was 1.75 hours after ingestion, whereas those with BB in the stomach presented on average 19.4 hours after ingestion (P < 0.035). An endoscopic intervention was done in only 8 of the 46 children. Two children had the BB in the esophagus and 6 children in the stomach. One child required intensive care unit with subsequent esophageal strictures. The mean time of esophageal BB removal was 1.7 hours from ingestion, whereas removal from the stomach was on average 27 hours after ingestion. Endoscopic injuries were noted in 87.5% of the children with BB in the esophagus or the stomach. No mortality occurred during the study period.

Conclusion : Button batteries ingestion is a common problem with variable time of presentation to the emergency department. Esophageal BB presents the highest risk of injury even in as short time as 2 hours. Gastric mucosal injury can occur within 10 hours of ingestion. Button batteries of 20-mm diameter need to be urgently removed from the esophagus and be considered for removal earlier than 24 hours if in the stomach.

Conclusion (proposition de traduction) : L'ingestion de piles boutons est un problème courant avec un temps de présentation variable aux urgences. Les piles boutons œsophagiennes présentent le risque de blessure le plus élevé, même en aussi peu de temps que 2 heures. Une lésion de la muqueuse gastrique peut survenir dans les 10 heures suivant l'ingestion. Les piles boutons de 20 mm de diamètre doivent être retirées d'urgence de l'œsophage et leur retrait doit être envisagé avant 24 heures si elles se trouvent dans l'estomac.

Pediatrics

Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old.
Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O'Leary ST, Okechukwu K, Woods CR Jr; SUBCOMMITTEE ON FEBRILE INFANTS. | Pediatrics. 2021 Aug;148(2):e2021052228
DOI: https://doi.org/10.1542/peds.2021-052228  | Télécharger l'article au format  
Keywords: Aucun

From the American Academy of Pediatrics

Editorial : This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Conclusion : Differing approaches to the management of very young febrile infants indicated the need for a guideline that is current, evidence- based, and developed by a national professional society or organization with broad representation. This led the American Academy of Pediatrics (AAP) to embark on developing this guideline with the assistance of an evidence review commissioned by the Agency for Healthcare Research and Quality (AHRQ).

Conclusion (proposition de traduction) : Les différentes approches de la prise en charge des très jeunes nourrissons fébriles ont indiqué le besoin d'une ligne directrice à jour, fondée sur des données probantes et élaborée par une société ou une organisation professionnelle nationale avec une large représentation. Cela a conduit l'American Academy of Pediatrics (AAP) à se lancer dans l'élaboration de cette directive avec l'aide d'un examen des preuves commandé par l'Agence pour la recherche et la qualité des soins de santé (AHRQ).

Commentaire : Vous trouverez les 3 algorithmes établis à partir des déclarations d'action clés (KAS) numérotées, 1-21 +/- un sous-titre (c'est-à-dire « 7 » ou « 7b »).
Chacun des algorithmes ci-dessous a une note explicative détaillée dans l'article original. Vous devez les lire, cliquez simplement sur l'image et vous serez redirigé vers le document AAP original.

Algorithm for 8- to 21-day-old infants  

Algorithm for 22- to 28-day-old infants  

Algorithm for 29- to 60-day-old infants  

Prehospital and Disaster Medicine

The Impact of Personal Protection Equipment on Intubation Times.
Doukas D, Arquilla B, Halpern P, Silverberg M, Sinert R. | Prehosp Disaster Med. 2021 Aug;36(4):375-379
DOI: https://doi.org/10.1017/s1049023x21000492
Keywords: decontamination; emergency medicine; hazardous materials (HAZMAT); intubation; personal protective equipment.

Original Research

Introduction : Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE.
Study objective: The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE.

Méthode : This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher's Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed.

Résultats : All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s).

Conclusion : There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.

Conclusion (proposition de traduction) : Il n'y avait aucune différence statistiquement significative pour le temps mis au gonflage du ballonnet ou à débuter la ventilation. Des niveaux plus élevés d'EPI ne semblent pas augmenter le délai pour l'intubation endotrachéale.

The Flatness Index of Inferior Vena Cava can be an Accurate Predictor for Hypovolemia in Multi-Trauma Patients.
Yazlamaz NO, Ozakin E, Bastug BT, Karakilic E, Kaya FB, Acar N, Koruk R. | Prehosp Disaster Med. 2021 Aug;36(4):414-420
DOI: https://doi.org/10.1017/s1049023x21000418
Keywords: computed tomography; flatness index of inferior vena cava; hypovolemic shock; multi-trauma.

ORIGINAL RESEARCH

Introduction : Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose.

Méthode : This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded.

Résultats : Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05).

Conclusion : The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.

Conclusion (proposition de traduction) : L'indice de collapsibilité de la veine cave inférieure peut être une méthode utile pour apprécier le choc hypovolémique à un stade précoce chez les patients polytraumatisés.

Commentaire : Initialement proposée en réanimation chez le patient en ventilation mécanique, la collapsibilité respiratoire de la veine cave inférieure (cVCI) : (Diamètre max – diamètre min)/((Diamètre max + diamètre min)/2), recueillie 3 cm en amont de l’abouchement de la veine cave au niveau de l’oreillette droite est prédictive d’une réponse positive au remplissage vasculaire (augmentation du débit cardiaque supérieure à 15 %) lorsque cette variation de diamètre est supérieure à 12 % avec une sensibilité et une spécificité de 93 % et 92 % respectivement.
Ces résultats ne se sont pas avérés transposables avec la même performance pour la prise en charge hémodynamique des patients en ventilation spontanée chez qui le volume courant inspiratoire ainsi que la pression négative pleurale développés au cours de l’inspiration sont très variables d’un cycle à l’autre et d’un patient à l’autre. Ainsi, Muller et al. rapportent que le seuil optimal de la cVCI prédictif d’une réponse positive au remplissage vasculaire chez des patients en insuffisance circulatoire aiguë en ventilation spontanée est de 25 % (ce seuil est de 40 % quand on applique la formule (Diamètre max– diamètre min)/(Diamètre max)) avec une sensibilité et une spécificité de 70 % et 80 % respectivement. Toutefois une cVCI inférieure à 25 % n’excluait pas une augmentation du débit cardiaque en réponse à un remplissage vasculaire.
En mesurant l’index de collapsibilité par la formule (Diamètre max – diamètre min)/(Diamètre max)) et en le comparant à la valeur de pression veineuse centrale (PVC) mesurée chez des patients de soins intensifs en ventilation spontanée, Stawicki et al. relèvent également qu’une PVC basse (< 7 mmHg) est associée à un index de collapsibilité supérieur à 60 %, alors qu’une PVC haute (> 12 mmHg) est associée à un index de collapsibilité inférieur à 20 % avec une large zone d’incertitude entre 20 et 60 %.
On retiendra donc qu’une collapsibilité selon la formule (Diamètre max – diamètre min)/(Diamètre max) supérieure à 50 % est un signe d’hypovolémie à l’échographie chez les patients en ventilation spontanée.
Le caractère dynamique de la mesure du diamètre de veine cave inférieure (variation respiratoire ou variation pour un même patient en réponse à une manoeuvre réanimatoire comme le remplissage vasculaire) est fondamental.

Trouvé sur : Anatole Harrois. Monitorage hémodynamique par les ultrasons. Le Congrès SFAR Médecins. Urgences vitales 2015  .

Endotracheal Tube Cuff Pressure - Comparison of the Two Filling Methods - Simulated Test.
Ilczak T, Ćwiertnia M, Białoń P, Szlagor M, Kudłacik B, Rak M, Bialka S, Ubych A, Stasicki A, Waksmańska W, Bujok J, Mikulska M, Bobiński R, Kawecki M. | Prehosp Disaster Med. 2021 Aug;36(4):421-425
DOI: https://doi.org/10.1017/s1049023x21000406
Keywords: cuff pressure; intubation; paramedic.

Original Research

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

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

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

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

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

Prehospital Decompression of Pneumothorax: A Systematic Review of Recent Evidence.
Robitaille-Fortin M, Norman S, Archer T, Mercier E. | Prehosp Disaster Med. 2021 Aug;36(4):450-459.
DOI: https://doi.org/10.1017/s1049023x21000509
Keywords: decompression; pneumothorax; prehospital; thoracic injuries; thoracostomy.

Systematic Review

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

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

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

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

Conclusion (proposition de traduction) : Sur la base d'études observationnelles de faible niveau de preuve, la décompression thoracique à l'aiguille préhospitalière doit être réalisée à l'aide d'une aiguille de plus de 7 cm de long avec une approche latérale ou antérieure. Alors que la thoracostomie digitale est une approche diagnostique et thérapeutique intéressante, les preuves sur les taux de réussite et les complications sont limitées. Des études de haute qualité sont nécessaires pour déterminer l'approche de décompression thoracique optimale applicable en dehors de l'hôpital.

Association of Ventilation during Initial Trauma Resuscitation for Traumatic Brain Injury and Post-Traumatic Outcomes: A Systematic Review.
Howard MB, McCollum N, Alberto EC, Kotler H, Mottla ME, Tiusaba L, Keller S, Marsic I, Sarcevic A, Burd RS, O'Connell KJ. | Prehosp Disaster Med. 2021 Aug;36(4):460-465
DOI: https://doi.org/10.1017/s1049023x21000534
Keywords: resuscitation; traumatic brain injury (TBI); ventilation; wounds and injuries.

Systematic Review

Introduction : In the absence of evidence of acute cerebral herniation, normal ventilation is recommended for patients with traumatic brain injury (TBI). Despite this recommendation, ventilation strategies vary during the initial management of patients with TBI and may impact outcome. The goal of this systematic review was to define the best evidence-based practice of ventilation management during the initial resuscitation period.

Méthode : A literature search of PubMed, CINAHL, and SCOPUS identified studies from 2009 through 2019 addressing the effects of ventilation during the initial post-trauma resuscitation on patient outcomes.

Résultats : The initial search yielded 899 articles, from which 13 were relevant and selected for full-text review. Six of the 13 articles met the inclusion criteria, all of which reported on patients with TBI. Either end-tidal carbon dioxide (ETCO2) or partial pressure carbon dioxide (PCO2) were the independent variables associated with mortality. Decreased rates of mortality were reported in patients with normal PCO2 or ETCO2.

Conclusion : Normoventilation, as measured by ETCO2 or PCO2, is associated with decreased mortality in patients with TBI. Preventing hyperventilation or hypoventilation in patients with TBI during the early resuscitation phase could improve outcome after TBI.

Conclusion (proposition de traduction) : La normoventilation, telle que mesurée par ETCO2 ou PaCO2, est associée à une diminution de la mortalité chez les patients ayant subi un traumatisme crânien. La prévention de l'hyperventilation ou de l'hypoventilation chez les patients ayant subi un traumatisme crânien au cours de la phase de réanimation précoce pourrait améliorer les résultats après un traumatisme crânien.

Resuscitation

CPR compression strategy 30:2 is difficult to adhere to, but has better survival than continuous chest compressions when done correctly.
Schmicker RH, Nichol G, Kudenchuk P, Christenson J, Vaillancourt C, Wang HE, Aufderheide TP, Idris AH, Daya MR. | Resuscitation. 2021 Aug;165:31-37
DOI: https://doi.org/10.1016/j.resuscitation.2021.05.027
Keywords: 30:2; Adherence; Cardiopulmonary arrest; Continuous compressions.

Clinical paper

Introduction : A large, randomized trial showed no significant difference in survival to discharge between cardiopulmonary resuscitation (CPR) strategies of 30 compressions with pause for 2 ventilations per cycle (30:2) and continuous chest compression with asynchronous ventilations (CCC). Data from the same trial suggested that adherence to the intended CPR strategy was associated with significantly greater survival. We sought to determine the adherence rate with intended strategy and then explore the association of adherence with survival to discharge in the Resuscitation Outcomes Consortium (ROC).

Méthode : This secondary analysis of data from the ROC included three interventional trials and a prospective registry. We modified an automated software algorithm that classified care as 30:2 or CCC before intubation based on compression segment length (defined as the elapsed time from start of compressions to subsequent pause of ≥2 s), number of pauses per minute ≥2 s in length and chest compression fraction. Intended CPR strategy for individual agencies was based on study randomization (during trial phase) or local standard of care (during registry phase). We defined CPR delivered as adherent when its classification matched the intended strategy. We characterized adherence with intended strategy across trial and registry periods. We examined its association with survival to hospital discharge using multivariate logistic regression after adjustment for Utstein and other potential confounders. Effect modification with intended strategy was assessed through a multiplicative interaction term.

Résultats : Included were 26,810 adults with out of hospital cardiac arrest, of which 10,942 had an intended strategy of 30:2 and 15,868 an intended strategy of CCC. The automated algorithm classified 12,276 cases as CCC, 7037 as 30:2 and left 7497 as unclassified. Adherence to intended strategy was 54.4%; this differed by intended strategy (58.6% for CCC vs 48.3% for 30:2). Overall adherence was less during the registry phase as compared to during the trial phase(s). The association between adherence and survival was modified by treatment arm (CCC OR: 0.72, 95% CI: 0.64-0.81 vs 30:2 OR: 1.05, 95% CI: 0.90-1.22; interaction p-value<0.01) after adjustment for known confounders.

Conclusion : For intended strategy CCC, survival was significantly lower, OR (95%CI) = 0.72 (0.64, 0.81), when adhered to while for intended strategy 30:2, survival was higher, OR (95%CI) = 1.05 (0.90, 1.22), when adhered to. Intended strategy of 30:2 had lower adherence rates than CCC possibly a result of being a more difficult strategy to administer.

Conclusion (proposition de traduction) : Pour la stratégie prévue de compression thoracique continue avec ventilations asynchrones, la survie était significativement plus faible, odd ratio (IC à 95 %) = 0,72 (0,64, 0,81), lorsqu'elle était respectée alors que pour la stratégie prévue d'alternance compression/ventilation de 30:2, la survie était plus élevée, odd ratio (IC à 95 %) = 1,05 (0,90, 1,22), une fois respecté. La stratégie prévue d'alternance compression/ventilation de 30:2 avait des taux d'adhérence inférieurs à ceux de la compression thoracique continue avec des ventilations asynchrones, probablement en raison d'une stratégie plus difficile à administrer.

Pulseless electrical activity vs. asystole in adult in-hospital cardiac arrest: Predictors and outcomes.
Høybye M, Stankovic N, Lauridsen KG, Holmberg MJ, Andersen LW, Granfeldt A. | Resuscitation. 2021 Aug;165:50-57
DOI: https://doi.org/10.1016/j.resuscitation.2021.05.036  | Télécharger l'article au format  
Keywords: Asystole; Cardiac arrest characteristics; Comorbidities; In-hospital cardiac arrest; Initial rhythm; Non-shockable; Predictors; Pulseless electrical activity; 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 sans pouls initiale était associée à une chance plus élevé de reprise d'activité cardiaque spontanée (RACS), mais il n'y avait pas de différence dans la survie à 30 jours et à 1 an.

Assessment of chest compression interruptions during advanced cardiac life support.
Dewolf P, Wauters L, Clarebout G, Van Den Bempt S, Uten T, Desruelles D, Verelst S. | Resuscitation. 2021 Aug;165:140-147
DOI: https://doi.org/10.1016/j.resuscitation.2021.06.022
Keywords: ACLS; CCF; High-quality CC; Interruptions.

Clinical paper

Introduction : To identify potentially avoidable factors responsible for chest compression interruptions and to evaluate the influence of chest compression fraction on achieving return of spontaneous circulation and survival to hospital discharge.

Méthode : In this prospective observational study, each resuscitation managed by mobile medical teams from August 1st, 2016, to August 1st, 2018 was video recorded using a body-mounted GoPro camera. The duration of all chest compression interruptions was recorded and chest compression fraction was calculated. All actions causing an interruption of at least 10 s were analyzed.

Résultats : Two hundred and six resuscitations of both in- and out-of-hospital cardiac arrest patients were analysed. In total 1867 chest compression interruptions were identified. Of these, 623 were longer than 10 s in which a total of 794 actions were performed. In 4.3% of the registered pauses, cardiopulmonary resuscitation was interrupted for more than 60 s. The most performed actions during prolonged interruptions were rhythm/pulse checks (51.6%), installation/use of mechanical chest compression devices (11.1%), cardiopulmonary resuscitation provider switches (6.7%) and ETT placements (6.2%). No statistically significant relationship was found between chest compression fraction and return of spontaneous circulation or survival.

Conclusion : The majority of chest compression interruptions during resuscitation were caused by prolonged rhythm checks, cardiopulmonary resuscitation provider switches, incorrect use of mechanical chest compression devices and ETT placement. No association was found between chest compression fraction and return of spontaneous circulation, nor an influence on survival. This was presumably caused by the high baseline chest compression fraction of >86%.

Conclusion (proposition de traduction) : La majorité des interruptions des compressions thoraciques pendant la réanimation ont été causées par des contrôles prolongés de rythme, des changements de prestataire de réanimation cardio-pulmonaire, une utilisation incorrecte des dispositifs de compression thoracique mécaniques et le placement de l'échocardiographie transthoracique. Aucune association n'a été trouvée entre la fraction de compression thoracique et la reprise d'activité cardiaque spontanée, ni d'influence sur la survie. Cela a probablement été causé par la fraction de compression thoracique de base élevée de > 86 %.

Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study.
Le Bastard Q, Rouzioux J, Montassier E, Baert V, Recher M, Hubert H, Leteurtre S, Javaudin F; GR-RéAC. | Resuscitation. 2021 Aug 18:S0300-9572(21)00314-2
DOI: https://doi.org/10.1016/j.resuscitation.2021.08.015
Keywords: Airway management; Endotracheal intubation; Paediatric out-of-hospital cardiac arrest; Supraglottic ventilation.

Online ahead of print

Introduction : Out-of-hospital cardiac arrest (OHCA) in children is associated with a low survival rate. Conclusions in the literature are conflicting regarding the best way to handle ventilation. The purpose of this study was to assess the impact of two airway management strategies, endotracheal intubation (ETI) vs. supraglottic procedure, during cardiopulmonary resuscitation (CPR) on 30-day survival in paediatric OHCA.

Méthode : This was a retrospective, observational, multicentre, registry-based study conducted from July 2011 to March 2018. All paediatric OHCA patients under 18 years of age and managed by a mobile intensive care unit were included. The primary endpoint was 30-day survival in a weighted population (based on propensity scores).

Résultats : Of 1579 children, 1355 (85.8%) received ETI and 224 (14.2%) received supraglottic ventilation during CPR. We observe a lower 30-day survival in the ETI group compared to the supraglottic group (7.7% vs. 14.3%, absolute difference, 6.6 percentage points; 95% confidence interval [CI], 2.3-12.0; propensity-adjusted odds ratio [paOR], 0.39; 95% CI, 0.25-0.62; p < 0.001), and also a poorer neurological outcome (paOR, 0.32; 95% CI, 0.19-0.54; p < 0.001). However, we did not identify any significant association between airway management strategy and return of spontaneous circulation (paOR, 1.15; 95% CI, 0.80-1.65; p = 0.46).

Conclusion : The findings of this large cohort study suggest that ETI in paediatric OHCA, although performed by trained physicians, is associated with a worse outcome, regardless of traumatic or non-traumatic aetiology.

Conclusion (proposition de traduction) : Les résultats de cette vaste étude de cohorte suggèrent que l'intubation endotrachéale dans les arrêts cardiaques pédiatriques extra-hospitaliers, bien qu'effectuée par des médecins qualifiés, est associée à un résultat plus défavorable, quelle que soit l'étiologie traumatique ou non traumatique.

Commentaire : Voir l'analyse de l'article sur le Board de la SFMU : L’intubation oro-trachéale des arrêts cardiaques pédiatriques pendant la réanimation améliore-t-elle le pronostic ?  . Rédigé par le Dr François Javaudin.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Point-of-care testing in out-of-hospital cardiac arrest: a retrospective analysis of relevance and consequences.
Gruebl T, Ploeger B, Wranze-Bielefeld E, Mueller M, Schmidbauer W, Kill C, Betz S. | Scand J Trauma Resusc Emerg Med. 2021 Aug 30;29(1):128
DOI: https://doi.org/10.1186/s13049-021-00943-w  | Télécharger l'article au format  
Keywords: Blood gas analysis; Hyperkalaemia; Hypokalaemia; H’s and T’s; OHCA; Out-of-hospital cardiac arrest; POCT; Point-of-care-testing; Resuscitation.

Original research

Introduction : Metabolic and electrolyte imbalances are some of the reversible causes of cardiac arrest and can be diagnosed even in the pre-hospital setting with a mobile analyser for point-of-care testing (POCT).

Méthode : We conducted a retrospective observational study, which included analysing all pre-hospital resuscitations in the study region between October 2015 and December 2016. A mobile POCT analyser (Alere epoc®) was available at the scene of each resuscitation. We analysed the frequency of use of POCT, the incidence of pathological findings, the specific interventions based on POCT as well as every patient's eventual outcome.

Résultats : N = 263 pre-hospital resuscitations were included and in n = 98 of them, the POCT analyser was used. Of these measurements, 64% were performed using venous blood and 36% using arterial blood. The results of POCT showed that 63% of tested patients had severe metabolic acidosis (pH < 7.2 + BE < - 5 mmol/l). Of these patients, 82% received buffering treatment with sodium bicarbonate. Potassium levels were markedly divergent normal (> 6.0 mmol/l/ < 2.5 mmol/l) in 17% of tested patients and 14% of them received a potassium infusion. On average, the pre-hospital treatment time between arrival of the first emergency medical responders and the beginning of transport was 54 (± 20) min without POCT and 60 (± 17) min with POCT (p = 0.07). Overall, 21% of patients survived to hospital discharge (POCT 30% vs no POCT 16%, p = 0.01, Φ = 0.16).

Conclusion : Using a POCT analyser in pre-hospital resuscitation allows rapid detection of pathological acid-base imbalances and potassium concentrations and often leads to specific interventions on scene and could improve the probability of survival.

Conclusion (proposition de traduction) : L'utilisation de la biologie déportée au point d'intervention en réanimation pré-hospitalière permet une détection rapide des déséquilibres acido-basiques pathologiques et des concentrations de potassium et conduit souvent à des interventions spécifiques sur place et pourrait améliorer la probabilité de survie.

Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis.
Colombo G, Bonzi M, Fiorelli E, Jachetti A, Bozzano V, Casazza G, Solbiati M, Costantino G. | Scand J Trauma Resusc Emerg Med. 2021 Aug 23;29(1):123
DOI: https://doi.org/10.1186/s13049-021-00936-9  | Télécharger l'article au format  
Keywords: Antithrombotic agents; Delayed intracerebral bleeding; Intracerebral hemorrhage; Traumatic brain injury.

Review

Introduction : The scientific evidence regarding the risk of delayed intracranial bleeding (DB) after mild traumatic brain injury (MTBI) in patients administered an antiplatelet agent (APA) is scant and incomplete. In addition, no consensus exists on the utility of a routine repeated head computed tomography (CT) scan in these patients.
Objective: The aim of this study was to evaluate the risk of DB after MTBI in patients administered an APA.

Méthode : A systematic review and meta-analysis of prospective and retrospective observational studies enrolling adult patients with MTBI administered an APA and who had a second CT scan performed or a clinical follow-up to detect any DB after a first negative head CT scan were conducted. The primary outcome was the risk of DB in MTBI patients administered an APA. The secondary outcome was the risk of clinically relevant DB (defined as any DB leading to neurosurgical intervention or death).

Résultats : Sixteen studies comprising 2930 patients were included in this meta-analysis. The pooled absolute risk for DB was 0.77% (95% CI 0.23-1.52%), ranging from 0 to 4%, with substantial heterogeneity (I2 = 61%). The pooled incidence of clinically relevant DB was 0.18%. The subgroup of patients on dual antiplatelet therapy (DAPT) had an increased DB risk, compared to the acetylsalicylic acid (ASA)-only patients (2.64% vs. 0.22%; p = 0.04).

Conclusion : Our systematic review showed a very low risk of DB in MTBI patients on antiplatelet therapy. We believe that such a low rate of DB could not justify routine repeated CT scans in MTBI patients administered a single APA. We speculate that in the case of clinically stable patients, a repeated head CT scan could be useful for select high-risk patients and for patients on DAPT before discharge.

Conclusion (proposition de traduction) : Notre étude systématique a montré un très faible risque d'hémorragie intracrânienne tardive chez les patients victimes d'un traumatisme cérébral léger sous traitement antiplaquettaire. Nous pensons qu'un taux aussi faible d'hémorragie intracrânienne retardée ne pourrait pas justifier la répétition systématique des tomodensitométries chez les patients victimes d'un traumatisme cérébral léger auxquels on administre un seul agent antiplaquettaire. Nous supposons que, dans le cas de patients cliniquement stables, un scanner cérébral répétée pourrait être utile pour sélectionner les patients à haut risque et pour les patients sous double antiagrégation plaquettaire avant leur sortie.

Commentaire : Le terme « double antiagrégation plaquettaire » (DAAP) se réfère à l'association d'aspirine et d'un inhibiteur du récepteur P2Y12 (IR-P2Y12) comme ticlodopine, clopidogrel, prasugrel et ticagrélor.

Symptoms presented during emergency telephone calls for patients with spontaneous subarachnoid haemorrhage.
Sonne A, Egholm S, Elgaard L, Breindahl N, Jensen AH, Eskesen V, Lippert F, Waldorff FB, Lohse N, Rasmussen LS. | Scand J Trauma Resusc Emerg Med. 2021 Aug 16;29(1):118
DOI: https://doi.org/10.1186/s13049-021-00934-x  | Télécharger l'article au format  
Keywords: Emergency medical dispatch; Emergency medical service; Headache; Spontaneous subarachnoid haemorrhage; Symptoms; Telephone; Triage; Visitation.

Original research

Introduction : A spontaneous subarachnoid haemorrhage (SAH) is one of the most critical neurological emergencies a dispatcher can face in an emergency telephone call. No study has yet investigated which symptoms are presented in emergency telephone calls for these patients. We aimed to identify symptoms indicative of SAH and to determine the sensitivity of these and their association (odds ratio, OR) with SAH.

Méthode : This was a nested case-control study based on all telephone calls to the medical dispatch center of Copenhagen Emergency Medical Services in a 4-year time period. Patients with SAH were identified in the Danish National Patient Register; diagnoses were verified by medical record review and their emergency telephone call audio files were extracted. Audio files were replayed, and symptoms extracted in a standardized manner. Audio files of a control group were replayed and assessed as well.

Résultats : We included 224 SAH patients and 609 controls. Cardiac arrest and persisting unconsciousness were reported in 5.8% and 14.7% of SAH patients, respectively. The highest sensitivity was found for headache (58.9%), nausea/vomiting (46.9%) and neck pain (32.6%). Among conscious SAH patients these symptoms were found to have the strongest association with SAH (OR 27.0, 8.41 and 34.0, respectively). Inability to stand up, speech difficulty, or sweating were reported in 24.6%, 24.2%, and 22.8%. The most frequent combination of symptoms was headache and nausea/vomiting, which was reported in 41.6% of SAH patients. More than 90% of headaches were severe, but headache was not reported in 29.7% of conscious SAH patients. In these, syncope was described by 49.1% and nausea/vomiting by 37.7%.

Conclusion : Headache, nausea/vomiting, and neck pain had the highest sensitivity and strongest association with SAH in emergency telephone calls. Unspecific symptoms such as inability to stand up, speech difficulty or sweating were reported in 1 out of 5 calls. Interestingly, 1 in 3 conscious SAH patients did not report headache.

Conclusion (proposition de traduction) : Céphalées, nausées/vomissements et douleurs cervicales étaient les plus sensibles et les plus fortement associés à l’hémorragie sous-arachnoidienne lors des appels téléphoniques d’urgence. Des symptômes non spécifiques tels que l’incapacité de se lever, des difficultés d’élocution ou la transpiration ont été rapportés dans 1 appel sur 5. Fait intéressant, 1 patient sur 3 souffrant d’hémorragie sous-arachnoidienne conscient n’a pas signalé de céphalées.

Patient outcomes after electrical injury - a retrospective study.
Ahmed J, Stenkula C, Omar S, Ghanima J, Bremtun FF, Bergan J, Raouf N, Ghanima W. | Scand J Trauma Resusc Emerg Med. 2021 Aug 6;29(1):114
DOI: https://doi.org/10.1186/s13049-021-00920-3  | Télécharger l'article au format  
Keywords: Arrhythmia; Electrical injury; High voltage.

Original research

Introduction : People exposed to electrical injuries are often admitted to hospital for observation. Current evidence suggests that patients who have a normal ECG on admission after a low-voltage injury, with no loss of consciousness or initial cardiac arrest may be discharged home after a short observation time. Currently, there are no established standards for the duration of monitoring after electric shock, but 24 h of observation is the most commonly adopted approach. We carried out a retrospective study of patients admitted after electrical injuries to determine the in-hospital outcomes and 30-day mortality in these patients.

Méthode : We performed a chart review of all patients with electrical injuries admitted to Østfold Hospital, Norway between the years 2001 and 2019, to determine in-hospital and 30-day mortality and the frequency of various cardiac and non-cardiac complications.

Résultats : Mean age of 465 included patients (88% males) was 31 years. Of all injuries, 329 (71%) were work-related, 17 (3.7%) involved loss of consciousness. Furthermore, 29/437 (6.6%) were high voltage (> 1000 V), and 243/401 (60.6%) were transthoracic injuries. 369 (79.4%) were discharged same day. None of the admitted patients died in hospital nor did any die within 30 days of admission, yielding a 30-day mortality of 0% (95% CI 0-0.8). At admission troponin was elevated in three (0.6%) patients, creatinine kinase (CK) in 30 (6.5%) and creatinine in six (1.3%). Electrocardiogram (ECG) abnormalities were described in 85 (18%) patients. No serious arrhythmias were detected. When comparing high- vs low-voltage or transthoracic vs other injuries, there were no significant differences between most of the outcomes, except for more ECG abnormalities in the transthoracic group, whereas more patients had elevated CK, and fewer discharged the same day in high-voltage injuries.

Conclusion : No in-hospital nor 30-day mortality or serious arrhythmias were encountered in those who were assessed, regardless of the type of injury. Troponin and creatinine were rarely elevated. It seems that conscious patients admitted with a normal ECG following a low-voltage injury may safely be discharged home after a quick clinical assessment including ECG.

Conclusion (proposition de traduction) : Aucun décès à l’hôpital ou après 30  jours ou arythmies graves n’a été observé chez les personnes évaluées, peu importe le type d'atteinte. Les taux de troponine et de créatinine ont été rarement élevés. Il semble que les patients conscients admis avec un ECG normal à la suite d’une lésion de basse tension puissent être renvoyés chez eux en toute sécurité après une évaluation clinique rapide incluant un ECG.

Large variations of oxygen delivery in self-inflating resuscitation bags used for preoxygenation - a mechanical simulation.
Grauman S, Johansson J, Drevhammar T. | Scand J Trauma Resusc Emerg Med. 2021 Jul 19;29(1):98
DOI: https://doi.org/10.1186/s13049-021-00885-3  | Télécharger l'article au format  
Keywords: BVM; Emergency anaesthesia; Oxygen delivery; Preoxygenation; Self-inflating resuscitation bags.

Original research

Introduction : Self-Inflating Resuscitation Bags (SIRB) are common and essential tools in airway management and ventilation. They are often used in resuscitation and emergency anaesthesia outside the operating theatre. There is a common notion that all SIRBs applied with a tight sealed mask will deliver close to 100 % oxygen during spontaneous breathing. The aim of the study was to measure the oxygen delivery of six commonly used SIRBs in a mechanical spontaneous breathing adult in vitro model.

Méthode : Three SIRBs of each of the six models were evaluated for oxygen delivery during simulated breathing with an adult mechanical lung. The test was repeated three times per device (54 tests in total). The breathing profile was fixed to a minute volume of 10 L/min, a tidal volume of 500 mL and the SIRBs supplied with an oxygen fresh gas flow of 15 L/min. The fraction of delivered oxygen (FDO2) was measured over a three-minute period. Average FDO2 was calculated and compared at 30, 60 and 90 s.

Résultats : At 90 s all models had reached a stable FDO2. Average FDO2 at 90 s; Ambu Oval Plus 99,5 %; Ambu Spur II 99,8 %; Intersurgical BVM Resuscitator 76,7 %; Laerdal Silicone 97,3 %; Laerdal The Bag II 94,5 % and the O-Two Smart Bag 39,0 %. All differences in FDO2 were significant apart from the two Ambu models.

Conclusion : In simulated spontaneous breathing, four out of six (by Ambu and Laerdal) Self-Inflating Resuscitation Bags delivered a high fraction of oxygen while two (Intersurgical and O-two) underperformed in oxygen delivery. These large variations confirm results reported in other studies. It is our opinion that underperforming Self-Inflating Resuscitation Bags might pose a serious threat to patients' health if used in resuscitation and anaesthesia. Manufacturers of Self-Inflating Resuscitation Bags rarely provide information on performance for spontaneous breathing. This poses a challenge to all organizations that need their devices to deliver adequate oxygen during spontaneous breathing.

Conclusion (proposition de traduction) : En ventilation spontanée en simulation, quatre sur les six (par Ambu et Laerdal) ballon autoremplisseur à valve unidirectionnel ont fourni une forte proportion d’oxygène, tandis que deux autres (interchirurgicale et O-deux) ont fourni moins d’oxygène. Ces écarts importants confirment les résultats rapportés dans d’autres études. Nous sommes d’avis que les ballons autoremplisseurs à valve unidirectionnel sous-performants pourraient représenter une grave menace pour la santé des patients s’ils sont utilisés pour la réanimation et l’anesthésie. Les fabricants de ballons autoremplisseurs à valve unidirectionnel fournissent rarement des informations sur la performance pour la ventilation spontanée. Cela pose un défi à toutes les organisations qui ont besoin de leurs appareils pour fournir suffisamment d’oxygène pendant la ventilation spontanée.

Shock

Childhood Mortality After Fluid Bolus With Septic or Severe Infection Shock: A Systematic Review and Meta-Analysis.
Yue J, Zheng R, Wei H, Li J, Wu J, Wang P, Zhao H. | Shock. 2021 Aug 1;56(2):158-166
DOI: https://doi.org/10.1097/shk.0000000000001657
Keywords: Aucun

Review Article

Introduction : A considerable debate on whether fluid bolus could decrease childhood mortality in pediatric patients with septic or severe infection shock is still unresolved. A systematic review and meta-analysis was conducted to investigate the mortality rates after fluid bolus among children with septic or severe infection shock.

Méthode : A systematic electronic search of PubMed, MEDLINE, Cochrane Library, and EMBASE databases was conducted to identify relevant published studies till March 30, 2020.

Résultats : A total of 19 studies with 9,321 severe sepsis or septic shock pediatric patients were included and exhibited an acceptable quality. Of the 17 studies that reported mortality at 48 h, no bolus group decreased the mortality rate when compared with bolus group with a risk ratio (RR) of 0.74 [95% confidence interval (CI) = 0.62-0.88, P < 0.01], and showed no heterogeneity (I2 = 0%). Similar results were observed on colloids and crystalloids solution in malaria shock cases with a RR of 0.79 (95% CI = 0.62-1.02). For the subgroup of general shock patients, no significant difference was shown with an RR of 0.79 (95% CI = 0.62-1.02, P = 0.07) and no significant heterogeneity (I2 = 0%). Two studies reported mortality at week 4 and pooled results indicated that no bolus group was protective against mortality when compared with bolus group with RR of 0.71 (95% CI = 0.57-0.88, I2 = 0%).

Conclusion : For the mortality at 48 h, the no bolus group showed decreased mortality when compared with the bolus group, especially in the malaria group. Similar results were found in the colloids and crystalloids solution in patients with malaria shock. Meta-analysis studies with long-term follow-up period and larger sample size are warranted to address the conclusion in the future.

Conclusion (proposition de traduction) : Pour la mortalité à 48 h, le groupe sans bolus a montré une diminution de la mortalité par rapport au groupe bolus, en particulier dans le groupe paludisme. Des résultats similaires ont été trouvés pour la solution de colloïdes et de cristalloïdes chez des patients en choc palustre. Des études de méta-analyse avec une période de suivi à long terme et une plus grande taille d'échantillon sont justifiées pour aborder la conclusion à l'avenir.

Stroke

Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign.
Ovesen C, Jakobsen JC, Gluud C, Steiner T, Law Z, Flaherty K, Dineen RA, Christensen LM, Overgaard K, Rasmussen RS, Bath PM, Sprigg N, Christensen H. | Stroke. 2021 Aug;52(8):2629-2636
DOI: https://doi.org/10.1161/strokeaha.120.032426
Keywords: angiography; cerebral hemorrhage; computed tomography angiography; hematoma; tranexamic acid

Original contribution

Introduction : The computed tomography angiography or contrast-enhanced computed tomography based spot sign has been proposed as a biomarker for identifying on-going hematoma expansion in patients with acute intracerebral hemorrhage. We investigated, if spot-sign positive participants benefit more from tranexamic acid versus placebo as compared to spot-sign negative participants.

Méthode : TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) was a randomized, placebo-controlled clinical trial recruiting acutely hospitalized participants with intracerebral hemorrhage within 8 hours after symptom onset. Local investigators randomized participants to 2 grams of intravenous tranexamic acid or matching placebo (1:1). All participants underwent computed tomography scan on admission and on day 2 (24±12 hours) after randomization. In this sub group analysis, we included all participants from the main trial population with imaging allowing adjudication of spot sign status.

Résultats : Of the 2325 TICH-2 participants, 254 (10.9%) had imaging allowing for spot-sign adjudication. Of these participants, 64 (25.2%) were spot-sign positive. Median (interquartile range) time from symptom onset to administration of the intervention was 225.0 (169.0 to 310.0) minutes. The adjusted percent difference in absolute day-2 hematoma volume between participants allocated to tranexamic versus placebo was 3.7% (95% CI, -12.8% to 23.4%) for spot-sign positive and 1.7% (95% CI, -8.4% to 12.8%) for spot-sign negative participants (Pheterogenity=0.85). No difference was observed in significant hematoma progression (dichotomous composite outcome) between participants allocated to tranexamic versus placebo among spot-sign positive (odds ratio, 0.85 [95% CI, 0.29 to 2.46]) and negative (odds ratio, 0.77 [95% CI, 0.41 to 1.45]) participants (Pheterogenity=0.88).

Conclusion : Data from the TICH-2 trial do not support that admission spot sign status modifies the treatment effect of tranexamic acid versus placebo in patients with acute intracerebral hemorrhage. The results might have been affected by low statistical power as well as treatment delay.

Conclusion (proposition de traduction) : Les données de l'essai TICH-2 ne confirment pas que le statut du Spot Sign à l'admission modifie l'effet du traitement par l'acide tranexamique par rapport au placebo chez les patients présentant une hémorragie intracérébrale aiguë. Les résultats pourraient avoir été affectés par une faible puissance statistique ainsi que par un délai de mise en place du traitement.

Commentaire : « Spot sign » : visualisation en phase aiguë de l’extravasation de produit de contraste au sein de l’HIC qui pourrait être un élément prédictif d’une extension de l’HIC.

The American Journal of Emergency Medicine

Effects of ultrasound-guided techniques for radial arterial catheterization: A meta-analysis of randomized controlled trials.
Zhao W, Peng H, Li H, Yi Y, Ma Y, He Y, Zhang H, Li T. | Am J Emerg Med. 2021 Aug;46:1-9
DOI: https://doi.org/10.1016/j.ajem.2020.04.064
Keywords: Aucun

Original Contribution

Introduction : This study aimed to evaluate whether ultrasound-guided techniques are superior compared to traditional palpation techniques in patients undergoing radial artery catheterization (RAC).

Méthode : Electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched to identify randomized controlled trials (RCTs). The relative risks (RRs) or weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were used to calculate the pooled effect estimates using the random effects model for categories and continuous data, respectively.

Résultats : A total of 19 RCTs comprising a total of 3220 individuals were selected for final analysis. The pooled RR suggested that ultrasound-guided techniques were associated with higher incidence of first attempt success than traditional palpation techniques (RR, 1.39; 95% CI, 1.21-1.59; P < 0.001). Moreover, we noted that ultrasound-guided techniques were associated with fewer mean attempts to success (WMD, -0.80 s; 95% CI, -1.35 to -0.25; P = 0.004) and a shorter mean time to success (WMD, -41.18 s; 95% CI, -75.43 to -6.93; P = 0.018) than traditional palpation techniques. Furthermore, individuals using ultrasound-guided techniques had a reduced risk of hematoma (RR, 0.40; 95% CI, 0.22-0.72; P = 0.003).

Conclusion : This study indicated that ultrasound-guided techniques were superior compared to traditional palpation techniques for RAC in terms of efficacy and complications.

Conclusion (proposition de traduction) : Cette étude a montré que les techniques guidées par échographie étaient supérieures aux techniques de palpation traditionnelles pour le cathétérisme de l'artère radiale en termes d'efficacité et de complications.

The prognostic value of early lactate clearance for survival after out-of-hospital cardiac arrest.
Lonsain WS, De Lausnay L, Wauters L, Desruelles D, Dewolf P. | Am J Emerg Med. 2021 Aug;46:56-62
DOI: https://doi.org/10.1016/j.ajem.2021.03.013
Keywords: Lactate clearance; OHCA; Prognostication; Resuscitation.

Original contribution

Introduction : Prognostication of survival after out-of-hospital cardiac arrest (OHCA) remains challenging with current guidelines recommending the prognostication no earlier than 72 h after return of spontaneous circulation (ROSC). Prognostic factors that could be used earlier after ROSC, like lactate clearance, are still being studied.
Objectives : This paper aims to investigate the prognostic strength of early lactate clearance for survival after OHCA.

Méthode : This retrospective observational single-center study focuses on patients for whom ROSC was achieved after OHCA. Patients ≥18 years admitted between September 2012 and January 2019, for which arterial serum lactate measurements were available immediately at and 3 h after hospital admission (T0 and T3), were included.

Résultats : 192 patients were included. Lactate clearance at T3 (p < 0.001) was identified as an independent predictor for 24 h, 48 h and 72 h survival. Witnessed arrest, bystander CPR and initial shockable rhythm were independent significant predictors for long term survival after ROSC (1 month, 3 months and 1 year; p < 0.05), but not for 24 h survival. Age (above or below 65 years) was not significant for predicting survival. Upon combination of witnessed arrest, bystander CPR and initial shockable rhythm in a multivariate logistic regression model for long term survival, the initial rhythm was the dominant factor in the combined model, making witnessed arrest and bystander CPR redundant.

Conclusion : Lactate clearance at T3 after ROSC is associated with 24 h, 48 h and 72 h survival. Further research is needed to determine how to incorporate lactate clearance as part of a clinically useful tool to predict long term survival.

Conclusion (proposition de traduction) : La clairance du lactate, 3 h après l'hospitalisation, après reprise d'activité cardiaque spontanée, est associée à une survie de 24 h, 48 h et 72 h. Des recherches supplémentaires sont nécessaires pour déterminer comment intégrer la clairance du lactate dans le cadre d'un outil cliniquement utile pour prédire la survie à long terme.

Diagnostic value of transthoracic echocardiography compared to electrocardiogram in predicting coronary artery stenosis among patients after cardiac arrest.
Kim J, Cho YS, Lee BK, Lee DH, Jung E, Moon JM, Chun BJ. | Am J Emerg Med. 2021 Aug;46:97-101
DOI: https://doi.org/10.1016/j.ajem.2021.02.053
Keywords: Cardiac arrest; Coronary artery stenosis; Echocardiography; Electrocardiogram.

Original contribution

Introduction : In the absence of ST-segment elevation (STE) in post-return of spontaneous circulation (ROSC) electrocardiogram (ECG), coronary angiography (CAG) is required in patients with suspected coronary artery disease (CAD). However, it is a challenge to identify patients with CAD after cardiac arrest (CA). Recent European Society of Cardiology guidelines recommends transthoracic echocardiography in patients presenting with cardiac arrest. We aimed to assess the diagnostic value of regional wall motion abnormalities (RWMAs) on transthoracic echocardiography (TTE) compared to ECG in diagnosing significant coronary artery stenosis in CA patients.

Méthode : This is a retrospective, observational study of adult CA patients with presumed cardiac etiology who underwent CAG from a single tertiary care hospital. We compared the predictive value of RWMA on TTE and STE on ECG in significant stenosis of ≥70% of the coronary artery diameter. The primary outcome was significant stenosis on CAG.

Résultats : There were 145 patients included in this study and CAG revealed significant stenosis in 76 (52.4%) patients. Among the 76 patients with significant stenosis, 68 (89.5%) had RWMA on TTE and 41 (54.0%) had STE. RWMA on TTE (OR 3.67; 95% CI 1.52-8.85) was independently associated with significant stenosis. Combining both RWMA on TTE and STE on ECG improved performance in the receiver operating characteristic curve analysis (area under the curve 0.722) for predicting significant stenosis compared to using only ECG alone (p = 0.001).

Conclusion : RWMAs on TTE was independently associated with significant stenosis. The RWMA and STE combination had better predictive performance than using only STE on ECG to predict significant stenosis.

Conclusion (proposition de traduction) : Les anomalies régionales du mouvement de la paroi à l'échocardiographie transthoracique étaient indépendamment associées à une sténose significative. L'anomalie régionale du mouvement de la paroi et la combinaison avec une sur-élévation du segment ST avaient de meilleures performances prédictives que d'utiliser uniquement la sur-élévation du segment ST sur l'ECG pour prédire une sténose significative.

Arterial or cuff pressure: Clinical predictors among patients in shock in a critical care resuscitation unit.
Raffman A, Tanveer S, Jones K, Parker BM, Haase DJ, Tran QK. | Am J Emerg Med. 2021 Aug;46:109-115
DOI: https://doi.org/10.1016/j.ajem.2021.03.012
Keywords: Clinically relevant difference; Invasive arterial blood pressure; Noninvasive arterial blood pressure; Shock.

Original contribution

Introduction : Blood pressure (BP) measurement is essential for managing patients with hypotension. There are differences between invasive arterial blood pressure (IABP) and noninvasive blood pressure (NIBP) measurements. However, the clinical applicability of these differences in patients with shock [need for vasopressor or serum lactate ≥ 4 millimole per liter (mmol/L)] has not been reported. This study investigated differences in IABP and NIBP as well as changes in clinical management in critically ill patients with shock.

Méthode : This was a retrospective study involving adult patients admitted to the Critical Care Resuscitation Unit (CCRU). Adult patients who received IABP upon admission between 01/01/2017-12/31/2017 with non-hypertensive diseases were eligible. The primary outcome, clinically relevant difference (CRD), was defined as difference of 10 mm of mercury (mmHg) between IABP and NIBP and change of blood pressure management according to goal mean arterial pressure (MAP) ≥ 65 mmHg. We performed forward stepwise multivariable logistic regression to measure associations.

Résultats : Sample size calculation recommended 200 patients, and we analyzed 263. 121 (46%) patients had shock, 23 (9%) patients had CRD. Each mmol/L increase in serum lactate was associated with 11% higher likelihood of having CRD (OR 1.11, 95%CI 1.002-1.2). Peripheral artery disease and any kidney disease was significantly associated with higher likelihood of MAP difference ≥ 10 mmHg.

Conclusion : Approximately 9% of patients with shock had clinically-relevant MAP difference. Higher serum lactate was associated with higher likelihood of CRD. Until further studies are available, clinicians should consider using IABP in patients with shock.

Conclusion (proposition de traduction) : Environ 9 % des patients en état de choc présentaient une différence de pression artérielle moyenne cliniquement pertinente. Un taux de lactate sérique plus élevé était associé à une probabilité plus élevée de différence cliniquement pertinente. Jusqu'à ce que d'autres études soient disponibles, les cliniciens devraient envisager d'utiliser la pression artérielle invasive chez les patients en état de choc.

Multicenter retrospective analysis of the risk factors for delayed neurological sequelae after acute carbon monoxide poisoning.
Zhang Y, Lu Q, Jia J, Xiang D, Xi Y. | Am J Emerg Med. 2021 Aug;46:165-169
DOI: https://doi.org/10.1016/j.ajem.2020.06.090
Keywords: Carbon monoxide poisoning; Delayed neurological sequelae; Risk factors.

Original contribution

Introduction : Delayed neurological sequelae (DNS) is a devastating consequence following acute carbon monoxide (CO) poisoning. This study aims at exploring the independent predictors of DNS in patients with CO exposure.

Méthode : Data of patients with diagnosis of CO poisoning was retrospectively collected and reviewed in 5 regional medical facilities. Patients were classified into the DNS group and non-DNS group according to clinical findings during a follow-up period of 6 months. Demographic characteristics, co-morbidities, clinical manifestations, and treatment strategies were compared to identify possible correlative factors. Multivariate analysis was performed to determine the independent predictors of DNS.

Résultats : We screened 1129 patients and enrolled 326 cases (158 males, average age 44.56 ± 16.08 years) in the analysis. Thirty-seven (11.35%) developed DNS at a median interval of 33 days. Uni-variable analysis identified older age, higher body mass index, hypertension, loss of consciousness, longer CO exposure, lower Glasgow Coma Scale (GCS) on-site/at emergency room, and elevation of lactate as relevant factors for DNS; while multivariable logistic regression revealed that older age (OR = 1.11; p < 0.001), longer duration of CO exposure (OR = 1.54; p = 0.023), GCS on-site (OR = 2.06; p < 0.001), and GCS at emergency room (OR = 1.33; p = 0.048) were independent predictors for DNS.

Conclusion : Our multicenter study demonstrated older age, longer duration of CO exposure, and GCS score were independent predictors of DNS in COP patients. GCS scored on-site might be a more sensitive and specific parameter compared with GCS evaluated at the emergency room. Further prospective studies in a larger patient cohort are warranted to draw a comprehensive conclusion.

Conclusion (proposition de traduction) : Notre étude multicentrique a démontré qu'un âge plus avancé, une durée d'exposition au monoxyde de carbone plus longue et le score de l'échelle de coma de Glasgow étaient des prédicteurs indépendants de séquelles neurologiques retardées chez les patients intoxiqués au monoxyde de carbone. L'échelle de coma de Glasgow évaluée sur place pourrait être un paramètre plus sensible et spécifique par rapport à l'échelle de coma de Glasgow évaluée en salle d'urgence. D'autres études prospectives dans une plus grande cohorte de patients sont justifiées pour tirer une conclusion complète.

Ideal high sensitivity troponin baseline cutoff for patients with renal dysfunction.
Limkakeng AT Jr, Hertz J, Lerebours R, Kuchibhatla M, McCord J, Singer AJ, Apple FS, Peacock WF, Christenson RH, Nowak RM. | Am J Emerg Med. 2021 Aug;46:170-17
DOI: https://doi.org/10.1016/j.ajem.2020.06.072
Keywords: Acute coronary syndrome; Acute myocardial infarction; High-sensitivity troponin assays; Renal disease.

Original contribution

Introduction : High-sensitivity cardiac troponin assays (hs-cTn) aid in diagnosis of myocardial infarction (MI). These assays have lower specificity for non-ST Elevation MI (NSTEMI) in patients with renal disease. Our objective was to determine an optimized cutoff for patients with renal disease.

Méthode : We conducted an a priori secondary analysis of a prospective FDA study in adults with suspected MI presenting to 29 academic urban EDs between 4/2015 and 4/2016. Blood was drawn 0, 1, 2-3, and 6-9 h after ED arrival. We recorded cTn and estimated glomerular filtrate rate (eGFR) by Chronic Kidney Disease Epidemiology Collaboration equation. The primary endpoint was NSTEMI (Third Universal Definition of MI), adjudicated by physicians blinded to hs-cTn results. We generated an adjusted hscTn rule-in cutoff to increase specificity.

Résultats : 2505 subjects were enrolled; 234 were excluded. Patients were mostly male (55.7%) and white (57.2%), median age was 56 years 472 patients [20.8%] had an eGFR <60 mL/min/1.73 m2. In patients with eGFR <15 mL/min/1.73 m2, a baseline rule-in cutoff of 120 ng/L led to a specificity of 85.0% and Positive Predictive Value (PPV) of 62.5% with 774 patients requiring further observation. Increasing the cutoff to 600 ng/L increased specificity and PPV overall and in every eGFR subgroup (specificity and PPV 93.3% and 78.9%, respectively for eGFR <15 mL/min/1.73m2), while increasing the number (79) of patients requiring observation.

Conclusion : An eGFR-adjusted baseline rule-in threshold for the Siemens Atellica hs-cTnI improves specificity with identical sensitivity. Further study in a prospective cohort with higher rates of renal disease is warranted.

Conclusion (proposition de traduction) : Un seuil de référence de référence ajusté par le débit de filtrat glomérulaire estimé pour les dosages de troponine cardiaque à haute sensibilité Siemens Atellica améliore la spécificité avec une sensibilité identique. Une étude plus approfondie dans une cohorte prospective avec des taux plus élevés de maladie rénale est justifiée.

Commentaire : Une DFGe < 15 ml/min/1,73 m2 semble nécessiter un relèvement du taux normal de troponineus (plus de 120 ng/L à 600 ng/L) pour une spécificité de 85,0 % et une valeur prédictive positive (VPP) de 62,5 %.

Intravenous magnesium sulfate vs. morphine sulfate in relieving renal colic: A randomized clinical trial.
Zolfaghari Sadrabad A, Azimi Abarghouei S, Farahmand Rad R, Salimi Y. | Am J Emerg Med. 2021 Aug;46:188-192
DOI: https://doi.org/10.1016/j.ajem.2020.07.035
Keywords: Magnesium sulfate; Morphine; Pain management; Randomized controlled trial; Renal colic.

Original contribution

Introduction : Renal colic emerging from renal stone is virtually the most severe pain which is experienced. Intravenous infusion of morphine sulfate is known as a usual treatment for the disease. This study was designed to compare the efficacy of magnesium sulfate vs morphine sulfate in renal colic relief as for analgesic effect as well as lack of morphine sulfate side effects when using magnesium sulfate.

Méthode : We conducted a double-blind randomized clinical trial in renal colic patients who had referred to the emergency department of Shahid Sadoughi Hospital in Yazd, Iran. A total of 80 eligible patients were selected and randomly assigned into two groups; patients in the case group received 50 mg/kg intravenous magnesium sulfate, and those in the control group 0.1 mg/kg intravenous morphine. The primary outcome was the pain score measured on a numerical rating scale at 0, 10 and 20 minutes after infusion. Data were analyzed using SPSS16.

Résultats : The two groups were similar in terms of demographic features and pain intensity at the time of referral (P <.0001). Ten minutes after drug administration, the pain mean score in the morphine group leveled at 4.88, and in the magnesium group 5.70, which proved to be greater in the morphine group (P- = 0.06). However, the pain mean score turned out to be 3.65 in the morphine group and 3.20 in the magnesium group thus significantly indifferent (P = .48).

Conclusion : In this study, we concluded that administration of intravenous 50 mg/kg magnesium sulfate could be as effective as morphine in reducing renal colic without any further complications.

Conclusion (proposition de traduction) : Dans cette étude, nous avons conclu que l'administration de 50 mg/kg de sulfate de magnésium par voie intraveineuse pourrait être aussi efficace que la morphine pour réduire les coliques néphrétiques sans autre complication.

Incidence of prescription errors in patients discharged from the emergency department.
Gregory H, Cantley M, Calhoun C, Hall GA, Matuskowitz AJ, Weant KA. | Am J Emerg Med. 2021 Aug;46:266-270
DOI: https://doi.org/10.1016/j.ajem.2020.07.061
Keywords: Emergency department; Medication errors; Pharmacist review; Prescription errors.

Original contribution

Introduction : The Emergency Department (ED) is known for its high rates of medication errors secondary to many characteristics such as unfamiliar patients, lack of continuity of care, increasing patient volumes, reliance on verbal orders, and fewer safety mechanisms. The purpose of this study was to quantify and characterize the medication errors that occur in patients discharged from the ED.

Méthode : Prescriptions for patients discharged from the adult ED at an academic medical center from 2015 to 2018 were reviewed. Errors in discharge medication orders were documented as well as characteristics of these errors including medication class, errors in prescription directions, quantity prescribed, and refills given inappropriately.

Résultats : A total of 115,933 prescriptions were reviewed and a total of 20,498 errors were identified within 19,126 prescriptions. Of the errors identified, 4048 (19.7%) involved prescription directions, 6537 (31.9%) were errors in quantity prescribed, and 9913 (48.4%) were prescriptions written with refills. The proportion of errors among different prescriber statuses was significantly different when comparing all prescribers (p < .001). Prescriptions written by Non-Emergency Medicine residents had significantly more errors in quantity and refills (p < .001, p < .001), and prescriptions written by Emergency Medicine residents had significantly more errors in directions (p < .001).

Conclusion : This review identified a 16.5% error rate among all prescriptions provided to patients upon ED discharge that varied among different subcategories of medications. This is consistent with the limited literature that is currently available on the topic. These results could assist institutions in developing targeted mitigation strategies to limit medication misadventures in patients discharged from the ED.

Conclusion (proposition de traduction) : Cette revue a identifié un taux d'erreur de 16,5 % parmi toutes les ordonnances fournies aux patients à leur sortie du service d'urgence, qui variait selon les différentes sous-catégories de médicaments. Ceci est cohérent avec la littérature limitée actuellement disponible sur le sujet. Ces résultats pourraient aider les établissements à développer des stratégies d'atténuation ciblées pour limiter les mésaventures médicamenteuses chez les patients sortis des urgences.

A novel approach: Point-of-care ultrasound for the diagnosis of retropharyngeal abscess.
Malia L, Sivitz A, Chicaiza H. | Am J Emerg Med. 2021 Aug;46:271-275
DOI: https://doi.org/10.1016/j.ajem.2020.07.060
Keywords: POCUS; Point-of-care ultrasound; RPA; Retropharyngeal abscess.

Original contribution

Editorial : Deep space neck infections in children, specifically retropharyngealabscesses (RPA), are uncommon. Retropharyngeal abscesses are generally a disease of young children, peaking between 2 and 4 years of age,although can be seen at any age. They are most commonly seen secondary to a preceding infection, though can result from trauma. Failure to recognize and appropriately treat can have potentially serioussequelae. Complications range from airway obstruction, sepsis, andspread to other deep neck spaces or structures such as the internal jugular vein, carotid artery, or mediastinum

Conclusion : Ultrasound use to detect a retropharyngeal abscesses has been minimally studied. We describe a technique here for point-of-care ultrasound to assess for retropharyngeal abscesses. Transcutaneous ultrasound should be considered in the evaluation ofsuspected retropharyngeal abscess. Further research on this Point-of-Care UltraSound application is needed to determine its usefulness on a larger scale.

Conclusion (proposition de traduction) : L'utilisation de l'échographie pour détecter un abcès rétropharyngé a été peu étudiée. Nous décrivons ici une technique d'échographie au point d'intervention pour évaluer les abcès rétropharyngés. L'échographie transcutanée doit être envisagée dans l'évaluation d'un abcès rétropharyngien suspecté. Des recherches supplémentaires sur cette application de l'échographie au point d'intervention sont nécessaires pour déterminer son utilité à plus grande échelle.

Use of high-flow nasal cannula and noninvasive ventilation in patients with COVID-19: A multicenter observational study.
Duan J, Chen B, Liu X, Shu W, Zhao W, Li J, Li Y, Hong Y, Pan L, Wang K. | Am J Emerg Med. 2021 Aug;46:276-281
DOI: https://doi.org/10.1016/j.ajem.2020.07.071  | Télécharger l'article au format  
Keywords: COVID-19; High-flow nasal cannula; Intubation; Noninvasive ventilation.

Original contribution

Introduction : The use of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) in patients with COVID-19 is debated.

Méthode : This study was performed in four hospitals of China from January to March 2020. We retrospectively enrolled 23 and 13 COVID-19 patients who used HFNC and NIV as first-line therapy, respectively.

Résultats : Among the 23 patients who used HFNC as first-line therapy, 10 experienced HFNC failure and used NIV as rescue therapy. Among the 13 patients who used NIV as first-line therapy, one (8%) used HFNC as rescue therapy due to NIV intolerance. The duration of HFNC + NIV (median 7.1, IQR: 3.5-12.2 vs. 7.3, IQR: 5.3-10.0 days), intubation rate (17% vs. 15%) and mortality (4% vs. 8%) did not differ between patients who used HFNC and NIV as first-line therapy. In total cohorts, 6 (17%) patients received intubation. Time from initiation of HFNC or NIV to intubation was 8.4 days (IQR: 4.4-18.5). And the time from initiation of HFNC or NIV to termination in patients without intubation was 7.1 days (IQR: 3.9-10.3). Among all the patients, C-reactive protein was independently associated with intubation (OR = 1.04, 95% CI: 1.01-1.07). In addition, no medical staff got nosocomial infection who participated in HFNC and NIV management.

Conclusion : In critically ill patients with COVID-19 who used HFNC and NIV as first-line therapy, the duration of HFNC + NIV, intubation rate and mortality did not differ between two groups. And no medical staff got nosocomial infection during this study.

Conclusion (proposition de traduction) : Chez les patients de réanimation présentant une pneumopathie COVID-19 qui ont bénéficié d'OHD et de VNI comme traitement de première intention, la durée OHD + VNI, le taux d'intubation et la mortalité ne différaient pas entre les deux groupes. Et aucun membre du personnel médical n'a contracté d'infection nosocomiale au cours de cette étude.

Evaluation of the blood pressure effects of diltiazem versus metoprolol in the acute treatment of atrial fibrillation with rapid ventricular rate.
Nuñez Cruz S, DeMott JM, Peksa GD, Slocum GW. | Am J Emerg Med. 2021 Aug;46:329-334
DOI: https://doi.org/10.1016/j.ajem.2020.10.003
Keywords: Atrial fibrillation; Atrial flutter; Diltiazem; Metoprolol; Rapid ventricular rate.

Original contribution

Introduction : To evaluate the difference in blood pressure effects of diltiazem intravenous push (IVP) and metoprolol IVP in the acute management of atrial fibrillation with rapid ventricular rate (AF with RVR).

Méthode : This was a single-center, retrospective cohort study evaluating patients who presented to the emergency department (ED) between January 2012 and September 2018 in AF with RVR and received either diltiazem IVP or metoprolol IVP as the first agent for rate control. The primary objective was the change in systolic blood pressure (SBP) within one hour of initial medication administration. Secondary outcomes included repeat doses within one hour, rate control to <110 beats per minute, and SBP <90 mmHg or decrease by >40% within three hours. Subgroup analysis of patients with a baseline SBP <110 mmHg was conducted.

Résultats : Of the 160 patients included, 80 received diltiazem and 80 metoprolol. The primary outcome of median change in SBP at one hour was a difference of -9 [-21 to 6] mmHg in the diltiazem group versus a difference of -4 [-18 to 9] mmHg in the metoprolol group (p = 0.102). Subgroup analysis (n = 28) of patients with a baseline SBP <110 mmHg demonstrated an increase of 7 [-0.25 to 19] mmHg in the diltiazem group versus increase of 7 [0 to 13] in the metoprolol group (p = 0.910).

Conclusion : No significant difference was observed in the blood pressure effects of diltiazem IVP versus metoprolol IVP in the acute management of AF with RVR.

Conclusion (proposition de traduction) : Aucune différence significative n'a été observée sur la pression artérielle avec l'administration intraveineuse de diltiazem par rapport à l'administration intraveineuse de métoprolol dans la gestion aiguë de la fibrillation atriale avec une fréquence ventriculaire rapide.

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock.
Jouffroy R, Léguillier T, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Gueye-Ngalgou P, Nivet-Antoine V, Beaudeux JL, Vivien B. | Am J Emerg Med. 2021 Aug;46:367-373
DOI: https://doi.org/10.1016/j.ajem.2020.10.018
Keywords: Association; Blood lactate; Clearance; Prehospital setting; Septic shock; Severe sepsis.

Original contribution

Introduction : Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes.

Méthode : From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate.

Résultats : Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l-1 vs 1.65 ± 2.88 mmol.l-1, p = 0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26-0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08-3.84], p = 0.028).

Conclusion : A prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.

Conclusion (proposition de traduction) : Une clairance préhospitalière du lactate sanguin < 10 % est associée à une augmentation de la mortalité à 30 jours chez les patients présentant un choc septique traité par l'intervention de l'unité mobile de soins intensifs préhospitalière. D'autres études seront nécessaires pour évaluer si la clairance du lactate sanguin préhospitalier seule ou combinée avec des scores cliniques pourrait affecter le processus de prise de décision de triage pour ces patients.

Transport of awake hypoxemic probable COVID 19 patients in the prone position.
Şan İ, Yıldırım Ç, Bekgöz B, Gemcioğlu E. | Am J Emerg Med. 2021 Aug;46:420-423
DOI: https://doi.org/10.1016/j.ajem.2020.10.036  | Télécharger l'article au format  
Keywords: COVID 19; Hypoxemia; Prone position; Transport.

Original contribution

Introduction : We aimed to investigate the effects of transport with prone position on hypoxemia in hypoxemic and awake probable COVID 19 pneumonia patients.

Méthode : Hypoxic and awake patients with probable COVID 19 pneumonia who were referred to the Ankara City Hospital Emergency Department from 1 April to 31 May 2020 were included in this prospective study. Patients were transported in prone position and fixed on the stretcher. During the transport, patients continued receiving 2 l per minute oxygen with nasal cannula. Arterial blood gases were obtained from the patients before and after transport. The transport time was recorded as minutes. The primary outcome of the study is the increase of partial oxygen value in the arterial blood gas of patients after transport.

Résultats : It was found that pO2 and SpO2 end values were statistically significantly higher in the patient group compared to the initial values. In the group with transport duration of more than 15 min, a difference was found between the initial and end values in pO2 and SpO2 parameters similar to the whole group. However, there was no statistically significant difference between the initial and end values in the group with transport duration of 15 min or below.

Conclusion : Awake hypoxemic patients can be transported without complications in prone position during transport. Transports more than 15 min, prone position may be recommended because the partial oxygen pressure of the patients increases.

Conclusion (proposition de traduction) : Les patients hypoxémiques non sédatés peuvent être transportés sans complications en position ventrale. Pour les transports de plus de 15 min, la position ventrale peut être recommandée car elle augmente la pression partielle d'oxygène des patients.

Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis.
Yin X, Wang X, He C. | Am J Emerg Med. 2021 Aug;46:424-429
DOI: https://doi.org/10.1016/j.ajem.2020.10.038
Keywords: Analgesics; Emergency; Network meta-analysis; Traumatic musculoskeletal pain.

Original contribution

Introduction : Musculoskeletal pain control is essential in the management of trauma patients in the emergency department (ED). Here, we performed a network meta-analysis of the use of analgesics to manage traumatic musculoskeletal pain.

Méthode : This network meta-analysis (NMA) protocol was registered in PROSPERO (CRD42020150145). Electronic databases were searched for randomized controlled trials comparing systemic pharmaceutical interventions for treating traumatic musculoskeletal pain in the ED setting. The outcomes were global efficacy and changes in pain intensity.

Résultats : Eighteen studies (2656 patients, four medication classes) met the inclusion criteria. The top-ranking medication class for global efficacy was nonsteroidal anti-inflammatory drugs (NSAIDs; network odds ratio: 0.52, 95% credible interval: 0.34-0.81, surface under the cumulative ranking curve score: 86). No interventions were more effective at decreasing pain intensity than opioids at 60 min.

Conclusion : NSAIDs were the most effective medications for treating traumatic musculoskeletal pain, and combination therapies may not have advantages in the ED setting.

Conclusion (proposition de traduction) : Les AINS étaient les médicaments les plus efficaces pour traiter les douleurs musculo-squelettiques traumatiques, et les traitements combinées peuvent ne pas présenter d'avantages dans le contexte des urgences.

Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses.
Davis EM, Feinsmith S, Amick AE, Sell J, McDonald V, Trinquero P, Moore A, Gappmaier V, Colton K, Cunningham A, Ford W, Feinglass J, Barsuk JH. | Am J Emerg Med. 2021 Aug;46:539-544
DOI: https://doi.org/10.1016/j.ajem.2020.11.013
Keywords: Delays; Difficult access; Peripheral intravenous; Throughput; Ultrasound-guided.

Original contribution

Introduction : Difficult intravenous access (DIVA) is a common problem in Emergency Departments (EDs), yet the prevalence and clinical impact of this condition is poorly understood. Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is a successful modality for obtaining intravenous (IV) access in patients with DIVA.
Objectives: We aimed to describe the prevalence of DIVA, explore how DIVA affects delivery of care, and determine if nurse insertion of USGPIV improves care delays among patients with DIVA.

Méthode : We retrospectively queried the electronic medical record for all ED patients who had a peripheral IV (PIV) inserted at a tertiary academic medical center from 2015 to 2017. We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV. We compared metrics for care delivery including time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED length of stay (LOS) between patients with and without DIVA. We also compared these metrics in patients with DIVA with a physician-inserted USGPIV versus those with a nurse-inserted USGPIV.

Résultats : A total of 147,260 patients were evaluated during the study period. Of these, 13,192 (8.9%) met criteria for DIVA. Patients with DIVA encountered statistically significant delays in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients without DIVA (all p < 0.001). Patients with nurse-inserted USGPIVs also had statistically significant improvements in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients with physician-inserted USGPIVs (all p < 0.001).

Conclusion : DIVA affects many ED patients and leads to delays in PIV access-related care. Nurse insertion of USGPIVs improves care in patients with DIVA.

Conclusion (proposition de traduction) : Un accès intraveineux difficile affecte de nombreux patients aux urgences et entraîne des retards dans les soins liés à l'accès IV périphérique. L'insertion par l'infirmière d'un cathéter intraveineux périphérique guidé par échographie améliore les soins aux patients ayant un accès intraveineux difficile.

Evaluation of metoprolol versus diltiazem for rate control of atrial fibrillation in the emergency department.
McGrath P, Kersten B, Chilbert MR, Rusch C, Nadler M. | Am J Emerg Med. 2021 Aug;46:585-590
DOI: https://doi.org/10.1016/j.ajem.2020.11.039
Keywords: Atrial fibrillation; Diltiazem; Metoprolol; Rate control; Tachycardia.

Original contribution

Introduction : The purpose of this study was to compare the effectiveness and safety of the metoprolol and diltiazem administration in the Emergency Department (ED) for rate control of supraventricular tachycardia.

Méthode : This was a retrospective cohort study of adult patients who presented to the ED with ventricular rates ≥120 beats per minute (bpm) and who received bolus doses of either intravenous metoprolol or intravenous diltiazem. The primary outcome was achievement of rate control, defined as heart rate < 110 bpm, at two hours after administration of the last bolus dose of metoprolol or diltiazem. Safety outcomes included occurrence of hypotension, defined as systolic blood pressure < 90 mmHg or diastolic blood pressure < 60 mmHg, and bradycardia, defined as heart rate < 60 bpm.

Résultats : There were 166 patients receiving metoprolol and 183 patients receiving diltiazem included in the study. The primary outcome, rate control at two hours after the last bolus dose of metoprolol or diltiazem was similar between the two groups (45.8% vs 42.6%, p = 0.590, respectively). The percentage of patients achieving rate control was also similar (47.0% vs 41.6%, p = 0.333) at one hour. At 0.5 h HR had a significantly greater numerical (diltiazem: 29.3 ± 23.1 bpm vs metoprolol: 21.8 ± 18.9 bpm, p = 0.012) and percent decrease (21.1% vs 15.94%, p = 0.014) in the diltiazem group compared to metoprolol. There was no significant difference in occurrence of bradycardia in the two groups (diltiazem: 3.83% vs metoprolol: 1.2%, p = 0.179). More patients in the diltiazem group compared to the metoprolol group experienced hypotension (39.3% vs 23.5%, p = 0.002). The difference in systolic hypotension events was not significantly different (9.29% vs 5.42%, p = 0.221), while the difference in diastolic hypotension events was significantly different (37.7% vs 22.3%, p = 0.002).

Conclusion : There was no difference in acute rate control effectiveness two hours after the last bolus dose of diltiazem and metoprolol for supraventricular tachycardias. There was a significantly higher occurrence of hypotension in the diltiazem group which was driven by higher rates of diastolic blood pressures less than 60 mmHg.

Conclusion (proposition de traduction) : Il n'y avait aucune différence dans l'efficacité du contrôle de la fréquence en aiguë deux heures après le dernière bolus de diltiazem et de métoprolol dans les tachycardies supraventriculaires. Il y avait une occurrence significativement plus élevée d'hypotension dans le groupe diltiazem qui était due à des taux plus élevés de pression artérielle diastolique inférieure à 60 mmHg.

The Journal of Emergency Medicine

Ultrasonography for Acute Heart Failure Compared With Chest X-Ray Study Among Dyspneic Older Patients in the Emergency Department.
Nakao S, Vaillancourt C, Taljaard M, Nemnom MJ, Woo MY, Stiell IG. | J Emerg Med. 2021 Aug;61(2):161-168
DOI: https://doi.org/10.1016/j.jemermed.2021.02.019
Keywords: acute heart failure; emergency medicine; point-of-care ultrasonography; shortness of breath.

Ultrasound in Emergency Medicine - Research article

Introduction : Acute heart failure and exacerbation of chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED).
Objectives: We sought to determine the classification performance of lung point-of-care ultrasound (POCUS) compared with chest x-ray study to identify acute heart failure in an older population.

Méthode : We conducted a cohort study with additional health records review between March and September 2017. We included consecutive patients aged 50 years and older with shortness of breath from suspected acute heart failure or COPD. The reference standard was discharged diagnosis, ED diagnosis with confirmation by another physician, or diagnosis made by health record reviews. We calculated the classification performance of lung POCUS to diagnose acute heart failure as well as that of chest x-ray study, and compared them by exact McNemar test.

Résultats : There were 81 patients evaluated with lung POCUS, and 67 had acute heart failure. Emergency physicians identified acute heart failure by lung POCUS with sensitivity of 92.5% (95% confidence interval [CI] 83.4-97.5%) and specificity of 85.7% (95% CI 57.2-98.2%). The radiology reading of chest x-ray study had sensitivity of 63.6% (95% CI 50.9-75.1%) and specificity of 92.9% (95% CI 66.1-99.8%). The sensitivity of lung POCUS was significantly higher than that of chest x-ray study (p = 0.0003).

Conclusion : Lung POCUS in a real clinical setting was highly sensitive and specific in identifying acute heart failure, and performed better than chest x-ray in an older population.

Conclusion (proposition de traduction) : L'échographie pulmonaire au point d'intervention dans un contexte clinique réel était très sensible et spécifique dans l'identification de l'insuffisance cardiaque aiguë, et a donné de meilleurs résultats que la radiographie pulmonaire dans une population plus âgée.

The Journal of Trauma and Acute Care Surgery

Physician-staffed ambulance and increased in-hospital mortality of hypotensive trauma patients following prolonged prehospital stay: A nationwide study.
Yamamoto R, Suzuki M, Yoshizawa J, Nishida Y, Junichi S. | J Trauma Acute Care Surg. 2021 Aug 1;91(2):336-343
DOI: https://doi.org/10.1097/ta.0000000000003239
Keywords: Aucun

Original article

Introduction : The benefits of physician-staffed emergency medical services (EMS) for trauma patients remain unclear because of the conflicting results on survival. Some studies suggested potential delays in definitive hemostasis due to prolonged prehospital stay when physicians are dispatched to the scene. We examined hypotensive trauma patients who were transported by ambulance, with the hypothesis that physician-staffed ambulances would be associated with increased in-hospital mortality, compared with EMS personnel-staffed ambulances.

Méthode : A retrospective cohort study that included hypotensive trauma patients (systolic blood pressure ≤ 90 mm Hg at the scene) transported by ambulance was conducted using the Japan Trauma Data Bank (2004-2019). Physician-staffed ambulances are capable of resuscitative procedures, such as thoracotomy and surgical airway management, while EMS personnel-staffed ambulances could only provide advanced life support. In-hospital mortality and prehospital time until the hospital arrival were compared between patients who were classified based on the type of ambulance. Inverse probability weighting was conducted to adjust baseline characteristics including age, sex, comorbidities, mechanism of injury, vital signs at the scene, injury severity, and ambulance dispatch time.

Résultats : Among 14,652 patients eligible for the study, 738 were transported by a physician-staffed ambulance. In-hospital mortality was higher in the physician-staffed ambulance than in the EMS personnel-staffed ambulance (201/699 [28.8%] vs. 2287/13,090 [17.5%]; odds ratio, 1.90 [1.61-2.26]; adjusted odds ratio, 1.22 [1.14-1.30]; p < 0.01), and the physician-staffed ambulance showed longer prehospital time (50 [36-66] vs. 37 [29-48] min, difference = 12 [11-12] min, p < 0.01). Such potential harm of the physician-staffed ambulance was only observed among patients who arrived at the hospital with persistent hypotension (systolic blood pressure < 90 mm Hg on hospital arrival) in subgroup analyses.

Conclusion : Physician-staffed ambulances were associated with prolonged prehospital stay and increased in-hospital mortality among hypotensive trauma patients compared with EMS personnel-staffed ambulance.

Conclusion (proposition de traduction) : Les ambulances armées avec un médecin étaient associées à des interventions préhospitalières prolongées et à une augmentation de la mortalité hospitalière chez les patients traumatisés hypotendus par rapport aux ambulances dotés par les personnels des Services Médicaux d'Urgence (ndlr : paramédicaux).

Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma.
Mikdad S, Mokhtari AK, Luckhurst CM, Breen KA, Liu B, Kaafarani HMA, Velmahos G, Mendoza AE, Bloemers FW, Saillant N. | J Trauma Acute Care Surg. 2021 Aug 1;91(2):352-360
DOI: https://doi.org/10.1097/ta.0000000000003247
Keywords: Aucun

Original article

Introduction : Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application.

Méthode : A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as >2 hours). Statistical analyses were performed to generate primary and secondary results.

Résultats : A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity.

Conclusion : In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts.

Conclusion (proposition de traduction) : En résumé, l'utilisation d'un garrot en préhospitalier est devenue largement adoptée dans le cadre civil, fréquemment effectuée par le personnel des services médicaux civils et non urgents. Parmi les garrots préhospitaliers placés, près de la moitié n'avaient pas d'indication claire pour le placement et plus d'un quart des garrots préhospitaliers ont été mal appliqués avec une morbidité associée notable. Les résultats suggèrent que les sujets concernant l'indication clinique et l'utilisation appropriée des garrots peuvent être des domaines importants comme objectifs continus dans les futurs programmes éducatifs sur les garrots, ainsi que les futurs efforts d'évaluation de la qualité.

Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review.
Sweet AAR, Beks RB, de Jong MB, van Baal MCPM, IJpma FFA, Hietbrink F, Beeres FJP, Leenen LPH, Groenwold RHH, Houwert RM. | J Trauma Acute Care Surg. 2021 Aug 1;91(2):427-434
DOI: https://doi.org/10.1097/ta.0000000000003118
Keywords: Aucun

SYSTEMATIC REVIEWS

Introduction : The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients.

Méthode : A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal.

Résultats : Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention.

Conclusion : In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed.

Conclusion (proposition de traduction) : Chez les patients non ventilés, un patient sur dix a développé une pathologie récurrente après l'ablation du drain thoracique et près d'un quart d'entre eux ont subi une réintervention. Dans deux études qui ont rendu compte des symptômes cliniques, toutes les réinterventions ont été effectuées chez des patients présentant des symptômes de pathologie récurrente. Dans ces deux études, l'omission de la radiographie thorax post-ablation de routine semblait sûre. Cependant, la littérature actuelle reste insuffisante pour tirer des conclusions définitives à ce sujet, et de futures études sont nécessaires.

The New England Journal of Medicine

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation.
Desch S, , Freund A, Akin I and al; TOMAHAWK Investigators. | N Engl J Med. 2021 Aug 29.
DOI: https://doi.org/10.1056/nejmoa2101909
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear.

Méthode : In this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days.

Résultats : A total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P = 0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups.

Conclusion : Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause.

Conclusion (proposition de traduction) : Parmi les patients réanimés avec succès après un arrêt cardiaque en dehors de l'hôpital sans infarctus du myocarde avec sus-décalage du segment ST, une stratégie consistant à effectuer une angiographie immédiate n'a apporté aucun bénéfice, par rapport à une stratégie différée/sélective, en termes de mortalité toutes causes confondues à 30 jours.

Commentaire : Voir l'analyse de l'article sur le site Univadis from Medscape : ESC 2021 — Il est inutile de précipiter les survivants d’un ACDH sans STEMI au laboratoire de cathétérisme  . Rédigé par le Dr Pavankumar Kamat, le 2 sept. 2021.


Mois d'août 2021