Association between Troponin I Levels during Sepsis and Postsepsis Cardiovascular Complications.
Garcia MA, Rucci JM, Thai KK, Lu Y, Kipnis P, Go AS, Desai M, Bosch NA, Martinez A, Clancy H, Devis Y, Myers LC, Liu VX, Walkey AJ. | Am J Respir Crit Care Med. 2021 Sep 1;204(5):557-565
DOI: https://doi.org/10.1164/rccm.202103-0613oc
Keywords: cardiovascular risk; infection; mortality; sepsis; troponin.

Critical Care

Introduction : Sepsis commonly results in elevated serum troponin levels and increased risk for postsepsis cardiovascular complications; however, the association between troponin levels during sepsis and cardiovascular complications after sepsis is unclear.
Objectives: To evaluate the association between serum troponin levels during sepsis and 1 year after sepsis cardiovascular events.

Méthode : We analyzed adults aged ⩾40 years without preexisting cardiovascular disease within 5 years, admitted with sepsis across 21 hospitals from 2011 to 2017. Peak serum troponin I levels during sepsis were grouped as normal (⩽0.04 ng/ml) or tertiles of abnormal (>0.04 to ⩽0.09 ng/ml, >0.09 to ⩽0.42 ng/ml, or >0.42 ng/ml). Multivariable adjusted cause-specific Cox proportional hazards models with death as a competing risk were used to assess associations between peak troponin I levels and a composite cardiovascular outcome (atherosclerotic cardiovascular disease, atrial fibrillation, and heart failure) in the year following sepsis. Models were adjusted for presepsis and intrasepsis factors considered potential confounders.

Résultats : Among 14,046 eligible adults with troponin I measured, 2,012 (14.3%) experienced the composite cardiovascular outcome, including 832 (10.9%) patients with normal troponin levels, as compared with 370 (17.3%), 376 (17.6%), and 434 (20.3%) patients within each sequential abnormal troponin tertile, respectively (P < 0.001). Patients within the elevated troponin tertiles had increased risks of adverse cardiovascular events (adjusted hazard ratio [aHR]_{troponin0.04-0.09} = 1.37; 95% confidence interval [CI], 1.20-1.55; aHR_{troponin0.09-0.42} = 1.44; 95% CI, 1.27-1.63; and aHR_{troponin>0.42} = 1.77; 95% CI, 1.56-2.00).

Conclusion : Among patients without preexisting cardiovascular disease, troponin elevation during sepsis identified patients at increased risk for postsepsis cardiovascular complications. Strategies to mitigate cardiovascular complications among this high-risk subset of patients are warranted.

Conclusion (proposition de traduction) : Parmi les patients sans maladie cardiovasculaire préexistante, l'élévation de la troponine pendant la septicémie a identifié les patients présentant un risque accru de complications cardiovasculaires post-septiques. Des stratégies pour atténuer les complications cardiovasculaires chez ce sous-ensemble de patients à haut risque sont justifiées.

Oxygen Toxicity in Critically Ill Adults.
Hochberg CH, Semler MW, Brower RG. | Am J Respir Crit Care Med. 2021 Sep 15;204(6):632-641
DOI: https://doi.org/10.1164/rccm.202102-0417ci
Keywords: ICUs; hyperoxia; oxygen inhalational therapy.

Concise Clinical Review

Editorial : Oxygen supplementation is one of the most common interventions in critically ill patients. Despite over a century of data suggesting both beneficial and detrimental effects of supplemental oxygen, optimal arterial oxygenation targets in adult patients remain unclear. Laboratory animal studies have consistently showed that exposure to a high FiO2 causes respiratory failure and early death. Human autopsy studies from the 1960s purported to provide histologic evidence of pulmonary oxygen toxicity in the form of diffuse alveolar damage. However, concomitant ventilator-induced lung injury and/or other causes of acute lung injury may explain these findings. Although some observational studies in general populations of critically adults showed higher mortality in association with higher oxygen exposures, this finding has not been consistent. For some specific populations, such as those with cardiac arrest, studies have suggested harm from targeting supraphysiologic PaO2 levels. More recently, randomized clinical trials of arterial oxygenation targets in narrower physiologic ranges were conducted in critically ill adult patients. Although two smaller trials came to opposite conclusions, the two largest of these trials showed no differences in clinical outcomes in study groups that received conservative versus liberal oxygen targets, suggesting that either strategy is reasonable. It is possible that some strategies are of benefit in some subpopulations, and this remains an important ongoing area of research. Because of the ubiquity of oxygen supplementation in critically ill adults, even small treatment effects could have a large impact on a global scale.

Conclusion : Despite the knowledge that administering oxygen to acutely ill patients may confer both benefits and harms, we are just beginning to understand the nuances of oxygen therapy in critical illness. Although observational and trial data are inconsistent, there is accumulating evidence that targeting supranormal PaO levels can lead to harm. In contrast, targeting oxygen therapy to maximum PaO2 and SpO2 targets within a physiologic range appears to be safe. As one of the most widespread interventions in medicine worldwide, further optimizing oxygen therapy could have large global effects on important patient outcomes. We look forward to results of ongoing RCTs to help further guide our understanding of how to best use oxygen therapy to improve outcomes for critically ill patients.

Conclusion (proposition de traduction) : Bien que l'on sache que l'administration d'oxygène aux patients de réanimation peut conférer à la fois des avantages et des inconvénients, nous commençons tout juste à comprendre les nuances de l'oxygénothérapie dans les maladies graves. Bien que les données d'observation et d'essai soient incohérentes, il existe de plus en plus de preuves que le ciblage des niveaux de PaO₂ supranormaux peut entraîner des dommages. En revanche, cibler l'oxygénothérapie sur des cibles maximales de PaO₂ et de SpO₂ dans une plage physiologique semble être sans danger. En tant que l'une des interventions médicales les plus répandues dans le monde, une optimisation supplémentaire de l'oxygénothérapie pourrait avoir des effets mondiaux importants sur les résultats importants pour les patients. Nous attendons avec impatience les résultats des essais contrôlés randomisés en cours pour nous aider à mieux comprendre comment utiliser au mieux l'oxygénothérapie pour améliorer les résultats pour les patients de réanimation.

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies.
Karamchandani K, Wheelwright J, Yang AL, Westphal ND, Khanna AK, Myatra SN. | Anesth Analg. 2021 Sep 1;133(3):648-662
DOI: https://doi.org/10.1213/ane.0000000000005644
Keywords: Aucun

Narrative Review Article

Editorial : Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

Conclusion : As airway experts, anesthesia providers must be prepared to take their skills from the OR to less controlled environments in various other areas of the hospital for emergent airway management. Considering the high rates of complications associated with emergency airway management out of the OR, it is prudent that a well-thought out, patient and situation-specific plan is established before the procedure. A thorough airway examination including assessment of physiological challenges, availability of appropriate personnel and equipment, hemodynamic goal setting, and multidisciplinary collaboration are essential to improve patient outcomes. Pre- and apneic oxygenation should be considered in patients with precarious respiratory status and optimization of hemodynamics with pressors or fluid administration should be tailored to individual patient needs.

Conclusion (proposition de traduction) : En tant qu'experts des voies respiratoires, les anesthésistes doivent être prêts à transférer leurs compétences du bloc opératoire à des environnements moins contrôlés dans divers autres domaines de l'hôpital pour la gestion des voies respiratoires d'urgence. Compte tenu des taux élevés de complications associées à la gestion d'urgence des voies respiratoires hors du bloc opératoire, il est prudent d'établir un plan bien pensé, spécifique au patient et à la situation avant l'intervention. Un examen approfondi des voies respiratoires comprenant l'évaluation des défis physiologiques, la disponibilité du personnel et de l'équipement appropriés, l'établissement d'objectifs hémodynamiques et la collaboration multidisciplinaire sont essentiels pour améliorer les résultats pour les patients. L'oxygénation pré- et apnéique doit être envisagée chez les patients présentant un état respiratoire précaire et l'optimisation de l'hémodynamique avec des amines ou le remplissage vasculaire doit être adaptée aux besoins de chaque patient.

Commentaire :  Algorithme de gestion des voies respiratoires survenant hors de la salle d'opération.
*Patient may be transferred to higher level of care for further monitoring and management. **2 hand technique, use nasal/oral airway, change mask grip. $Surgical cricothyroidotomy, needle cricothyroidotomy with a pressure-regulated device, large bore cannula cricothyroidotomy, or surgical tracheostomy. #Surgical cricothyroidotomy, needle cricothyroidotomy with a pressure-regulated device, large bore cannula cricothyroidotomy or surgical tracheostomy, retrograde wire guided intubation, percutaneous tracheostomy, rigid bronchoscopy, and extracorporeal membrane oxygenation (ECMO). $#Invasive airway should be performed by an individual trained in invasive airway techniques, whenever possible. INTUBE study: Russotto et al.5 BiPAP indicates bilevel positive airway pressure; BMV, bag mask ventilation; EPAP, expiratory positive airway pressure; Fio2, fraction of inspired oxygen; HFNO, high-flow nasal oxygen; IPAP, inspiratory positive airway pressure; NIV, noninvasive ventilation; OR, operating room; SGA, supraglottic airway.

Point-of-care Ultrasound in Cardiac Arrest.
Paul JA, Panzer OPF. | Anesthesiology. 2021 Sep 1;135(3):508-519
DOI: https://doi.org/10.1097/aln.0000000000003811
Keywords: Aucun

Education: Clinical Focus Review

Editorial : Point-of-care ultrasound is established as a reliable, bedside diagnostic modality for the differentiation of shock, and it is used increasingly during the management of cardiac arrest as well. Because ultrasound machines are accessible in most perioperative and intensive care unit settings and handheld technology is evolving, it has become practical to deploy this tool to the many locations in which arrests occur.

Conclusion : In addition to collecting outcome data for point-of-care ultrasound in cardiac arrest and determining the relative effi- cacy of protocols, continued efforts to provide training for this tool to not only residents and fellows but also attending anesthesiologists and surgeons are critical. Given that we are intimately familiar with our patients’ histories and the events that precede perioperative cardiac arrests, we are already adept at developing hypotheses about underlying etiologies. Focused ultrasound offers us a powerful tool to further refine our differential and tailor therapies for successful resuscitation.

Conclusion (proposition de traduction) : En plus de recueillir des données sur les résultats de l'échographie au point d'intervention en cas d'arrêt cardiaque et de déterminer l'efficacité relative des protocoles, les efforts continus pour fournir une formation à cet outil non seulement aux résidents et aux boursiers, mais également aux anesthésistes et aux chirurgiens traitants sont essentiels. Étant donné que nous connaissons précisément les antécédents de nos patients et les événements qui précèdent les arrêts cardiaques périopératoires, nous sommes déjà aptes à développer des hypothèses sur les étiologies sous-jacentes. L'échographie focalisée nous offre un outil puissant pour affiner davantage nos traitement différentiels et personnalisées pour une réanimation réussie.

Commentaire :  (A) Exemple de vues échographiques au point de service qui peuvent être obtenues lors d'un arrêt cardiaque, y compris des images sous-costales (à obtenir lors de la vérification du pouls) et des images extracardiaques (qui peuvent être obtenues parallèlement à la RCP active). Vous trouverez également (encadré) des rappels pour encourager l'efficacité et la sécurité.
(B) Images échographiques représentatives pouvant être associées à certaines des causes sous-jacentes de l'arrêt cardiaque, organisées par type de choc (cardiogénique, obstructif ou hypovolémique) pouvant entraîner l'arrêt.
ACLS, Advanced Cardiac Life Support; Cpr, cardiopulmonary resuscitation. themselves

Venous Thromboembolic Risk in Patients with Lower Limb Trauma Requiring Immobilization: Towards an Individualized Approach.
Douillet D, Barbère T, Peintre M, Moumneh T, Morin F, Savary D, Penaloza A, Roy PM. | Ann. Fr. Med. Urgence. 2021 Sept;11(5):311-319
DOI: https://doi.org/10.3166/afmu-2021-0345
Keywords: Venous thromboembolism; Risk stratification; Immobilisation; Thromboprophylaxis; Trauma

Update

Editorial : Un traumatisme d’un membre inférieur nécessitant une immobilisation est une situation à risque de développement de maladie thromboembolique veineuse (MTEV). Cependant, les recommandations et les pratiques varient notablement d’un pays à un autre et d’un centre à un autre. Cette revue narrative a pour objectifs de décrire l’épidémiologie, la prévention et les algorithmes de prédiction de la MTEV chez les patients traumatisés d’un membre inférieur nécessitant une immobilisation. L’incidence de la MTEV varie selon les études du fait de la grande hétérogénéité des patients inclus (de l’entorse de cheville à une lésion chirurgicale) et du fait des différents critères d’évaluation utilisés. L’incidence des événements thromboemboliques veineux symptomatiques est estimée à 2,0 % (intervalle de confiance à 95 % : 1,3 à 2,7). L’efficacité de la thromboprophylaxie a été démontrée dans des méta-analyses récentes. Cependant, la confiance à accorder à ces résultats est médiocre, car de nombreux essais présentaient des faiblesses méthodologiques. L’étude la plus importante et la plus récente ne montre pas de bénéfice de la prévention par héparine de bas poids moléculaire sur les événements symptomatiques dans une population non ciblée. Ces résultats suggèrent d’adopter une démarche personnalisée en réservant la prophylaxie aux patients à risque. Plusieurs scores existent pour évaluer le risque thromboembolique individuel. La prise en compte des caractéristiques du patient, du traumatisme et de l’immobilisation permet d’identifier un large sous-groupe de patients chez qui la prévention ne semble pas utile et un sous-groupe de patients à haut risque où la prévention devrait être prescrite, voire renforcée.

Conclusion : In conclusion, in the case of lower limb trauma requiring immobilization, the indication for thromboprophylaxis should be guided by the individual assessment of thrombotic risk.

Conclusion (proposition de traduction) :  En conclusion, lors d’un traumatisme d’un membre inférieur nécessitant une immobilisation, l’indication d’une thromboprophylaxie devrait être guidée par l’évaluation individuelle du risque thrombotique.

Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma.
Abid Z, Kuppermann N, Tancredi DJ, Dayan PS. | Ann Emerg Med. 2021 Sep;78(3):321-330.e1
DOI: https://doi.org/10.1016/j.annemergmed.2021.04.015  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics

Introduction : Infants with head trauma often have subtle findings suggestive of traumatic brain injury. Prediction rules for traumatic brain injury among children with minor head trauma have not been specifically evaluated in infants younger than 3 months old. We aimed to determine the risk of clinically important traumatic brain injuries, traumatic brain injuries on computed tomography (CT) images, and skull fractures in infants younger than 3 months of age who did and did not meet the age-specific Pediatric Emergency Care Applied Research Network (PECARN) low-risk criteria for children with minor blunt head trauma.

Méthode : We conducted a secondary analysis of infants <3 months old in the public use data set from PECARN's prospective observational study of children with minor blunt head trauma. Main outcomes included (1) clinically important traumatic brain injury, (2) traumatic brain injury on CT, and (3) skull fracture on CT.

Résultats : Of 10,904 patients <2 years old, 1,081 (9.9%) with complete data were <3 months old; most (750/1081, 69.6%) sustained falls, and 633/1081 (58.6%) underwent CT scans. Of the 514/1081 (47.5%) infants who met the PECARN low-risk criteria, 1/514 (0.2%, 95% confidence interval [CI] 0.005% to 1.1%), 10/197 (5.1%, 2.5% to 9.1%), and 9/197 (4.6%, 2.1% to 8.5%) had clinically important traumatic brain injuries, traumatic brain injuries on CT, and skull fractures, respectively. Of 567 infants who did not meet the low-risk PECARN criteria, 24/567 (4.2%, 95% CI 2.7% to 6.2%), 94/436 (21.3%, 95% CI 17.6% to 25.5%), and 122/436 (28.0%, 95% CI 23.8% to 32.5%) had clinically important traumatic brain injuries, traumatic brain injuries, and skull fractures, respectively.

Conclusion : The PECARN traumatic brain injury low-risk criteria accurately identified infants <3 months old at low risk of clinically important traumatic brain injuries. However, infants at low risk for clinically important traumatic brain injuries remained at risk for traumatic brain injuries on CT, suggesting the need for a cautious approach in these infants.

Conclusion (proposition de traduction) : Les critères PECARN de faible risque de lésion cérébrale traumatique ont permis d'identifier avec précision les nourrissons de moins de 3 mois à faible risque de lésion cérébrale traumatique cliniquement importante. Cependant, les nourrissons présentant un faible risque de lésions cérébrales traumatiques cliniquement importantes sont restés exposés à un risque de lésions cérébrales traumatiques au scanner, ce qui suggère la nécessité d'une approche prudente chez ces nourrissons.

Commentaire : Pour mémoire, trouvez ci-dessous, la règle PECARN :
Règle de décision dans la prescription d’un scanner cérébral chez un enfant < 2 ans

Règle de décision dans la prescription d’un scanner cérébral chez un enfant ≥ 2 ans
Trouvé sur : LORTON F. et al. Traumatisme crânien léger de l’enfant. Urgences 2015  

Trouvé sur : PECARN Pediatric Head CT Algorithm  

et le calculateur en ligne sur le site MDCalc  .
Article de référence : Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0  .

Managing Diabetic Ketoacidosis in Children.
Tzimenatos L, , Nigrovic LE. | Ann Emerg Med. 2021 Sep;78(3):340-345
DOI: https://doi.org/10.1016/j.annemergmed.2021.02.028  | Télécharger l'article au format  
Keywords: Aucun

PEDIATRICS/EXPERT CLINICAL MANAGEMENT

Editorial : Diabetic ketoacidosis is a life-threatening complication of childhood diabetes (mainly associated with type 1 or insulin-dependent diabetes). Thirty percent of children with new-onset type 1 diabetes present with diabetic ketoacidosis, and an additional 6% to 8% develop diabetic ketoacidosis each year. Presenting symptoms may be nonspecific, but laboratory findings of hyperglycemia and ketosis are diagnostic. Treatment involves administration of intravenous fluids and insulin. Children with diabetic ketoacidosis require serial laboratory studies for electrolyte derangements and close clinical monitoring for signs of cerebral edema, an uncommon but potentially fatal complication of pediatric diabetic ketoacidosis. For years, clinical guidelines for the treatment of diabetic ketoacidosis have recommended limited (if any) fluid resuscitation, isotonic fluids, and slow fluid rehydration rates in order to reduce the rate of cerebral edema. A recently completed clinical trial explored the relationship between fluid replacement and cerebral injury and edema, and it provided new evidence to guide safe and effective fluid treatment for pediatric diabetic ketoacidosis.

Conclusion : In conclusion, children with diabetic ketoacidosis, particularly those with previously undiagnosed diabetes, may present with nonspecific symptoms. Early recognition with appropriate laboratory screening can identify children with diabetic ketoacidosis and drive appropriate therapy. Fluid hydration coupled with continuous insulin infusion is the cornerstone of therapy. Frequent clinical and laboratory monitoring is essential for clinicians to recognize and address complications, including cerebral edema. In contrast with prior teachings, intravenous fluid administration can be liberalized to appropriately treat dehydration associated with diabetic ketoacidosis in patients without evidence of cerebral edema prior to treatment.

Conclusion (proposition de traduction) : En conclusion, les enfants en acidocétose diabétique, en particulier ceux dont le diabète n'avait pas été diagnostiqué auparavant, peuvent présenter des symptômes non spécifiques. Une reconnaissance précoce avec un dépistage en laboratoire approprié peut identifier les enfants en acidocétose diabétique et conduire à un traitement approprié. Le remplissage vasculaire associée à une perfusion continue d'insuline est la pierre angulaire du traitement. Une surveillance clinique et biologique fréquente est essentielle pour que les cliniciens reconnaissent et traitent les complications, y compris l'œdème cérébral. Contrairement aux enseignements antérieurs, le remplissage vasculaire peut être libéralisée pour traiter de manière appropriée la déshydratation associée à l'acidocétose diabétique chez les patients sans signe d'œdème cérébral avant le traitement.

Commentaire :  Algorithme clinique de l'acidocétose diabétique.
Concept adapté de Translating Emergency Knowledge for Kids Pediatric. Visitez www.trekk.ca   pour l'algorithme complet.
ABC, airway, breathing, circulation; DKA, diabetic ketoacidosis; GCS, Glasgow Coma Scale; K, potassium; KAcetate, potassium acetate; KCl, potassium chloride; NaCl, sodium chloride; NS, normal saline solution; VBG, venous blood gas.

Effect of Ultrashort-Acting Beta Blocker Administration on Mortality for Patients With Sepsis and Persistent Tachycardia Despite Initial Resuscitation.
Gottlieb M, Murcia HM, Rentz MF. | Ann Emerg Med. 2021 Sep;78(3):381-383
DOI: https://doi.org/10.1016/j.annemergmed.2021.04.022  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : The authors searched 3 major databases for randomized controlled trials that compared the mortality of patients with sepsis treated using ultrashort-acting, highly selective b1-blockers. The databases were MEDLINE (1966 to April 2020), Cochrane Central Register of Controlled Trials (through April 2020), and Embase (1974 to April 2020). The authors used the following keywords: “esmolol,” “landiolol,” “adrenergic beta agonist,” “sepsis,” “systemic inflammatory response syndrome,” and “multiple organ failure.” There were no language restrictions.

Méthode : Two reviewers independently screened abstracts and full-text articles for inclusion, with disagreements resolved by consensus. The authors of the trials were contacted when information was unclear. The inclusion criteria consisted of randomized controlled trials of adults (ie, patients !18 years) with sepsis as defined per Sepsis-1, -2, or -3 that received any dose of intravenous esmolol or landiolol with a control group that received either placebo or no intervention. The primary outcome was 28-day mortality. The secondary outcomes were lactic acid levels at baseline and 24, 48, and 72 hours after admission; pulse rate; mean arterial pressure; norepinephrine dose; cardiac index; stroke volume index; and WBC count at 24 hours after admission.

Résultats : Data were independently extracted by 2 reviewers using a standardized form, with disagreements resolved by discussion. In cases where there were multiple publications by the same investigator, the investigator was contacted to ensure that no duplicate data were analyzed. The risk of bias was assessed by 2 reviewers using the Cochrane Collaboration’s risk of bias tool for randomized trials.1 A third reviewer was involved to resolve discrepancies. Random-effects modeling was used with binary outcomes reported as risk ratio with 95% confidence intervals, while continuous outcomes were reported as a standardized mean difference with 95% confidence intervals. Heterogeneity was assessed using the c2 and I2 statistics. Sensitivity analyses were performed according to the severity of illness (ie, mortality rate [<66% or !66%]) and sample size (<100 or !100). The authors assessed for publication bias with a funnel plot using both the Begg rank correlation test and the Egger linear regression test.

Conclusion : Among septic patients with persistent tachycardia despite initial resuscitation, ultrashort-acting b- blockers (eg, esmolol and landiolol) are associated with reduced 28-day mortality.

Conclusion (proposition de traduction) : Chez les patients septiques présentant une tachycardie persistante malgré la réanimation initiale, les bêtabloquants à action ultracourte (p. ex., esmolol et landiolol) sont associés à une mortalité réduite à 28 jours.

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department.
Hawk K, Hoppe J, Ketcham E, LaPietra A, Moulin A, Nelson L, Schwarz E, Shahid S, Stader D, Wilson MP, D'Onofrio G. | Ann Emerg Med. 2021 Sep;78(3):434-442
DOI: https://doi.org/10.1016/j.annemergmed.2021.04.023  | Télécharger l'article au format  
Keywords: Aucun

The Practice of Emergency Medicine

Editorial : The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.

Conclusion : Detecting and offering evidenced-based treatments for patients with opioid use disorder is aligned with the goals of emergency medicine to intervene on high-mortality disease processes. The window of opportunity to begin lifesaving pharmacotherapy may be fleeting. The ED’s 24-hour, 365- day accessibility ideally positions it as a cornerstone of care to close the enormous treatment gap for patients with opioid use disorder.

Conclusion (proposition de traduction) : Détecter et offrir des traitements fondés sur des données probantes aux patients atteints de troubles liés à la consommation d’opioïdes est conforme aux objectifs de la médecine d’urgence pour intervenir sur les processus pathologiques à forte mortalité. La fenêtre d’opportunité pour commencer une pharmacothérapie salvatrice peut être éphémère. L’accessibilité 24 heures sur 24 et 365 jours du service d’urgence le positionne idéalement comme une pierre angulaire des soins pour combler l’énorme écart de traitement pour les patients atteints d’un trouble de consommation d’opioïdes.

Commentaire : Supplemental Materials  

Preventing Post-Lumbar Puncture Headache.
Cognat E, Koehl B, Lilamand M, Goutagny S, Belbachir A, de Charentenay L, Guiddir T, Zetlaoui P, Roos C, Paquet C. | Ann Emerg Med. 2021 Sep;78(3):443-450
DOI: https://doi.org/10.1016/j.annemergmed.2021.02.019
Keywords: Aucun

The Practice of Emergency Medicine

Editorial : Post-lumbar puncture headache is the main adverse event from lumbar puncture and occurs in 3.5% to 33% of patients, causing functional and socio-professional disability. We searched the post-lumbar puncture headache literature and, based on this review and personal expertise, identified and addressed 19 frequently asked questions regarding post-lumbar puncture headache risk factors and prevention. Among the nonmodifiable factors, older age is associated with a lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.

Conclusion : Among nonmodifiable factors, older age is associated with lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.

Conclusion (proposition de traduction) : Parmi les facteurs non modifiables, l'âge avancé est associé à une incidence plus faible de céphalées post-ponction lombaire, tandis que le sexe féminin, un indice de masse corporelle inférieur et des antécédents de céphalées pourraient être associés à un risque accru. L'utilisation d'aiguilles atraumatiques et non coupantes est l'intervention la plus efficace pour la prévention des céphalées post-ponction lombaire. Ces aiguilles ne sont pas plus difficiles à utiliser que les aiguilles coupantes. D'autres mesures couramment recommandées (p. ex., supplémentation hydrique, caféine) semblent inutiles, et certaines (p. ex., alitement) peuvent aggraver les céphalées post-ponction lombaire.

Commentaire : Sur le sujet, retrouvez la fiche mémo de la Haute Autorité de Santé (HAS) de juin 2019 :
Prévention et prise en charge des effets indésirables pouvant survenir après une ponction lombaire  .

L’aiguille atraumatique (dite à pointe de crayon) avec introducteur s’utilise de la même façon qu’une aiguille traumatique.
Article extrait de : La lettre de l’Association des juniors pédiatres. Numéro 17 [Janvier 2019]  . (https://api.reseauprosante.fr/files/revues/file-523.pdf  )

Trouvé sur : HAS. Ponction lombaire. Modalités de réalisation et recommandations pour en limiter les effets secondaires   (infographie).
(Prévention et prise en charge des effets indésirables pouvant survenir après une ponction lombaire  . Recommandation de bonne pratique - Mis en ligne le 11 juil. 2019).

La taille des aiguilles traumatiques (type Quincke) habituellement utilisée chez l'adulte sont : 22G (noire, 75 mm) et 20G (jaune, 75 mm).
Pour les aiguilles atraumatiques (Biseau de type Whitacre ou Sprotte), on peut utiliser des diamètres inférieurs : 24G (mauve, 90 mm), 25G (orange, 90 mm), 27G (grise, 90 mm) ou 29G (rouge, 90 mm) avec introducteur de 38 mm de long et de diamètre extérieur de 0,7 à 0,9 mm.

Admission serum myoglobin and the development of acute kidney injury after major trauma.
Tarazona V, Figueiredo S, Hamada S, Pochard J, Haines RW, Prowle JR, Duranteau J, Vigué B, Harrois A. | Ann Intensive Care. 2021 Sep 24;11(1):140
DOI: https://doi.org/10.1186/s13613-021-00924-3  | Télécharger l'article au format  
Keywords: Acute kidney injury; Creatine-kinase; Myoglobin; Rhabdomyolysis; Trauma.

Research

Introduction : Myoglobin and creatine kinase (CK) are both established markers of muscle injury but their hospital admission values have never been compared to predict post-traumatic acute kidney injury (AKI).

Méthode : An observational registry study of consecutive trauma patients admitted to a major regional trauma centre. The primary outcome was stage 1 or more AKI in the first 7 days after trauma. We assessed the association of hospital admission myoglobin or CK with development of AKI both alone and when added to two existing risk prediction models for post traumatic AKI.

Résultats : Of the 857 trauma patients (median age 36 [25-52], 96% blunt trauma, median ISS of 20 [12-47]) included, 102 (12%) developed AKI. Admission myoglobin performed better than CK to predict AKI any stage with an AUC-ROC of 0.74 (95% CI 0.68-0.79) and 0.63 (95% CI 0.57-0.69), respectively (p < 0.001). Admission myoglobin also performed better than CK to predict AKI stage 2 or 3 [AUC-ROC of 0.79 (95% CI 0.74-0.84) and 0.74 (95% CI 0.69-0.79), respectively (p < 0.001)] with a best cutoff value of 1217 µg/L (sensitivity 74%, specificity 77%). Admission myoglobin added predictive value to two established models of AKI prediction and showed significant ability to reclassify subjects regarding AKI status, while admission CK did not. Decision curve analysis also revealed that myoglobin added net benefit to established predictive models. Admission myoglobin was better than CK at predicting development of significant rhabdomyolysis.

Conclusion : Admission myoglobin better predicts the development of AKI and severe rhabdomyolysis after major trauma. Admission myoglobin should be added in established predictive models of post-traumatic AKI to early identify high-risk patients.

Conclusion (proposition de traduction) : La myoglobine à l'admission prédit mieux le développement d'une insuffisance rénale aiguë et d'une rhabdomyolyse sévère après un traumatisme majeur. La myoglobine à l'admission devrait être ajoutée dans les modèles prédictifs établis d'insuffisance rénale aiguë post-traumatique pour identifier rapidement les patients à haut risque.

Physiologic Scoring Systems versus Glasgow Coma Scale in Predicting In-Hospital Mortality of Trauma Patients; a Diagnostic Accuracy Study.
Heydari F, Azizkhani R, Ahmadi O, Majidinejad S, Nasr-Esfahani M, Ahmadi A. | Arch Acad Emerg Med. 2021 Sep 23;9(1):e64
DOI: https://doi.org/10.22037/aaem.v9i1.1376  | Télécharger l'article au format  
Keywords: Emergency service; Injury severity score; Multiple trauma; Patient outcome assessment; Prognosis; hospital; scoring system/ Clinical Decision Rules.

Original/Research Article

Introduction : In recent years, several scoring systems have been developed to assess the severity of trauma and predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) in predicting the in-hospital mortality of trauma patients.

Méthode : This diagnostic accuracy study was done on adult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020, following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS, and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operating characteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools.

Résultats : Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. The mean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS, MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI [0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMS was significantly higher than GCS (p=0.035). The sensitivities of GCS ≤ 11, ISS ≥ 13, REMS ≥ 4, and MEWS ≥ 3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS, REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively.

Conclusion : It seems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality ≥ 24 hours of multiple trauma patients.

Conclusion (proposition de traduction) : Il semble que le score REMS soit plus précis que le GCS, l'ISS et le MEWS pour prédire la mortalité hospitalière ≥ 24 heures des patients polytraumatisés.

Commentaire : Le score REMS n'utilise que des variables susceptibles d'être systématiquement colligées à l'admission des patients : l'âge, la fréquence cardiaque, la fréquence respiratoire, la pression artérielle systolique, le score de Glasgow et la saturation.
Pour Olsson, Risque élevé (REMS ≥3) : le patient peut avoir besoin d'un traitement intensif. La mortalité augmente rapidement au-dessus d'un score de 10.
Risque faible (REMS < 3) : le patient nécessite seulement un traitement habituel (dans l'étude d'Olsson de 2004, tous les patients avec un REMS < 3 ont survécu). Dans le cadre de la COVID-19, pour les patients de plus de 65 ans, un seuil de 6 est plus performant pour prédire la mortalité (Pour les moins de 65 ans, le seuil le plus pertinent était de 5).
Calcul du score d'évaluation rapide en médecine d'urgence (Rapid Emergency Medicine Score, REMS) sur Med+Calc  .
Olsson T, Terent A, Lind L. Rapid emergency medicine score can predict long-term mortality in nonsurgical emergency department patients. Acad Emerg Med. 2004;11(10):1008–13  .

Impaired kidney function at ED admission: a comparison of bleeding complications of patients with different oral anticoagulants.
Müller M, Traschitzger M, Nagler M, Arampatzis S, Exadaktylos AK, Sauter TC. | BMC Emerg Med. 2021 Sep 18;21(1):105
DOI: https://doi.org/10.1186/s12873-021-00497-1  | Télécharger l'article au format  
Keywords: Anticoagulants; Bleeding; Direct oral anticoagulants; Kidney function; Vitamin-K antagonist.

RESEARCH

Introduction : Up to a fourth of patients at emergency department (ED) presentation suffer from acute deterioration of renal function, which is an important risk factor for bleeding events in patients on oral anticoagulation therapy. We hypothesized that outcomes of patients, bleeding characteristics, therapy, and outcome differ between direct oral anticoagulants (DOACs) and vitamin-K antagonists (VKAs).

Méthode : All anticoagulated patients older than 17 years with an impaired kidney function treated for an acute haemorrhage in a large Swiss university ED from 01.06.2012 to 01.07.2017 were included in this retrospective cohort study. Patient, treatment, and bleeding characteristics as well as outcomes (length of stay ED, intensive care unit and in-hospital admission, ED resource consumption, in-hospital mortality) were compared between patients on DOAC or VKA anticoagulant.

Résultats : In total, 158 patients on DOAC and 419 patients on VKA with acute bleeding and impaired renal function were included. The renal function in patients on VKA was significantly worse compared to patients on DOAC (VKA: median 141 μmol/L vs. DOAC 132 μmol/L, p = 0.002). Patients on DOAC presented with a smaller number of intracranial bleeding compared to VKA (14.6% DOAC vs. 22.4% VKA, p = 0.036). DOAC patients needed more emergency endoscopies (15.8% DOAC vs, 9.1% VKA, p = 0.020) but less interventional emergency therapies to stop the bleeding (13.9% DOAC vs. 22.2% VKA, p = 0.027). Investigated outcomes did not differ significantly between the two groups.

Conclusion : DOAC patients were found to have a smaller proportional incidence of intracranial bleedings, needed more emergency endoscopies but less often interventional therapy compared to patients on VKA. Adapted treatment algorithms are a potential target to improve care in patients with DOAC.

Conclusion (proposition de traduction) : Les patients sous AOD se sont avérés avoir une incidence proportionnelle plus faible d'hémorragies intracrâniennes, avaient besoin de plus d'endoscopies d'urgence mais moins souvent d'un traitement interventionnel par rapport aux patients sous AVK. Des algorithmes de traitement adaptés sont une cible potentielle pour améliorer la prise en charge des patients sous AOD.

Association between emergency medical service transport time and survival in patients with traumatic cardiac arrest: a Nationwide retrospective observational study.
Naito H, Yumoto T, Yorifuji T, Nojima T, Yamamoto H, Yamada T, Tsukahara K, Inaba M, Nishimura T, Uehara T, Nakao A. | BMC Emerg Med. 2021 Sep 16;21(1):104
DOI: https://doi.org/10.1186/s12873-021-00499-z  | Télécharger l'article au format  
Keywords: Cardiac arrest; Mortality; Time-to-treatment; Trauma care.

RESEARCH

Introduction : Patients with traumatic cardiac arrest (TCA) are known to have poor prognoses. In 2003, the joint committee of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma proposed stopping unsuccessful cardiopulmonary resuscitation (CPR) sustained for > 15 min after TCA. However, in 2013, a specific time-limit for terminating resuscitation was dropped, due to the lack of conclusive studies or data. We aimed to define the association between emergency medical services transport time and survival to demonstrate the survival curve of TCA.

Méthode : A retrospective review of the Japan Trauma Data Bank. Inclusion criteria were age ≥ 16, at least one trauma with Abbreviated Injury Scale score (AIS) ≥ 3, and CPR performed in a prehospital setting. Exclusion criteria were burn injury, AIS score of 6 in any region, and missing data. Estimated survival rate and risk ratio for survival were analyzed according to transport time for all patients. Analysis was also performed separately on patients with sustained TCA at arrival.

Résultats : Of 292,027 patients in the database, 5336 were included in the study with 4141 sustained TCA. Their median age was 53 years (interquartile range (IQR) 36-70), and 67.2% were male. Their median Injury Severity Score was 29 (IQR 22-41), and median transport time was 11 min (IQR 6-17). Overall survival after TCA was 4.5%; however, survival of patients with sustained TCA at arrival was only 1.2%. The estimated survival rate and risk ratio for sustained TCA rapidly decreased after 15 min of transport time, with estimated survival falling below 1%.

Conclusion : The chances of survival for sustained TCA declined rapidly while the patient is transported with CPR support. Time should be one reasonable factor for considering termination of resuscitation in patients with sustained TCA, although clinical signs of life, and type and severity of trauma should be taken into account clinically.

Conclusion (proposition de traduction) : Les chances de survie en cas d'arrêt cardiaque traumatique prolongé ont diminué rapidement pendant que le patient était transporté en cours de réanimation cardio-pulmonaire. Le temps doit être un facteur raisonnable pour envisager l'interruption de la réanimation chez les patients ayant subi un arrêt cardiaque traumatique prolongé, bien que les signes cliniques de vie, ainsi que le type et la gravité du traumatisme doivent être pris en compte cliniquement.

Live video from bystanders’ smartphones to medical dispatchers in real emergencies.
Linderoth G, Lippert F, Østergaard D, Ersbøll AK, Meyhoff CS, Folke F, Christensen HC. | BMC Emerg Med. 2021 Sep 6;21(1):101
DOI: https://doi.org/10.1186/s12873-021-00493-5  | Télécharger l'article au format  
Keywords: Dispatcher; Emergency medical dispatcher; Emergency medical service; Health technology; Telehealth; Telemedicine; Telephone triage; Videoconference.

Research article

Introduction : Medical dispatchers have limited information to assess the appropriate emergency response when citizens call the emergency number. We explored whether live video from bystanders' smartphones changed emergency response and was beneficial for the dispatcher and caller.

Méthode : From June 2019 to February 2020, all medical dispatchers could add live video to the emergency calls at Copenhagen Emergency Medical Services, Denmark. Live video was established with a text message link sent to the caller's smartphone using GoodSAM®. To avoid delayed emergency response if the video transmission failed, the medical dispatcher had to determine the emergency response before adding live video to the call. We conducted a cohort study with a historical reference group. Emergency response and cause of the call were registered within the dispatch system. After each video, the dispatcher and caller were given a questionnaire about their experience.

Résultats : Adding live video succeeded in 838 emergencies (82.2% of attempted video transmissions) and follow-up was possible in 700 emergency calls. The dispatchers' assessment of the patients' condition changed in 51.1% of the calls (condition more critical in 12.9% and less critical in 38.2%), resulting in changed emergency response in 27.5% of the cases after receiving the video (OR 1.58, 95% CI: 1.30-1.91) compared to calls without video. Video was added more frequently in cases with sick children or unconscious patients compared with normal emergency calls. The dispatcher recognized other or different disease/trauma in 9.9% and found that patient care, such as the quality of cardiopulmonary resuscitation, obstructed airway or position of the patient, improved in 28.4% of the emergencies. Only 111 callers returned the questionnaire, 97.3% of whom felt that live video should be implemented.

Conclusion : It is technically feasible to add live video to emergency calls. The medical dispatcher's perception of the patient changed in about half of cases. The odds for changing emergency response were 58% higher when video was added to the call. However, use of live video is challenging with the existing dispatch protocols, and further implementation science is necessary.

Conclusion (proposition de traduction) : Il est techniquement possible d'ajouter de la vidéo en direct aux appels d'urgence. La perception du patient par l'assistant de régulation médicale a changé dans environ la moitié des cas. Les chances de changer la réponse d'urgence étaient 58 % plus élevées lorsque la vidéo était ajoutée à l'appel. Cependant, l'utilisation de la vidéo en direct est difficile avec les protocoles d'envoi existants, et une technique de mise en œuvre supplémentaire est nécessaire.

2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist.
Stiell IG, de Wit K, Scheuermeyer FX, Vadeboncoeur A, Angaran P, Eagles D, Graham ID, Atzema CL, Archambault PM, Tebbenham T, McRae AD, Cheung WJ, Parkash R, Deyell MW, Baril G, Mann R, Sahsi R, Upadhye S, Brown E, Brinkhurst J, Chabot C, Skanes A. | CJEM. 2021 Sep;23(5):604-610
DOI: https://doi.org/10.1007/s43678-021-00167-y  | Télécharger l'article au format  
Keywords: Aucun

CAEP Position Statement & Guidelines

Editorial : Our hope is that the 2021 CAEP Acute Atrial Fibrilla- tion/Flutter Best Practices Checklist will standardize and improve care of AF and AFL in large and small EDs alike. We believe that these patients can be managed rapidly and safely, with early ED discharge and return to normal activities.

Conclusion (proposition de traduction) : Nous espérons que la Checklist des meilleures pratiques en matière de fibrillation/flutter auriculaire aiguë du CAEP 2021 normalisera et améliorera les soins de la fibrillation atriale et du flutter auriculaire dans les grands et les petits services d'urgences. Nous pensons que ces patients peuvent être pris en charge rapidement et en toute sécurité, avec une sortie précoce du service d'urgence et un retour à des activités normales.

Commentaire :  Aperçu de la checklist des meilleures pratiques CAEP pour AF/AFL 2021

The use and misuse of the Dix-Hallpike test in the emergency department.
Dmitriew C, Bodunde O, Regis A, Lepage R, Turgeon Z, Johns P, McIsaac S, Ohle R. | CJEM. 2021 Sep;23(5):613-616
DOI: https://doi.org/10.1007/s43678-021-00110-1
Keywords: BPPV; Dix-Hallpike; Vertigo.

Brief Original Research

Introduction : A simple bedside test, the Dix-Hallpike test (DHT), can reliably diagnose benign paroxysmal positional vertigo (BPPV) in patients with acute onset dizziness or vertigo. We evaluated patterns of DHT use by emergency physicians in patients presenting with dizziness and vertigo. Our objective was to assess the frequency and clinically appropriate use of the DHT in an emergency department.

Méthode : A health records review was performed using data from patients who presented to a tertiary care emergency department between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient records were reviewed for documentation of symptoms consistent with BPPV and DHT usage.

Résultats : A total of 2309 patients met inclusion criteria. Of all dizzy patients who had complete documentation of signs and symptoms consistent with BPPV, 53% were assessed with a DHT. Of 469 patients who received a DHT, 134 (29%) of tests were done on patients who had documentation of at least one characteristic that was inconsistent with a diagnosis of BPPV. Eight patients who received a DHT were ultimately diagnosed with a central cause for their vertigo.

Conclusion : The DHT is both underutilized and frequently applied to patients whose symptoms are not consistent with BPPV. This may result in prolonged patient discomfort and increased resource utilization, as well as increasing the risk of misdiagnosing central vertigo.

Conclusion (proposition de traduction) : Le test de Dix-Hallpike est à la fois sous-utilisé et fréquemment appliqué aux patients dont les symptômes ne correspondent pas à un vertige positionnel paroxystique bénin. Cela peut entraîner une gêne prolongée pour le patient et une utilisation accrue des ressources, ainsi qu'une augmentation du risque de diagnostic erroné de vertige central.

Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management.
Krishnamoorthy V, Komisarow JM, Laskowitz DT, Vavilala MS. | Chest. 2021 Sep;160(3):956-964
DOI: https://doi.org/10.1016/j.chest.2021.01.016
Keywords: critical care; multiorgan dysfunction; traumatic brain injury.

CHEST Reviews

Editorial : Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.

Conclusion : Severe TBI results in significant dysfunction to extracranial organ systems, which contribute to secondary brain injuries and poor clinical outcomes. Although current evidence points to autonomic dysfunction and systemic inflammation as primary causative mechanisms of multiorgan dysfunction after severe TBI, it remains an understudied area. Future research should focus on understanding underlying mechanisms, improving prediction and prevention of multiorgan dysfunction, and clinical trials to identify the best strategies for patient management. Optimal prevention and treatment of multiorgan dysfunction after severe TBI has the potential to improve TBI clinical outcomes worldwide.

Conclusion (proposition de traduction) : Une lésion cérébrale traumatique grave entraîne un dysfonctionnement important des systèmes d'organes extracrâniens, ce qui contribue à des lésions cérébrales secondaires et à de mauvais résultats cliniques. Bien que les preuves actuelles indiquent que le dysfonctionnement autonome et l'inflammation systémique sont les principaux mécanismes responsables de la défaillance multiviscérale après une lésion cérébrale traumatique grave, cela reste un domaine sous-étudié. Les recherches futures devraient se concentrer sur la compréhension des mécanismes sous-jacents, l'amélioration de la prédiction et de la prévention de la défaillance multiviscérale, et des essais cliniques pour identifier les meilleures stratégies de prise en charge des patients. La prévention et le traitement optimaux de la défaillance multiviscérale après un traumatisme crânien grave ont le potentiel d'améliorer les résultats cliniques des traumatismes crâniens dans le monde entier.

Commentaire :  Mécanismes pertinents et conséquences cliniques de la dysfonction multiviscérale après un traumatisme crânien sévère. DIC = disseminated intravascular coagulation; TBI = traumatic brain injury.

informations cliniques importantes
CPP = cerebral perfusion pressure; ICP = intracranial pressure; PEEP = positive end-expiratory pressure; SBP = systolic BP; TBI = traumatic brain injury.

The use of head helmets to deliver noninvasive ventilatory support: a comprehensive review of technical aspects and clinical findings.
Coppadoro A, Zago E, Pavan F, Foti G, Bellani G. | Crit Care. 2021 Sep 8;25(1):327
DOI: https://doi.org/10.1186/s13054-021-03746-8  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; COVID-19; Continuous positive airway pressure; Helmets; Noninvasive ventilation.

Review

Editorial : A helmet, comprising a transparent hood and a soft collar, surrounding the patient's head can be used to deliver noninvasive ventilatory support, both as continuous positive airway pressure and noninvasive positive pressure ventilation (NPPV), the latter providing active support for inspiration. In this review, we summarize the technical aspects relevant to this device, particularly how to prevent CO2 rebreathing and improve patient-ventilator synchrony during NPPV. Clinical studies describe the application of helmets in cardiogenic pulmonary oedema, pneumonia, COVID-19, postextubation and immune suppression. A section is dedicated to paediatric use. In summary, helmet therapy can be used safely and effectively to provide NIV during hypoxemic respiratory failure, improving oxygenation and possibly leading to better patient-centred outcomes than other interfaces.

Conclusion : Relevant evidence has been published in the last 20 years, and several trials are ongoing. The tragic COVID experience has led to more widespread use of helmets. Different technical solutions can be applied (free-flow CPAP vs. mechanical ventilator NPPV), and no data are available to establish whether either technique is superior. In any case, an adequate fresh gas flow must be provided to avoid CO2 rebreathing. As summarized above and by several meta-analyses, helmet therapy can be safely and effectively used to provide NIV during hypoxemic respiratory failure, better improving oxygenation than standard oxygen mask treatment and possibly leading to better patient-centred outcomes than other NIV interfaces.

Conclusion (proposition de traduction) : Des preuves pertinentes ont été publiées au cours des 20 dernières années et plusieurs essais sont en cours. L'expérience tragique de la COVID a conduit à une utilisation plus répandue des casques de ventilation (Helmet). Différentes solutions techniques peuvent être appliquées (CPAP à flux libre vs ventilation mécanique à pression positive non invasive) et aucune donnée n'est disponible pour établir si l'une ou l'autre des techniques est supérieure. Dans tous les cas, un débit de gaz frais suffisant doit être prévu pour éviter la réinhalation de CO₂. Comme résumé ci-dessus et par plusieurs méta-analyses, le traitement par casque de ventilation peut être utilisée de manière sûre et efficace pour fournir une assistance ventilatoire non invasive lors d'une insuffisance respiratoire hypoxémique, améliorant mieux l'oxygénation que le traitement au masque à oxygène standard et conduisant éventuellement à de meilleurs résultats centrés sur le patient que les autres interfaces d'assistance ventilatoire non invasive.

Classification and effectiveness of different oxygenation goals in mechanically ventilated critically ill patients: network meta-analysis of randomised controlled trials.
Zhao X, Xiao H, Dai F, Brodie D, Meng L. | Eur Respir J. 2021 Oct 1;58(3):2002928
DOI: https://doi.org/10.1183/13993003.02928-2020
Keywords: Aucun

Original Research Article - Critical care

Introduction : The optimal oxygenation in mechanically ventilated critically ill patients remains unclear.

Méthode : We performed a systematic review of randomised controlled trials (RCTs) with the aim to classify oxygenation goals and investigate their relative effectiveness. RCTs investigating different oxygenation goal-directed mechanical ventilation in critically ill adult patients were eligible for the analysis. The trinary classification classified oxygenation goals into conservative (partial pressure of arterial oxygen (P_aO2) 55-90 mmHg), moderate (P_aO2 90-150 mmHg) and liberal (P aO2 >150 mmHg). The quadruple classification further divided the conservative goal from the trinary classification into far-conservative (P aO2 55-70 mmHg) and conservative (P_aO2 70-90 mmHg) goals. The primary outcome was 30-day mortality. The secondary outcomes included intensive care unit, hospital and 90-day mortalities. The effectiveness was estimated by the relative risk and 95% credible interval (CrI) using network meta-analysis and visualised using surface under the cumulative ranking curve (SUCRA) scores and survival curves.

Résultats : We identified eight eligible studies involving 2532 patients. There were no differences between conservative and moderate goals (relative risk 1.08, 95% CrI 0.85-1.36; moderate quality), between moderate and liberal goals (relative risk 0.83, 95% CrI 0.61-1.10; low quality) or between conservative and liberal goals (relative risk 0.89, 95% CrI 0.61-1.30; low quality) based on the trinary classification. There were no differences in secondary outcomes among the different goals. The results were consistent between the trinary and quadruple classifications. The SUCRA scores and survival curves suggested that the moderate goal in the trinary and quadruple classifications and the conservative goal in the quadruple classification may be superior to the liberal and far-conservative goals.

Conclusion : Different oxygenation goals do not lead to different mortalities in mechanically ventilated critically ill patients. The potential superiority of maintaining P_aO2 in the range 70-150 mmHg remains to be validated.

Conclusion (proposition de traduction) : Des objectifs d'oxygénation différents ne conduisent pas à des mortalités différentes chez les patients de réanimation ventilés mécaniquement. La supériorité potentielle du maintien de la PaO₂ dans la gamme 70-150 mmHg reste à valider.

Management of sepsis and septic shock in the emergency department.
Gavelli F, Castello LM, Avanzi GC. | Intern Emerg Med. 2021 Sep;16(6):1649-1661
DOI: https://doi.org/10.1007/s11739-021-02735-7  | Télécharger l'article au format  
Keywords: Antibiotic therapy; Emergency medicine; Fluid resuscitation; Preload responsiveness; Vasopressors.

EM - REVIEW

Editorial : Early management of sepsis and septic shock is crucial for patients' prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED.

Conclusion : Patients with severe sepsis and/or septic shock are at increased risk of death and organ dysfunction and display high in-hospital mortality. Since the last SSC guidelines were issued, a number of studies have provided new infor- mation on the pathophysiology and treatment of septic shock. Despite this growing knowledge, septic shock man- agement remains a challenging task for the emergency phy- sicians, who have to deal with the initial detection of the condition and the early phases of treatment. Thus, it is of utmost importance that emergency physicians be aware of the recent advances on septic patient management. In light of the above considerations, this narrative review provides a useful and updated learning tool that should enable emergency physicians to gather crucial information on past, present, and future research trajectories of sepsis research. Overall, we believe that a systematic approach consisting of coordinated detection of patients with sepsis and early treatment could significantly reduce the mortality of septic patients in the ED. To further optimize disease management, the emergency physician should administer treatment taking into account the patients’ characteristics.

Conclusion (proposition de traduction) : Les patients avec un sepsis sévère et/ou un état de choc septique présentent un risque accru de décès et de dysfonctionnement d'organe et présentent une mortalité hospitalière élevée. Depuis la publication des dernières lignes directrices de la Surviving Sepsis Campaign, un certain nombre d'études ont fourni de nouvelles informations sur la physiopathologie et le traitement du choc septique. Malgré ces connaissances croissantes, la gestion du choc septique reste une tâche difficile pour les médecins urgentistes, qui doivent faire face à la détection initiale de la maladie et aux premières phases du traitement. Ainsi, il est de la plus haute importance que les médecins urgentistes soient au courant des avancées récentes en matière de prise en charge des patients septiques. À la lumière des considérations ci-dessus, cette revue narrative fournit un outil d'apprentissage utile et mis à jour qui devrait permettre aux médecins des urgences de recueillir des informations cruciales sur les trajectoires de recherche passées, présentes et futures de la recherche sur le sepsis. Dans l'ensemble, nous pensons qu'une approche systématique consistant en une détection coordonnée des patients atteints de sepsis et un traitement précoce pourrait réduire considérablement la mortalité des patients septiques aux urgences. Pour optimiser davantage la prise en charge de la maladie, le médecin urgentiste doit administrer le traitement en tenant compte des caractéristiques des patients.

Commentaire :  Critères cliniques de définition du sepsis et du choc septique.
Adapted from [Singer M, Deutschman CS, Seymour CW et al (2016) The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315:801–810   ].
SOFA : Sequential Organ Failure Assessment
qSOFA : quick- SOFA

Colchicine efficacy and safety for the treatment of cardiovascular diseases.
Andreis A, Imazio M, Casula M, Avondo S, De Ferrari GM. | Intern Emerg Med. 2021 Sep;16(6):1691-1700
DOI: https://doi.org/10.1007/s11739-021-02654-7  | Télécharger l'article au format  
Keywords: Adverse events; Atrial fibrillation; Colchicine; Coronary artery disease; Heart failure; Pericarditis.

CE-SYSTEMATIC REVIEWS AND META-ANALYSIS

Editorial : The emerging role of colchicine in the treatment of cardiovascular diseases is a strong demand for a comprehensive understanding of its efficacy and safety.

Introduction : This meta-analysis and systematic review aimed to study the efficacy in the reduction of adverse cardiovascular outcomes (CO), and the risk of colchicine-related adverse events (CRAEs). Fourteen thousand and nine eighty three patients from 22 randomized controlled trials (RCTs) were included, 9 in patients with coronary artery disease-CAD, 9 in patients with pericarditis, 4 in patients with atrial fibrillation-AF or heart failure.

Méthode : Colchicine was efficacious in the reduction of adverse CO across different settings: pericardial diseases (reduced risk of recurrent pericarditis, 17.6% vs. 35%, RR 0.50, 95% CI 0.41-0.61), CAD (reduced risk of cardiac death, myocardial infarction, stroke,coronary revascularization or hospitalization, 6.1% vs. 8.5%, RR 0.73, 95% CI 0.64-0.83), AF (reduced risk of arrhythmia recurrence, 14.2% vs. 22.7%, RR 0.62, 95% CI 0.44-0.88). Colchicine was associated with increased risk of gastrointestinal CRAEs (11.2% vs. 8.8%, RR 1.87, 95% CI 1.41-2.47) and drug discontinuation (5.4% vs. 3.7%, RR 1.58, 95% CI 1.25-1.99). In both cases, the risk was proportional to the daily dose or duration of treatment, possibly due to early drug discontinuation or tolerance. Other CRAEs (muscle-related, liver,hematologic,cutaneous, infections) were not increased by colchicine, as long as all-cause death (2.2% vs. 1.9%, RR 1.11, 95% CI 0.79-1.54) or non-cardiovascular death (1.5% vs. 1%, RR 1.43, 95% CI 0.93-2.19).

Conclusion : Colchicine is efficacious and safe for the treatment of cardiovascular diseases. The risk of gastrointestinal CRAEs and drug discontinuation is not significant if colchicine is used at lower doses (0.5 mg daily) or for longer periods of time (> 6 months).

Conclusion (proposition de traduction) : La colchicine est efficace et sûre pour le traitement des maladies cardiovasculaires. Le risque d'effets indésirables gastro-intestinaux et d'arrêt du traitement n'est pas significatif si la colchicine est utilisée à des doses plus faibles (0,5 mg par jour) ou pendant des périodes plus longues (> 6 mois).

Multisystem inflammatory syndrome in children (MIS-C): a mini-review.
Giacalone M, Scheier E, Shavit I. | Int J Emerg Med. 2021 Sep 10;14(1):50
DOI: https://doi.org/10.1186/s12245-021-00373-6  | Télécharger l'article au format  
Keywords: COVID-19; Children; Inflammatory; SARS-CoV-2.

REVIEW

Introduction : Multisystem inflammatory syndrome in children (MIS-C) is a novel, life-threatening hyperinflammatory condition that develops in children a few weeks after infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).

Méthode : This disease has created a diagnostic challenge due to overlap with Kawasaki disease (KD) and KD shock syndrome. The majority of patients with MIS-C present with the involvement of at least four organ systems, and all have evidence of a marked inflammatory state. Most patients show an increase in the level of at least four inflammatory markers (C-reactive protein, neutrophil count, ferritin, procalcitonin, fibrinogen, interleukin-6, and triglycerides).

Conclusion : Therapy is primarily with immunomodulators, suggesting that the disease is driven by post-infectious immune dysregulation. Most patients, even those with severe cardiovascular involvement, recover without sequelae. Since coronary aneurysms have been reported, echocardiographic follow-up is needed.Further study is needed to create uniform diagnostic criteria, therapy, and follow-up protocols.

Conclusion (proposition de traduction) : Le traitement repose principalement sur des immunomodulateurs, ce qui suggère que la maladie est due à un dérèglement immunitaire post-infectieux. La plupart des patients, même ceux présentant une atteinte cardiovasculaire sévère, se rétablissent sans séquelles. Étant donné que des anévrismes coronariens ont été signalés, un suivi échocardiographique est nécessaire. Une étude plus approfondie est nécessaire pour mettre au point des critères de diagnostic, un traitement et des protocoles de suivi uniformes.

Commentaire : Syndrome inflammatoire multi-systémique pédiatrique (PIMS).
Covid-19 : repérer et déclencher la prise en charge du syndrome inflammatoire multi-systémique (PIMS) de l’enfant  . HAS, 7 juillet 2021.
Réponse rapide dans le cadre de la Covid-19 : Repérage et prise en charge du syndrome inflammatoire multi-systémique pédiatrique (PIMS) post-infectieux  . HAS, juillet 2021.

Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure: The REST Randomized Clinical Trial.
McNamee JJ, Gillies MA, Barrett NA, Perkins GD, Tunnicliffe W, Young D, Bentley A, Harrison DA, Brodie D, Boyle AJ, Millar JE, Szakmany T, Bannard-Smith J, Tully RP, Agus A, McDowell C, Jackson C, McAuley DF; REST Investigators. | JAMA. 2021 Sep 21;326(11):1013-1023. 2021 Sep 21;326(11):1013-1023
DOI: https://doi.org/10.1001/jama.2021.13374
Keywords: Aucun

Original Investigation

Introduction : In patients who require mechanical ventilation for acute hypoxemic respiratory failure, further reduction in tidal volumes, compared with conventional low tidal volume ventilation, may improve outcomes.
Objective : To determine whether lower tidal volume mechanical ventilation using extracorporeal carbon dioxide removal improves outcomes in patients with acute hypoxemic respiratory failure.

Méthode : This multicenter, randomized, allocation-concealed, open-label, pragmatic clinical trial enrolled 412 adult patients receiving mechanical ventilation for acute hypoxemic respiratory failure, of a planned sample size of 1120, between May 2016 and December 2019 from 51 intensive care units in the UK. Follow-up ended on March 11, 2020.
Interventions : Participants were randomized to receive lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal for at least 48 hours (n = 202) or standard care with conventional low tidal volume ventilation (n = 210).
Main outcomes and measures: The primary outcome was all-cause mortality 90 days after randomization. Prespecified secondary outcomes included ventilator-free days at day 28 and adverse event rates.

Résultats : Among 412 patients who were randomized (mean age, 59 years; 143 [35%] women), 405 (98%) completed the trial. The trial was stopped early because of futility and feasibility following recommendations from the data monitoring and ethics committee. The 90-day mortality rate was 41.5% in the lower tidal volume ventilation with extracorporeal carbon dioxide removal group vs 39.5% in the standard care group (risk ratio, 1.05 [95% CI, 0.83-1.33]; difference, 2.0% [95% CI, -7.6% to 11.5%]; P = .68). There were significantly fewer mean ventilator-free days in the extracorporeal carbon dioxide removal group compared with the standard care group (7.1 [95% CI, 5.9-8.3] vs 9.2 [95% CI, 7.9-10.4] days; mean difference, -2.1 [95% CI, -3.8 to -0.3]; P = .02). Serious adverse events were reported for 62 patients (31%) in the extracorporeal carbon dioxide removal group and 18 (9%) in the standard care group, including intracranial hemorrhage in 9 patients (4.5%) vs 0 (0%) and bleeding at other sites in 6 (3.0%) vs 1 (0.5%) in the extracorporeal carbon dioxide removal group vs the control group. Overall, 21 patients experienced 22 serious adverse events related to the study device.

Conclusion : Among patients with acute hypoxemic respiratory failure, the use of extracorporeal carbon dioxide removal to facilitate lower tidal volume mechanical ventilation, compared with conventional low tidal volume mechanical ventilation, did not significantly reduce 90-day mortality. However, due to early termination, the study may have been underpowered to detect a clinically important difference.

Conclusion (proposition de traduction) : Chez les patients en insuffisance respiratoire hypoxémique aiguë, l'utilisation de l'élimination extracorporelle du dioxyde de carbone pour faciliter la ventilation mécanique à faible volume courant, par rapport à la ventilation mécanique à faible volume courant classique, n'a pas réduit de manière significative la mortalité à 90 ours. Cependant, en raison d'une interruption prématurée, l'étude n'a peut-être pas été suffisamment puissante pour détecter une différence cliniquement importante.

Effect of Low-Normal vs High-Normal Oxygenation Targets on Organ Dysfunction in Critically Ill Patients: A Randomized Clinical Trial.
Gelissen H, de Grooth HJ, Smulders Y, Wils EJ, de Ruijter W, Vink R, Smit B, Röttgering J, Atmowihardjo L, Girbes A, Elbers P, Tuinman PR, Oudemans-van Straaten H, de Man A. | JAMA. 2021 Sep 14;326(10):940-948
DOI: https://doi.org/10.1001/jama.2021.13011
Keywords: Aucun

Original Investigation

Introduction : Hyperoxemia may increase organ dysfunction in critically ill patients, but optimal oxygenation targets are unknown.
Objective : To determine whether a low-normal Pao₂ target compared with a high-normal target reduces organ dysfunction in critically ill patients with systemic inflammatory response syndrome (SIRS).

Méthode : Multicenter randomized clinical trial in 4 intensive care units in the Netherlands. Enrollment was from February 2015 to October 2018, with end of follow-up to January 2019, and included adult patients admitted with 2 or more SIRS criteria and expected stay of longer than 48 hours. A total of 9925 patients were screened for eligibility, of whom 574 fulfilled the enrollment criteria and were randomized.
Interventions : Target Pao₂ ranges were 8 to 12 kPa (low-normal, n = 205) and 14 to 18 kPa (high-normal, n = 195). An inspired oxygen fraction greater than 0.60 was applied only when clinically indicated.
titre_Main outcomes and measuresen_plus: Primary end point was SOFARANK, a ranked outcome of nonrespiratory organ failure quantified by the nonrespiratory components of the Sequential Organ Failure Assessment (SOFA) score, summed over the first 14 study days. Participants were ranked from fastest organ failure improvement (lowest scores) to worsening organ failure or death (highest scores). Secondary end points were duration of mechanical ventilation, in-hospital mortality, and hypoxemic measurements.

Résultats : Among the 574 patients who were randomized, 400 (70%) were enrolled within 24 hours (median age, 68 years; 140 women [35%]), all of whom completed the trial. The median Pao₂ difference between the groups was -1.93 kPa (95% CI, -2.12 to -1.74; P < .001). The median SOFARANK score was -35 points in the low-normal Pao2 group vs -40 in the high-normal Pao₂ group (median difference, 10 [95% CI, 0 to 21]; P = .06). There was no significant difference in median duration of mechanical ventilation (3.4 vs 3.1 days; median difference, -0.15 [95% CI, -0.88 to 0.47]; P = .59) and in-hospital mortality (32% vs 31%; odds ratio, 1.04 [95% CI, 0.67 to 1.63]; P = .91). Mild hypoxemic measurements occurred more often in the low-normal group (1.9% vs 1.2%; median difference, 0.73 [95% CI, 0.30 to 1.20]; P < .001). Acute kidney failure developed in 20 patients (10%) in the low-normal Pao₂ group and 21 patients (11%) in the high-normal Pao₂ group, and acute myocardial infarction in 6 patients (2.9%) in the low-normal Pao₂ group and 7 patients (3.6%) in the high-normal Pao₂ group.

Conclusion : Among critically ill patients with 2 or more SIRS criteria, treatment with a low-normal Pao₂ target compared with a high-normal Pao₂ target did not result in a statistically significant reduction in organ dysfunction. However, the study may have had limited power to detect a smaller treatment effect than was hypothesized.

Conclusion (proposition de traduction) : Chez les patients de réanimation ayant deux critères SIRS ou plus, le traitement avec une cible PaO₂ basse-normale par rapport à une cible PaO₂ élevée-normale n’a pas entraîné de réduction statistiquement significative de la dysfonction d'organes. Toutefois, l’étude aurait pu avoir une capacité limitée de détecter un effet de traitement plus faible que prévu.

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 Investigation

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 sont pas en faveur de l'utilisation de 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 Aaron Lacy, le 17 septembre 2021.

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 sont pas en faveur de l'utilisation d'un débit de perfusion plus lent.

Percutaneous Myocardial Revascularization in Late-Presenting Patients With STEMI.
Bouisset F, Gerbaud E, Bataille V, Coste P, Puymirat E, Belle L, Delmas C, Cayla G, Motreff P, Lemesle G, Aissaoui N, Blanchard D, Schiele F, Simon T, Danchin N, Ferrières J; FAST-MI Investigators. | J Am Coll Cardiol. 2021 Sep 28;78(13):1291-1305
DOI: https://doi.org/10.1016/j.jacc.2021.07.039  | Télécharger l'article au format  
Keywords: acute coronary syndrome; acute myocardial infarction; immortal time bias; latecomer; percutaneous coronary revascularization.

ORIGINAL INVESTIGATION

Introduction : The optimal management of patients with ST-segment elevation myocardial infarction (STEMI) presenting late->12 hours following symptom onset-is still under debate.
Objectives: The purpose of this study was to describe characteristics, temporal trends, and impact of revascularization in a large population of latecomer STEMI patients.

Méthode : The authors analyzed the data of 3 nationwide observational studies from the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting between 12 and 48 hours after symptom onset were classified as latecomers.

Résultats : A total of 6,273 STEMI patients were included in the 3 cohorts, 1,169 (18.6%) of whom were latecomers. After exclusion of patients treated with fibrinolysis and patients deceased within 2 days after admission, 1,077 patients were analyzed, of whom 729 (67.7%) were revascularized within 48 hours after hospital admission. At 30-day follow-up, all-cause death rate was significantly lower among revascularized latecomers (2.1% vs 7.2%; P < 0.001). After a median follow-up of 58 months, the rate of all-cause death was 30.4 (95% CI: 25.7-35.9) per 1,000 patient-years in the revascularized latecomers group vs 78.7 (95% CI: 67.2-92.3) per 1,000 patient-years in the nonrevascularized latecomers group (P < 0.001). In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant reduction of mortality occurrence during follow-up (HR: 0.65 [95% CI: 0.50-0.84]; P = 0.001).

Conclusion : Coronary revascularization of latecomer STEMI patients is associated with better short and long-term clinical outcomes.

Conclusion (proposition de traduction) : La revascularisation coronaire des patients avec un syndrome coronarien aigu avec sus-décalage du segment ST tardif est associée à de meilleurs résultats cliniques à court et à long terme.

Intracranial Hemorrhage During Dual Antiplatelet Therapy: JACC Review Topic of the Week.
Ha ACT, Bhatt DL, Rutka JT, Johnston SC, Mazer CD, Verma S. | J Am Coll Cardiol. 2021 Sep 28;78(13):1372-1384
DOI: https://doi.org/10.1016/j.jacc.2021.07.048  | Télécharger l'article au format  
Keywords: dual antiplatelet therapy; intracranial hemorrhage; reversal agent; risk prediction.

JACC Review Topic of the Week

Editorial : Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y₁₂ inhibitor is an established therapy for a broad spectrum of patients with cardiovascular disease. The ischemic benefit of DAPT is partially offset by its increased bleeding risk, with intracranial hemorrhage (ICH) being the most serious complication. Although uncommon (0.2%-0.3% annually), its cumulative burden can be substantial given the number of patients afflicted by cardiovascular disease worldwide. Patients with a history of stroke or transient ischemic attack harbor a particularly high risk for ICH when treated with DAPT. Prediction rules may assist clinicians when weighing the risk/benefit ratio of prescribing DAPT for patients with stroke/transient ischemic attack in the nonacute, ambulatory setting. Currently, there are no reversal agents that can rapidly and effectively reverse the effect of P2Y₁₂ inhibitors in routine practice, although a reversal agent for ticagrelor is under clinical investigation.

Conclusion : DAPT with ASA and a P2Y12 inhibitor has well-proven ischemic protective effects for a wide spectrum of patients with cardiovascular disease. However, this is at the expense of increased risk of major bleeding events, with ICH being the most devastating bleeding complication. Although the incidence of ICH is relatively low among patients treated with antiplatelet agents (0.2%-0.3% annually), the cumulative number of antiplatelet-associated ICH cases is not inconsequential. The global burden of antiplatelet-related ICH will likely continue to rise, especially because DAPT is commonly prescribed and often for extended periodsoftime. The riskofICH associated with DAPT must be carefully considered for certain high-risk patient subsets, such as those with previous stroke/ TIA. Risk prediction scores may help physicians delineate this trade-off, which, in turn, can enhance shared decision-making with patients at high risk for bleeding. In current clinical practice, there are no reversal agents that can rapidly and effectively neutralize the antiplatelet effect of P2Y12 inhibitors. A reversal agent for ticagrelor is under investigation.

Conclusion (proposition de traduction) : La double antiagrégation plaquettaire (DAPT) avec l'acide acétylsalicylique et un inhibiteur P2Y₁₂ a des effets protecteur contre l'ischémie bien démontré dans un nombre de patients présentant des maladies cardiovasculaires. Toutefois, cela se fait au détriment d’un risque accru d’événements hémorragiques majeurs, l'hémorragie intracrânienne (ICH) étant la complication la plus grave. Bien que l’incidence de l’ICH soit relativement faible chez les patients traités avec des agents antiplaquettaires (0,2 % à 0,3 % par année), le nombre cumulatif de cas d’ICH associés aux antiplaquettaires n’est pas sans conséquence. Le poids imputable à l’ICH liée aux antiplaquettaires continuera probablement d’augmenter, surtout parce que le DAPT est couramment prescrit et souvent pour une période prolongée. Le risque d’ICH associé à la DAPT doit être soigneusement pris en compte pour certains sous-ensembles de patients à risque élevé, tels que ceux ayant présenté un AVC/AIT antérieur. Les scores de prédiction du risque peuvent aider les médecins à définir ce compromis qui, à son tour, peut améliorer la prise de décision partagée avec les patients à risque élevé de saignement. Dans la pratique clinique actuelle, il n’existe aucun agent de renversion qui puisse neutraliser rapidement et efficacement l’effet antiplaquettaire des inhibiteurs du P2Y₁₂, bien qu'un agent de réversion pour le ticagrelor soit en cours d'investigation clinique.

Compression-Only Versus Rescue-Breathing Cardiopulmonary Resuscitation After Pediatric Out-of-Hospital Cardiac Arrest.
Naim MY, Griffis HM, Berg RA, Bradley RN, Burke RV, Markenson D, McNally BF, Nadkarni VM, Song L, Vellano K, Vetter V, Rossano JW. | J Am Coll Cardiol.. 2021 Sep 7;78(10):1042-1052
DOI: https://doi.org/10.1016/j.jacc.2021.06.042  | Télécharger l'article au format  
Keywords: bystander CPR; cardiac arrest; child; compression-only CPR; out-of-hospital cardiac arrest; pediatric.

Research article

Introduction : There are conflicting data regarding the benefit of compression-only bystander cardiopulmonary resuscitation (CO-CPR) compared with CPR with rescue breathing (RB-CPR) after pediatric out-of-hospital cardiac arrest (OHCA).
titre_en_plusObjectives: This study sought to test the hypothesis that RB-CPR is associated with improved neurologically favorable survival compared with CO-CPR following pediatric OHCA, and to characterize age-stratified outcomes with CPR type compared with no bystander CPR (NO-CPR).

Méthode : Analysis of the CARES registry (Cardiac Arrest Registry to Enhance Survival) for nontraumatic pediatric OHCAs (patients aged ≤18 years) from 2013-2019 was performed. Age groups included infants (<1 year), children (1 to 11 years), and adolescents (≥12 years). The primary outcome was neurologically favorable survival at hospital discharge.

Résultats : Of 13,060 pediatric OHCAs, 46.5% received bystander CPR. CO-CPR was the most common bystander CPR type. In the overall cohort, neurologically favorable survival was associated with RB-CPR (adjusted OR: 2.16; 95% CI: 1.78-2.62) and CO-CPR (adjusted OR: 1.61; 95% CI: 1.34-1.94) compared with NO-CPR. RB-CPR was associated with a higher odds of neurologically favorable survival compared with CO-CPR (adjusted OR: 1.36; 95% CI: 1.10-1.68). In age-stratified analysis, RB-CPR was associated with better neurologically favorable survival versus NO-CPR in all age groups. CO-CPR was associated with better neurologically favorable survival compared with NO-CPR in children and adolescents, but not in infants.

Conclusion : CO-CPR was the most common type of bystander CPR in pediatric OHCA. RB-CPR was associated with better outcomes compared with CO-CPR. These results support present guidelines for RB-CPR as the preferred CPR modality for pediatric OHCA.

Conclusion (proposition de traduction) : La réanimation cardio-pulmonaire par compression seule était le type le plus courant de RCP par les témoins dans les arrêts cardiaques pédiatriques extrahospitaliers. La respiration artificielle et la réanimation cardio-pulmonaire étaient associées à de meilleurs résultats par rapport à la réanimation cardio-pulmonaire par compression uniquement. Ces résultats appuient les lignes directrices actuelles pour la respiration artificielle et la réanimation cardio-pulmonaire en tant que modalité de RCP préférée pour les arrêts cardiaques pédiatriques en dehors de l'hôpital.

Paracetamol use during pregnancy - a call for precautionary action.
Bauer AZ, Swan SH, Kriebel D, Liew Z, Taylor HS, Bornehag CG, Andrade AM, Olsen J, Jensen RH, Mitchell RT, Skakkebaek NE, Jégou B, Kristensen DM. | Nat Rev Endocrinol. 2021 Sep 23
DOI: https://doi.org/10.1038/s41574-021-00553-7  | Télécharger l'article au format  
Keywords: Aucun

Consensus Statement

Editorial : Paracetamol (N-acetyl-p-aminophenol (APAP), otherwise known as acetaminophen) is the active ingredient in more than 600 medications used to relieve mild to moderate pain and reduce fever. APAP is widely used by pregnant women as governmental agencies, including the FDA and EMA, have long considered APAP appropriate for use during pregnancy when used as directed. However, increasing experimental and epidemiological research suggests that prenatal exposure to APAP might alter fetal development, which could increase the risks of some neurodevelopmental, reproductive and urogenital disorders. Here we summarize this evidence and call for precautionary action through a focused research effort and by increasing awareness among health professionals and pregnant women. APAP is an important medication and alternatives for treatment of high fever and severe pain are limited. We recommend that pregnant women should be cautioned at the beginning of pregnancy to: forego APAP unless its use is medically indicated; consult with a physician or pharmacist if they are uncertain whether use is indicated and before using on a long-term basis; and minimize exposure by using the lowest effective dose for the shortest possible time. We suggest specific actions to implement these recommendations. This Consensus Statement reflects our concerns and is currently supported by 91 scientists, clinicians and public health professionals from across the globe.

Conclusion : We here recognize our professional and social responsibility to take this action, even in the face of uncertainty, in light of the serious consequences of inaction. This call to action is consistent with the 2016 Targeting Environmental Neuro-Developmental Risks (TENDR) Consensus Statement, which we support:
“We as a society should be able to take protective action when scientific evidence indicates a chemical is of concern, and not wait for unequivocal proof that a chemical is causing harm to our children. Evidence of neurodevelopmental toxicity of any type — epidemiological or toxicological or mechanistic — by itself should constitute a signal sufficient to trigger prioritization and some level of action.” In addition, a new opinion statement issued by the American College of Obstetricians and Gynecologists suggests that gynaecologists should screen patients for exposure to environmental chemicals before and during pregnancy and counsel on how to minimize risks. We support this statement, which is consistent with our recommendations.
Paracetamol is a modifiable exposure. We recognize that limited medical alternatives exist to treat pain and fever; however, we believe the combined weight of animal and human scientific evidence is strong enough for pregnant women to be cautioned by health professionals against its indiscriminate use, both as a single ingredient and in combination with other medications. We recommend that paracetamol should be used by pregnant women cautiously at the lowest effective dose for the shortest possible time. Long-term or high-dose use should be limited to indications as advised by a health professional. Packaging should include warning labels including these recommendations. Given the high prevalence of paracetamol use by pregnant women, the public health implications of use reduction might be substantial.

Conclusion (proposition de traduction) : Nous reconnaissons ici notre responsabilité professionnelle et sociale qui nous pousse à prendre cette mesure si l'on ne fait rien, même face à une incertitude, à la lumière des graves conséquences. Cet appel à l'action est conforme à la Déclaration de consensus sur le ciblage des risques neuro-développementaux environnementaux (Targeting Environmental Neuro-Developmental Risks - TENDR) de 2016, déclaration de consensus, que nous soutenons :
« En tant que société savante, nous devrions pouvoir prendre des mesures de protection lorsque des preuves scientifiques indiquent qu'un produit chimique est préoccupant, et ne pas attendre la preuve sans équivoque qu'un produit chimique cause des dommages à nos enfants. La preuve d'une toxicité neurodéveloppementale de tout type - épidémiologique, toxicologique ou mécaniste - devrait en elle-même constituer un signal suffisant pour déclencher une hiérarchisation et un certain niveau d'action. En outre, une nouvelle déclaration d'opinion publiée par l'American College of Obstetricians and Gynecologists suggère que les gynécologues devraient dépister les patients pour l'exposition aux produits chimiques environnementaux avant et pendant la grossesse et conseiller sur la façon de minimiser les risques. Nous appuyons cette déclaration, qui est conforme à nos recommandations.
L'exposition au paracétamol est modifiable. Nous reconnaissons qu'il existe des alternatives médicales limitées pour traiter la douleur et la fièvre ; cependant, nous pensons que le poids combiné des preuves scientifiques animales et humaines est suffisamment solide pour que les femmes enceintes soient mises en garde par les professionnels de la santé contre son utilisation sans discernement, à la fois comme ingrédient unique et en combinaison avec d'autres médicaments. Nous recommandons que le paracétamol soit utilisé avec prudence par les femmes enceintes à la dose efficace la plus faible pendant la durée la plus courte possible. L'utilisation à long terme ou à forte dose doit être limitée aux indications recommandées par un professionnel de la santé. L'emballage doit inclure des étiquettes d'avertissement comprenant ces recommandations. Compte tenu de la forte prévalence de la consommation de paracétamol chez les femmes enceintes, les implications de la réduction de la consommation sur la santé publique pourraient être substantielles.

Commentaire :  Les associations entre l’exposition prénatale au paracétamol, le développement reproductif et neurocomportemental ont été suggérées par des études observationnelles chez l'homme :
Des études d’observation chez l’humain suggèrent que l’exposition prénatale au N-acétyl-p-aminophénol (APAP - Paracétamol) pourrait être associée à des anomalies de la reproduction et du comportement neurologique chez les deux sexes. L’exposition au paracétamol pendant la grossesse pourrait accroître le risque d’anomalies urogénitales et de l’appareil reproducteur masculin, car des études ont révélé un risque élevé de testicules non descendus (cryptorchidisme) et une distance réduite entre l’anus et la base du pénis, une mesure connue sous le nom de distance anogénitale (AGD). L’AGD réduit et la cryptorchidie sont des indicateurs d’une masculinisation perturbée et de facteurs de risque de troubles de la reproduction à un âge avancé. L’exposition prénatale au paracétamol a également été associée à un développement pubertal précoce chez la femme. De plus, les études épidémiologiques suggèrent invariablement que l’exposition prénatale au paracétamol pourrait accroître le risque d’effets indésirables sur le développement neurologique et comportemental, tels que le trouble déficitaire de l’attention avec hyperactivité (TDAH), le trouble du spectre autistique, le retard du langage (pour les filles) et le diminution du quotient intellectuel. Collectivement, les études suggèrent que le moment et la durée de l’utilisation du paracétamol par la mère sont des facteurs déterminants.

Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension.
Zhang W, Zhang S, Deng Y, Wu S, Ren J, Sun G, Yang J, Jiang Y, Xu X, Wang TD, Chen Y, Li Y, Yao L, Li D, Wang L, Shen X, Yin X, Liu W, Zhou X, Zhu B, Guo Z, Liu H, Chen X, Feng Y, Tian G, Gao X, Kario K, Cai J; STEP Study Group. | N Engl J Med. 2021 Sep 30;385(14):1268-1279
DOI: https://doi.org/10.1056/nejmoa2111437
Keywords: Aucun

Original article

Introduction : The appropriate target for systolic blood pressure to reduce cardiovascular risk in older patients with hypertension remains unclear.

Méthode : In this multicenter, randomized, controlled trial, we assigned Chinese patients 60 to 80 years of age with hypertension to a systolic blood-pressure target of 110 to less than 130 mm Hg (intensive treatment) or a target of 130 to less than 150 mm Hg (standard treatment). The primary outcome was a composite of stroke, acute coronary syndrome (acute myocardial infarction and hospitalization for unstable angina), acute decompensated heart failure, coronary revascularization, atrial fibrillation, or death from cardiovascular causes.

Résultats : Of the 9624 patients screened for eligibility, 8511 were enrolled in the trial; 4243 were randomly assigned to the intensive-treatment group and 4268 to the standard-treatment group. At 1 year of follow-up, the mean systolic blood pressure was 127.5 mm Hg in the intensive-treatment group and 135.3 mm Hg in the standard-treatment group. During a median follow-up period of 3.34 years, primary-outcome events occurred in 147 patients (3.5%) in the intensive-treatment group, as compared with 196 patients (4.6%) in the standard-treatment group (hazard ratio, 0.74; 95% confidence interval [CI], 0.60 to 0.92; P = 0.007). The results for most of the individual components of the primary outcome also favored intensive treatment: the hazard ratio for stroke was 0.67 (95% CI, 0.47 to 0.97), acute coronary syndrome 0.67 (95% CI, 0.47 to 0.94), acute decompensated heart failure 0.27 (95% CI, 0.08 to 0.98), coronary revascularization 0.69 (95% CI, 0.40 to 1.18), atrial fibrillation 0.96 (95% CI, 0.55 to 1.68), and death from cardiovascular causes 0.72 (95% CI, 0.39 to 1.32). The results for safety and renal outcomes did not differ significantly between the two groups, except for the incidence of hypotension, which was higher in the intensive-treatment group.

Conclusion : In older patients with hypertension, intensive treatment with a systolic blood-pressure target of 110 to less than 130 mm Hg resulted in a lower incidence of cardiovascular events than standard treatment with a target of 130 to less than 150 mm Hg.

Conclusion (proposition de traduction) : Chez les patients plus âgés souffrant d'hypertension, un traitement intensif avec une cible de pression artérielle systolique de 110 à 130 mmHg a entraîné une incidence plus faible d'événements cardiovasculaires que le traitement standard avec une cible de 130 à 150 mmHg.

Treatment of Acute Uncomplicated Appendicitis.
Talan DA, Di Saverio S. | N Engl J Med. 2021 Sep 16;385(12):1116-1123
DOI: https://doi.org/10.1056/nejmcp2107675
Keywords: Aucun

CLINICAL PRACTICE - CME

Editorial : Acute appendicitis is the most common reason for emergency abdominal surgery. The peak incidence occurs among persons 10 to 19 years of age, and the lifetime risk is 7 to 8%. Untreated appendicitis, when associated with rupture, can lead to abscess, peritonitis, sepsis, and death. Uncomplicated appendicitis (i.e., localized appendicitis), which has traditionally been treated with urgent appendectomy, accounts for approximately 80% of cases. In the past three decades, numerous trials of nonoperative treatment in patients with acute uncomplicated appendicitis have been conducted, and the use of antibiotic agents as a first strategy has become acknowledged as a safe option. In this article, we review the expected outcomes associated with initial operative and nonoperative treatment of acute uncomplicated appendicitis and offer guidance on counseling patients to help them chose between the two approaches.

Conclusion : The patient in the vignette has clinical findings consistent with acute appendicitis. She is a candidate for either nonoperative treatment or appendectomy. Through shared decision making, we would objectively review outcomes associated with operative and nonoperative treatments and explore the patient’s priorities. She should be assured that she is not at increased risk for appendiceal rupture or death if she does not undergo emergency surgery.
If the patient chooses nonoperative treatment, a long-acting parenteral antibiotic, such as ertapenem, should be administered. As long as her pain and nausea can be effectively controlled and her condition is clinically stable, she is a candidate for outpatient care while receiving oral antibiotics such as cefdinir and metronidazole in order to cover both Gram-negative and anaerobic bacteria. A regimen of 7 to 10 days would be appropriate.
Initiation of pain control with a scheduled regimen of nonsteroidal antiinflammatory drugs and acetaminophen, as well as opiates (as needed). is recommended. An antiemetic agent should also be prescribed and taken as needed for the next few days. Improvement should be expected during a 48-hour period. Follow-up — including in the form of a telemedicine visit — is advisable. Worsening symptoms would prompt referral back to the emergency department. Diffuse peritonitis, sepsis, or the absence of improvement after 48 hours would be indications for appendectomy.

Conclusion (proposition de traduction) : La patiente de ce cas clinique présente des signes cliniques compatibles avec une appendicite aiguë. Elle est candidate à un traitement non opératoire ou à une appendicectomie. Grâce à une prise de décision partagée, nous examinerions objectivement les résultats associés aux traitements chirurgicaux et non chirurgicaux et explorerions les priorités du patient. Elle doit être assurée qu'elle n'est pas exposée à un risque accru de rupture appendiculaire ou de décès si elle ne subit pas une intervention chirurgicale d'urgence.
Si le patient choisit un traitement non opératoire, un antibiotique parentéral à longue durée d'action, tel que l'ertapénème, doit être administré. Tant que sa douleur et ses nausées peuvent être efficacement contrôlées et que son état est cliniquement stable, elle est candidate à des soins ambulatoires tout en recevant des antibiotiques oraux tels que le cefdinir et le métronidazole afin de couvrir à la fois les bactéries Gram-négatives et anaérobies. Un régime de 7 à 10 jours serait approprié.
Initiation du contrôle de la douleur avec un traitement programmé d'anti-inflammatoires non stéroïdiens et d'acétaminophène, ainsi que d'opiacés (au besoin) est recommandé. Un agent antiémétique doit également être prescrit et pris au besoin pendant les prochains jours. Une amélioration doit être attendue au cours d'une période de 48 heures. Un suivi, y compris sous la forme d'une visite de téléconsultation, est conseillé. L'aggravation des symptômes inciterait à un retour vers le service des urgences. Une péritonite diffuse, un sepsis ou l'absence d'amélioration après 48 heures seraient des indications d'appendicectomie.

Etiology, Management, and Outcome of Pediatric Epistaxis.
Send T, Bertlich M, Eichhorn KW, Ganschow R, Schafigh D, Horlbeck F, Bootz F, Jakob M. | Pediatr Emerg Care. 2021 Sep 1;37(9):466-470
DOI: https://doi.org/10.1097/pec.0000000000001698
Keywords: Aucun

Original article

Introduction : Epistaxis in children is one of the most common causes for seeking professional medical help. Patients may be treated by several disciplines with various approaches to pediatric epistaxis. We reviewed cases of pediatric epistaxis from an otorhinolaryngologist's point of view.

Méthode : A retrospective chart review was performed on all patients younger than 18 years presenting with epistaxis to the Department of Otorhinolaryngology at the University of Bonn, Germany.

Résultats : Sixty episodes of epistaxis in 58 patients were included in the study. Mean age was 10.1 ± 4.5 years. In terms of risk factors, 3 patients had a hemorrhagic diathesis, 3 had taken medication that interfered with hemostasis, and 8 had a history of previous trauma, most of which was digital manipulation. Twenty-six patients did not need invasive therapy. Twenty-six patients received cauterization to control the bleeding, and 4 patients needed surgery. The necessity for surgery was mainly noncooperation.

Conclusion : Epistaxis in children is seldom serious. However, hemorrhagic diathesis needs to be kept in mind as a potential cause of epistaxis. In most cases, careful instruction of the patients and the relatives concerning nasal mucosal care is sufficient. If cauterization is necessary, silver nitrate coagulation should be preferred over electrocoagulation.

Conclusion (proposition de traduction) : 'épistaxis chez les enfants est rarement grave. Cependant, la diathèse hémorragique doit être considérée comme une cause potentielle d'épistaxis. Dans la plupart des cas, une instruction attentive des patients et des proches concernant les soins de la muqueuse nasale est suffisante. Si une cautérisation est nécessaire, la coagulation au nitrate d'argent doit être préférée à l'électrocoagulation.

Chest Radiograph Alone Is Sufficient as the Foreign Body Survey for Children Presenting With Coin Ingestion.
Shatani N, Alshaibani S, Potts J, Phillips B, Bray H. | Pediatr Emerg Care. 2021 Sep 1;37(9):e524-e527
DOI: https://doi.org/10.1097/pec.0000000000001688
Keywords: Aucun

Original article

Introduction : Radiographic survey of the entire aerodigestive tract (nares to anus) is common practice in children presenting to the emergency department following coin ingestion. The purpose of our study was to determine the optimal protocol for radiographic survey post-coin ingestion. We hypothesized that for children presenting with a clear history of coin ingestion a frontal chest radiograph including the entire esophagus is adequate to guide treatment.

Méthode : We reviewed the clinical history and radiographic surveys of 134 patients presenting with suspected or witnessed coin ingestion to the emergency department of a tertiary care pediatric hospital between January 2012 and June 2016. Patient demographics, presenting symptoms, anatomic coverage of survey, type, number and location of radiopaque foreign bodies, intervention, and follow-up were recorded.

Résultats : Coins were identified on radiographic surveys in 109 of 134 patients; 25 of 134 patients had no coin. Of those with coins, none of 109 had coin(s) in the airway, 42 of 109 had coin(s) in the esophagus, and 67 of 109 had coin(s) distal to the esophagus. Of those with esophageal coins, 35 of 42 reported symptoms, 7 of 42 were asymptomatic, 40 of 42 underwent endoscopic coin removal, and 2 of 42 had no intervention. Of 92 of 134 surveyed patients with no coin or coin distal to the esophagus, 30 of 92 reported symptoms, 62 of 92 were asymptomatic, 90 of 92 had no further intervention, and 2 of 92 eventually underwent endoscopic coin removal for specific indications (abdominal pain, delayed passage). When there was no coin found in the esophagus, the negative predictive value for intervention was 97.8%.

Conclusion : Following a clear history of coin ingestion, a frontal chest radiograph including the entire length of the esophagus provides sufficient information to direct patient management.

Conclusion (proposition de traduction) : Après une histoire claire d'ingestion de pièces de monnaie, une radiographie thoracique de face incluant toute la longueur de l'œsophage fournit des informations suffisantes pour orienter la prise en charge du patient.

Predictive Utility of End-Tidal Carbon Dioxide on Defibrillation Success in Out-of-Hospital Cardiac Arrest.
Hubble MW, Van Vleet L, Taylor S, Bachman M, Williams JG, Vipperman R, Renkiewicz GK. | Prehosp Emerg Care. 2021 Sep-Oct;25(5):697-705
DOI: https://doi.org/10.1080/10903127.2020.1828518
Keywords: capnography; cardiac arrest; cardiopulmonary resuscitation; defibrillation; ventricular fibrillation.

Article

Introduction : The likelihood of survival from ventricular fibrillation (VF) declines 7%-10% per minute until successful defibrillation. When VF duration is prolonged, immediate defibrillation of the ischemic myocardium is less likely to result in ROSC, and repeated unsuccessful defibrillations are associated with post-resuscitation myocardial dysfunction. Thus, the timing of defibrillation should be based upon the probability of shock success-a function of VF duration. Unfortunately, VF duration is often unknown in out-of-hospital cardiac arrest (OHCA) and a better predictor of shock success is needed.
Objective: To assess the ability of end-tidal carbon dioxide (EtCO2) to predict successful defibrillation in OHCA.

Méthode : This retrospective study included adult patients among four EMS systems who experienced non-traumatic OHCA from August, 2015-July, 2017 and received one or more defibrillations. First and succedent shocks were analyzed separately. First shocks represented EMS-attempted defibrillation of patients who had not received a prior AED shock, whereas succedent shocks included all shocks subsequent to the first. Logistic regression provided odds ratios (OR) for first shocks resulting in ROSC, while a generalized estimating equation was used to analyze succedent shocks.

Résultats : Among 324 patients, 869 shocks were delivered by EMS (153 first and 716 succedent shocks). Layperson CPR was performed in 48.1% of cases and 21.6% received an AED shock before EMS arrival. First defibrillation ROSC was more likely with layperson CPR (OR = 4.41;p = 0.01) and increasing EtCO2 (OR = 1.03/mmHg;p = 0.01). No other variables were statistically significant. Notably, only one patient with EtCO2 < 20 mmHg was successfully defibrillated on the first shock. The probability of ROSC was higher with increasing values of EtCO2 when layperson CPR was provided, yet remained relatively unchanged across all values of EtCO2 ≥ 20 mmHg without layperson CPR. The optimal threshold first shock EtCO2 was 27 and 32 mmHg for those with/without layperson CPR, respectively. EtCO2 was not a predictor of ROSC for succedent shocks.

Conclusion :  An optimal defibrillation threshold EtCO2 of 27 and 32 mmHg was observed for patients with and without layperson CPR, respectively. Further studies are warranted to verify these results and to evaluate the clinical effect of delaying defibrillation in favor of chest compressions until these values are attained.

Conclusion (proposition de traduction) : Un seuil EtCO₂ de défibrillation optimal de 27 et 32 mmHg a été observé pour les patients avec et sans réanimation cardio-pulmonaire, respectivement. D'autres études sont nécessaires pour vérifier ces résultats et évaluer l'effet clinique du retardement de la défibrillation en faveur des compressions thoraciques jusqu'à ce que ces valeurs soient atteintes.

Validation of the NUE Rule to Predict Futile Resuscitation of Out-of-Hospital Cardiac Arrest.
Glober NK, Lardaro T, Christopher S, Tainter CR, Weinstein E, Kim D. | Prehosp Emerg Care. 2021 Sep-Oct;25(5):706-711
DOI: https://doi.org/10.1080/10903127.2020.1831666
Keywords: emergency medical services; out-of-hospital cardiac arrest; resuscitation.

Article

Introduction : We validated the NUE rule, using three criteria (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) to predict futile resuscitation of patients with out-of-hospital cardiac arrest (OHCA).

Méthode : We performed a retrospective cohort analysis of all recorded OHCA in Marion County, Indiana, from January 1, 2014 to December 31, 2019. We described patient, arrest, and emergency medical services (EMS) response characteristics, and assessed the performance of the NUE rule in identifying patients unlikely to survive to hospital discharge.

Résultats : From 2014 to 2019, EMS responded to 4370 patients who sustained OHCA. We excluded 329 (7.5%) patients with incomplete data. Median patient age was 62 years (IQR 49 - 73), 1599 (39.6%) patients were female, and 1728 (42.8%) arrests were witnessed. The NUE rule identified 290 (7.2%) arrests, of whom none survived to hospital discharge.

Conclusion : In external validation, the NUE rule (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) correctly identified 7.2% of OHCA patients unlikely to survive to hospital discharge. The NUE rule could be used in EMS protocols and policies to identify OHCA patients very unlikely to benefit from aggressive resuscitation.

Conclusion (proposition de traduction) : Lors de la validation externe, la règle NUE (rythme initial non choquant, arrêt sans témoin, quatre-vingts ans ou plus) a correctement identifié 7,2 % des patients en arrêt cardiaque extra-hospitalier peu susceptibles de survivre à la sortie de l'hôpital. La règle NUE pourrait être utilisée dans les protocoles et les politiques des services médicaux d'urgence pour identifier les patients en arrêt cardiaque en dehors de l'hôpital très peu susceptibles de bénéficier d'une réanimation agressive.

Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study.
Schwalbach KT, Yong SS, Chad Wade R, Barney J. | Resuscitation. 2021 Sep;166:7-13
DOI: https://doi.org/10.1016/j.resuscitation.2021.07.005
Keywords: In-Hospital Cardiac Arrest (IHCA); Intraosseous; Obesity; Resuscitation.

Clinical Paper

Introduction : To compare outcomes between Intraosseous (IO) and peripheral intravenous (PIV) injection during in-hospital cardiac arrest (IHCA) and examine its utility in individuals with obesity.

Méthode : We performed a retrospective cohort analysis of adult, atraumatic IHCA at a single tertiary care center. Subjects were classified as either IO or PIV resuscitation. The primary outcome of interest was survival to hospital discharge. The secondary outcomes of interest were survival with favourable neurologic status, rates-of-ROSC (ROR) and time-to-ROSC (TTR). Subgroup analysis among patients with BMI ≥ 30 kg/m² was performed.

Résultats : Complete data were available for 1852 subjects, 1039 of whom met eligibility criteria. A total of 832 were resuscitated via PIV route and 207 via IO route. Use of IO compared to PIV was associated with lower overall survival to hospital discharge (20.8% vs 28.4% p = 0.03), lower rates of survival with favourable neurologic status (18.4% vs 25.2% p = 0.04), lower ROR (72.2% vs 80.7%) and longer TTR (12:38 min vs 9:01 min). After multivariate adjustment there was no significant differences between IO and PIV in rates of survival to discharge (OR 0.71, 95% CI 0.47-1.06, p = 0.09) or rates of survival with favourable neurologic status (OR 0.74, 95% CI 0.49-1.13, p = 0.16). The ROR and TTR remained significantly worse in the IO group. Subgroup analysis of patients with BMI ≥ 30 kg/m² identified no benefit or harm with use of IO compared to PIV.

Conclusion : Intraosseous medication delivery is associated with inferior rates-of-ROSC and longer times-to-ROSC compared to PIV, but no differences in overall survival to hospital discharge or survival with favourable neurologic status during IHCA.

Conclusion (proposition de traduction) : L’administration de médicaments par voie intraosseuse est associée à des taux inférieurs de récupération d’activité circulatoire spontanée (RACS) et à des temps plus longs de récupération d'activité circulatoire spontanée par rapport à la voie veineuse périphérique, mais aucune différence dans la survie globale à la sortie de l’hôpital ou la survie avec un état neurologique favorable lors d'un arrêt cardiaque à l’hôpital.

Commentaire : Ha ACT and al. n’ont pas trouvé non plus d'association significative entre les types d’accès vasculaire (intra-osseuse versus intraveineuse) et les résultats neurologiques ou la survie à la sortie de l’hôpital, chez les patients en arrêt cardiaque extra-hospitalier. Le délai d’intervention a été identifié comme un modérateur de résultats important dans cette méta-analyse d'études observationnelles.

Ha ACT, Bhatt DL, Rutka JT, Johnston SC, Mazer CD, Verma S. Intracranial Hemorrhage During Dual Antiplatelet Therapy: JACC Review Topic of the Week. J Am Coll Cardiol. 2021;78(13):1372–84  .

Discrimination between the presence and absence of spontaneous circulation using smartphone seismocardiography: A preliminary investigation.
Lee HY, Jung YH, Jeung KW, Lee DH, Lee BK, Jang GY, Oh TI, Mamadjonov N, Heo T. | Resuscitation. 2021 Sep;166:66-73
DOI: https://doi.org/10.1016/j.resuscitation.2021.07.009
Keywords: Heart arrest; Smartphone; Vibration.

Clinical paper

Introduction : Seismocardiography measures the vibrations produced by the beating heart using an accelerometer sensor placed on the chest. We evaluated the ability of smartphone seismocardiography to distinguish between the presence and absence of spontaneous circulation.

Méthode : Seismocardiography signals were obtained using a smartphone placed on the sternum in a convenience sample of 60 adult patients (30 comatose patients with spontaneous circulation and 30 deceased patients). The maximum, minimum, and standard deviation (SD) of acceleration values for head-to-foot, right-to-left, and dorsoventral axes and the three axis-root mean square (RMS) of the acceleration signals were calculated. Blinded observers (n = 156) were each asked to determine the presence or absence of spontaneous circulation based on seismocardiography video clips for each of the 60 patients.

Résultats : The seismocardiography revealed periodic large positive peaks in the patients with spontaneous circulation, which were absent in the patients without spontaneous circulation. For each of the four output measurements (three independent axes plus the three-axis RMS), the acceleration maxima and SD were significantly higher and the minima significantly lower in the patients with spontaneous circulation than in those without spontaneous circulation (all P < 0.001 except the minimum of three axis-RMS results [P = 0.009]). The observers accurately identified the seismocardiography signals from patients without spontaneous circulation, with a sensitivity of 97.6% (95% confidence interval, 97.0%-98.2%) and a specificity of 98.4% (95% confidence interval, 97.8%-99.0%).

Conclusion : In conclusion, blinded observers accurately distinguished between seismocardiography signals from patients with and without spontaneous circulation.

Conclusion (proposition de traduction) : En conclusion, les observateurs en aveugle ont distingué avec précision les signaux de sismocardiographie des patients avec et sans circulation spontanée.

Commentaire : La sismocardiographie (SCG) consiste à mesurer les déplacements du sternum et des côtes générées par les battements cardiaques à l'aide d'accéléromètres.
Elle est notamment utilisée par les smartphones pour la détection de la fibrillation atriale.

Placement du smartphone pour collecter les signaux de sismocardiographie.
Le smartphone a été placé sur le sternum avec le bord inférieur du smartphone au niveau de l'appendice xiphoïde, de sorte que les axes longitudinal, latéral et antéro-postérieur de l'accéléromètre soient orientés le long de la tête aux pieds, de droite à gauche, et les axes dorsoventraux du patient, respectivement.

To ventilate or not to ventilate during bystander CPR — A EuReCa TWO analysis.
Wnent J, Tjelmeland I, Lefering R, Koster RW, Maurer H, Masterson S, Herlitz J, Böttiger BW, Ortiz FR, Perkins GD, Bossaert L, Moertl M, Mols P, Hadžibegović I, Truhlář A, Salo A, Baert V, Nagy E, Cebula G, Raffay V, Trenkler S, Markota A, Strömsöe A, Gräsner JT; national coordinators of EuReCa TWO and local contributors. | Resuscitation. 2021 Sep;166:101-109
DOI: https://doi.org/10.1016/j.resuscitation.2021.06.006  | Télécharger l'article au format  
Keywords: Bystander CPR; Chest-compression only CPR; EuReCa; Full CPR; Out-of-hospital cardiac arrest.

Clinical paper

Introduction : Survival after out-of-hospital cardiac arrest (OHCA) is still low. For every minute without resuscitation the likelihood of survival decreases. One critical step is initiation of immediate, high quality cardiopulmonary resuscitation (CPR). The aim of this subgroup analysis of data collected for the European Registry of Cardiac Arrest Study number 2 (EuReCa TWO) was to investigate the association between OHCA survival and two types of bystander CPR namely: chest compression only CPR (CConly) and CPR with chest compressions and ventilations (FullCPR).

Méthode : In this subgroup analysis of EuReCa TWO, all patients who received bystander CPR were included. Outcomes were return of spontaneous circulation and survival to 30-days or hospital discharge. A multilevel binary logistic regression analysis with survival as the dependent variable was performed.

Résultats : A total of 5884 patients were included in the analysis, varying between countries from 21 to 1444. Survival was 320 (8%) in the CConly group and 174 (13%) in the FullCPR group. After adjustment for age, sex, location, rhythm, cause, time to scene, witnessed collapse and country, patients who received FullCPR had a significantly higher survival rate when compared to those who received CConly (adjusted odds ration 1.46, 95% confidence interval 1.17-1.83).

Conclusion : In this analysis, FullCPR was associated with higher survival compared to CConly. Guidelines should continue to emphasise the importance of compressions and ventilations during resuscitation for patients who suffer OHCA and CPR courses should continue to teach both.

Conclusion (proposition de traduction) : Dans cette analyse, la RCP complète (compressions thoraciques et ventilations) était associée à une survie plus élevée par rapport à la RCP par compression thoracique seule. Les recomandations devraient continuer à souligner l'importance des compressions et de la ventilation pendant la réanimation pour les patients qui subissent un arrêt cardiaque en dehors de l'hôpital et les cours sur la RCP devraient continuer à enseigner les deux.

Expired carbon dioxide during newborn resuscitation as predictor of outcome.
Holte K, Ersdal H, Klingenberg C, Eilevstjønn J, Stigum H, Jatosh S, Kidanto H, Størdal K. | Resuscitation. 2021 Sep;166:121-128
DOI: https://doi.org/10.1016/j.resuscitation.2021.05.018  | Télécharger l'article au format  
Keywords: 24 Hour outcome; Bag-mask ventilation; Expired carbon dioxide; Heart rate; Newborn resuscitation.

Clinical paper

Introduction : To explore and compare expired CO₂ (ECO₂) and heart rate (HR), during newborn resuscitation with bag-mask ventilation, as predictors of 24-h outcome.

Méthode : Observational study from March 2013 to June 2017 in a rural Tanzanian hospital. Side-stream measures of ECO₂, ventilation parameters, HR, clinical information, and 24-h outcome were recorded in live born bag-mask ventilated newborns with initial HR < 120 bpm. We analysed the data using logistic regression models and compared areas under the receiver operating curves (AUC) for ECO₂ and HR within three selected time intervals after onset of ventilation (0-30 s, 30.1-60 s and 60.1-300 s).

Résultats : Among 434 included newborns (median birth weight 3100 g), 378 were alive at 24 h, 56 had died. Both ECO₂ and HR were independently significant predictors of 24-h outcome, with no differences in AUCs. In the first 60 s of ventilation, ECO₂ added extra predictive information compared to HR alone. After 60 s, ECO₂ lost significance when adjusted for HR. In 70% of newborns with initial ECO₂ <2% and HR < 100 bpm, ECO₂ reached ≥2% before HR ≥ 100 bpm. Survival at 24 h was reduced by 17% per minute before ECO₂ reached ≥2% and 44% per minute before HR reached ≥100 bpm.

Conclusion : Higher levels and a faster rise in ECO₂ and HR during newborn resuscitation were independently associated with improved survival compared to persisting low values. ECO₂ increased before HR and may serve as an earlier predictor of survival.

Conclusion (proposition de traduction) : Des niveaux plus élevés et une augmentation plus rapide de l'EtCO₂ et de la FC pendant la réanimation du nouveau-né étaient indépendamment associés à une amélioration de la survie par rapport à des valeurs faibles persistantes. L'EtCO₂ a augmenté avant la fréquence cardiaque et peut servir de prédicteur plus précoce de la survie.

Commentaire : Une EtCO₂ ≥ 2 % ou une fréquence cardiaque ≥ 100 ,bpm devrait encourager des efforts supplémentaires, même chez les nouveau-nés apparemment non viables.

Saucedo M, Tessier V, Leroux S, Almeras A, Deneux-Tharaux C. | Sages-Femmes. 2021;20(5):36–42
DOI: https://www.sciencedirect.com/science/article/pii/S1637408821001206
Keywords: maternal health; maternal mortality; quality of care; risk factor

Clinique

Editorial : Le sixième rapport de l’enquête nationale confidentielle sur les morts maternelles apporte des enseignements sur la fréquence, les facteurs de risque, les causes et l’évitabilité des décès maternels survenus de 2013 à 2015 en France. Il relève la persistance d’inégalités sociales et géographiques et montre que, si le taux global de ces décès reste stable, la contribution des hémorragies obstétricales continue à diminuer, tandis que les maladies cardio-vasculaires et les suicides sont devenus les causes les plus fréquentes. Des facteurs d’évitabilité utiles pour cibler les éléments liés aux soins et à leur organisation à améliorer ont été dégagés.

Conclusion :  En faisant la description des morts maternelles survenues en France, le sixième rapport de l’ENCMM fournit des informations sur les priorités en santé maternelle, en particulier la santé cardiovasculaire et la santé mentale. À chacun de s’emparer de ses résultats pour les décliner en actions d’amélioration des soins et de leur organisation, aux différents échelons. La diminution, historique, de la mortalité maternelle par hémorragie prouve qu’une réelle avancée est possible. Une amélioration doit être recherchée dans des domaines de la santé non strictement obstétricaux. Les sages-femmes, acteurs de première ligne pour la prévention, le dépistage et la coordination des soins en santé maternelle, ont un rôle de premier plan à jouer dans ce processus.

Incidence of hyperoxia in trauma patients receiving pre-hospital emergency anaesthesia: results of a 5-year retrospective analysis.
Leitch P, Hudson AL, Griggs JE, Stolmeijer R, Lyon RM, Ter Avest E; Air Ambulance Kent Surrey Sussex. | Scand J Trauma Resusc Emerg Med. 2021 Sep 10;29(1):134
DOI: https://doi.org/10.1186/s13049-021-00951-w  | Télécharger l'article au format  
Keywords: Emergency medical services; Hyperoxemia; Hyperoxia; Oxygen therapy; Pre-hospital anesthesia; Trauma; Ventilation.

Original research

Introduction : Previous studies have demonstrated an association between hyperoxia and increased mortality in various patient groups. Critically unwell and injured patients are routinely given high concentration oxygen in the pre-hospital phase of care. We aim to investigate the incidence of hyperoxia in major trauma patients receiving pre-hospital emergency anesthesia (PHEA) in the pre-hospital setting and determine factors that may help guide clinicians with pre-hospital oxygen administration in these patients.

Méthode : A retrospective cohort study was performed of all patients who received PHEA by a single helicopter emergency medical service (HEMS) between 1 October 2014 and 1 May 2019 and who were subsequently transferred to one major trauma centre (MTC). Patient and treatment factors were collected from the electronic patient records of the HEMS service and the MTC. Hyperoxia was defined as a PaO₂ > 16 kPA on the first arterial blood gas analysis upon arrival in the MTC.

Résultats : On arrival in the MTC, the majority of the patients (90/147, 61.2%) had severe hyperoxia, whereas 30 patients (20.4%) had mild hyperoxia and 26 patients (19.7%) had normoxia. Only 1 patient (0.7%) had hypoxia. The median PaO₂ on the first arterial blood gas analysis (ABGA) after HEMS handover was 36.7 [IQR 18.5-52.2] kPa, with a range of 7.0-86.0 kPa. SpO₂ pulse oximetry readings before handover were independently associated with the presence of hyperoxia. An SpO₂ ≥ 97% was associated with a significantly increased odds of hyperoxia (OR 3.99 [1.58-10.08]), and had a sensitivity of 86.7% [79.1-92.4], a specificity of 37.9% [20.7-57.8], a positive predictive value of 84.5% [70.2-87.9] and a negative predictive value of 42.3% [27.4-58.7] for the presence of hyperoxemia.

Conclusion : Trauma patients who have undergone PHEA often have profound hyperoxemia upon arrival at hospital. In the pre-hospital setting, where arterial blood gas analysis is not readily available a titrated approach to oxygen therapy should be considered to reduce the incidence of potentially harmful tissue hyperoxia.

Conclusion (proposition de traduction) : Les patients traumatisés qui ont bénéficié d'une anesthésie d'urgence préhospitalière présentent souvent une hyperoxémie profonde à leur arrivée à l'hôpital. En milieu préhospitalier, où l'analyse des gaz du sang artériel n'est pas facilement disponible, une approche titrée de l'oxygénothérapie doit être envisagée pour réduire l'incidence de l'hyperoxie tissulaire potentiellement nocive.

Commentaire : Caractéristiques des effets biologiques des molécules d'oxygène
✓ Oxygénation
 • Augmentation de la teneur en oxygène artériel et donc de l'apport d'oxygène systémique
 • Efficacité variable selon le type d'hypoxie
✓ Circulation
 • Vasoconstriction systémique
   — Augmentation de la résistance vasculaire systémique et donc de la pression artérielle systémique
   — Diminution du volume systolique cardiaque et du débit cardiaque
   — Diminution possible du flux sanguin tissulaire
 • Vasodilatation pulmonaire dans la zone touchée par l'oxygène inhalé
   — Diminution de la résistance vasculaire pulmonaire et donc de la pression artérielle pulmonaire
   — Augmentation du débit sanguin pulmonaire
   — Diminution du débit du shunt intracardiaque droite-gauche, s'il existe
 • Perfusion régionale
   — Diminution du débit sanguin coronaire
   — Aggravation des lésions ischémiques dans l'infarctus du myocarde
✓ Toxicité cellulaire
 • Inflammation : Induction de cytokines pro-inflammatoires
 • Production de dérivés réactifs de l'oxygène
   — Augmentation des dommages neurologiques après reperfusion d'ischémie
   — Lésion pulmonaire induite et dysfonctionnement possible d'autres organes
✓ Autres
 • Occurrence d'atélectasie de résorption
 • Altération de la clairance mucociliaire dans la trachée/les bronches
 • Immunité innée compromise.

In: Nakane M. Biological effects of the oxygen molecule in critically ill patients. J Intensive care. 2020;8(95):1–12  .

Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study.
Breindahl N, Baekgaard J, Christensen RE, Jensen AH, Creutzburg A, Steinmetz J, Rasmussen LS. | Scand J Trauma Resusc Emerg Med. 2021 Sep 15;29(1):136
DOI: https://doi.org/10.1186/s13049-021-00948-5  | Télécharger l'article au format  
Keywords: Intubation; Ketamine; Pre-hospital; Propofol; Rapid sequence induction; Trauma.

Original research

Introduction : Rapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI.

Méthode : In this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals.

Résultats : From January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58-1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation.

Conclusion : In this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.

Conclusion (proposition de traduction) : Dans cette étude, les patients traumatisés intubés avec de la kétamine n'avaient pas une mortalité à 30 jours inférieure à celle du propofol.

Use of troponin assay after electrical injuries: a 15-year multicentre retrospective cohort in emergency departments.
Douillet D, Kalwant S, Amro Y, Gicquel B, Arnaudet I, Savary D, Le Bastard Q, Javaudin F. | Scand J Trauma Resusc Emerg Med. 2021 Sep 26;29(1):141
DOI: https://doi.org/10.1186/s13049-021-00955-6  | Télécharger l'article au format  
Keywords: Electric injuries, Troponin, MACE, Emergency Department, Cardiac arrhythmias

ORIGINAL RESEARCH

Introduction : Patients with electrical injury are considered to be at risk of cardiac arrhythmia. Assessing the risk of developing a major adverse cardiac event (MACE) is the cornerstone of patient management. The aim of this study was to assess the performance of initial troponin and troponin rise to predict Major Adverse Cardiac Events (MACEs) in all patients with electrical injuries admitted to the Emergency Department.

Méthode : This is a multicentre retrospective study in which consecutive patients with electrical injuries admitted to the Emergency Departments (ED) (adult and paediatric) of five French Hospitals were included between 2005 and 2019. The threshold for troponin elevation is based on the European Society of Cardiology guidelines for patients presenting without persistent ST segment elevation. The primary endpoint was the rate of MACE.

Résultats : A total of 785 included patients were admitted to ED with a first diagnosis of electrical injury during the study period. Troponin assays were performed in 533 patients (67.9%), including 465 of 663 adults (70.1%) and 68 of 122 children (55.7%) and 17/533 (3.2%) of patients had an initial elevated troponin. If none of the clinical criteria for MACE were present (i.e., previous known heart disease, exposure to a high voltage of ≥ 1000 Volts, initial loss of consciousness, or an abnormal initial ECG), this defined a low-risk subgroup (n = 573, 76.0%) that could be safely discharged. The initial positive troponin assay had a sensitivity of 83.3 (95% CI 35.9–99.6%), a specificity of 97.7 (95% CI 96.1–98.8%), a positive likelihood ratio 36.6 (95% CI 18.8–71.1%) and a negative predictive value of 99.9 (95% CI 99.2–99.9%) in predicting a MACE.

Conclusion : Troponin assay appears to be a predictive marker of MACE risk and should be considered in high-risk patients.

Conclusion (proposition de traduction) : Le dosage de la troponine semble être un marqueur prédictif du risque d'événement cardiaque indésirable majeur (MACE) et doit être envisagé chez les patients à haut risque.

Commentaire :  Correction to: Use of troponin assay after electrical injuries: a 15-year multicentre retrospective cohort in emergency departments  .

Prognostic Accuracy of VqSOFA for Predicting 28-day Mortality in Patients with Suspected Sepsis in the Emergency Department.
Suttapanit K, Wisan M, Sanguanwit P, Prachanukool T. | Shock. 2021 Sep 1;56(3):368-373
DOI: https://doi.org/10.1097/shk.0000000000001754
Keywords: Aucun

Clinical Science Aspect

Introduction : Sepsis screening in the emergency department (ED) is challenging. The quick Sequential Organ Failure Assessment (qSOFA) score had poor accuracy for predicting mortality in both the intensive care unit and ED. High lactate levels were associated with an increased mortality. However, a previous study using lactate levels in combination with the qSOFA score did not observe a meaningful improvement in predictive accuracy. This study assessed the prognostic accuracy of venous lactate levels plus the qSOFA (VqSOFA) score for predicting 28-day mortality.

Méthode : Patients who visited the Ramathibodi ED with suspected sepsis were enrolled. The VqSOFA, qSOFA, and Sequential Organ Failure Assessment (SOFA) scores were calculated using the initial vital signs and laboratory values. Prognostic accuracy was measured using the area under the receiver operating characteristic (AUROC) curve of the VqSOFA score and Sepsis-3 criteria for predicting 28-day mortality.

Résultats : In total, 1,139 patients were enrolled, 118 of whom died within 28 days of admission. The AUROCs of the VqSOFA, qSOFA, and SOFA scores were 0.851 (95% CI 0.813-0.889), 0.813 (95% CI 0.772-0.854), and 0.728 (95% CI 0.671-0.784), respectively. Using VqSOFA score ≥ 3 as the cutoff, the sensitivity, specificity, and positive likelihood ratio were 74.6%, 82.5%, and 4.25%, respectively. VqSOFA ≥ 3 was linked to a low probability of 28-day survival and higher odds of vasopressor and ventilator use within 24 h.

Conclusion : VqSOFA was more predictive of 28-day mortality and vasopressor and mechanical ventilator use than the qSOFA and SOFA scores.

Conclusion (proposition de traduction) : Le VqSOFA était plus prédictif de la mortalité à 28 jours et de l'utilisation de vasopresseurs et de ventilation mécanique que les scores qSOFA et SOFA.

Commentaire : Le score VqSOFA ≥ 3 était associée à une faible probabilité de survie de 28 jours et à une forte probabilité d'administration de vasopresseur dans les 24 heures ou de la nécessité d'un ventilation mécanique dans les 28 jours.

Brief High Oxygen Concentration Induces Oxidative Stress in Leukocytes and Platelets: A Randomized Cross-over Pilot Study in Healthy Male Volunteers.
Hafner C, Pramhas S, Schaubmayr W, Assinger A, Gleiss A, Tretter EV, Klein KU, Scharbert G. | Shock. 2021 Sep 1;56(3):384-395
DOI: https://doi.org/10.1097/shk.0000000000001728
Keywords: Aucun

Clinical Science Aspect

Introduction : Supplemental oxygen is administered routinely in the clinical setting to relieve or prevent tissue hypoxia, but excessive exposure may induce oxidative damage or disrupt essential homeostatic functions. It is speculated that oxidative stress in leukocytes and platelets may contribute to vascular diseases by promoting inflammation and cell aggregation.

Méthode : In this pilot study 30 healthy male volunteers (18-65 years) were exposed to high oxygen concentration (non-rebreather mask, 8 L/min, 100% O2) and synthetic air (non-rebreather mask, 8 L/min, 21% O2) in a cross-over design for 20 min at a 3-week interval. Venous blood samples were obtained at baseline and 1, 3, and 6 h postintervention. Primary outcome was generation of reactive oxygen species in leukocytes as measured by the redox-sensitive fluorescent dye dihydrorhodamine 123. Additional outcomes were oxidative stress in platelets and platelet aggregation as measured by thromboelastography (ROTEM) and Multiplate analyses.

Résultats : High oxygen exposure induced oxidative stress in leukocytes as evidenced by significantly higher mean fluorescence intensity (MFI) compared with synthetic air at 3 h postintervention (47% higher, P = 0.015) and 6 h postintervention (37% higher, P = 0.133). Oxidative stress was also detectable in platelets (33% higher MFI in comparison with synthetic air at 6 h, P = 0.024; MFI 20% above baseline at 3 h, P = 0.036; 37% above baseline at 6 h, P = 0.002). ROTEM analyses demonstrated reduced mean clotting time 1 h postintervention compared with baseline (-4%, P = 0.049), whereas there were no significant effects on other surrogate coagulation parameters.

Conclusion : Clinically relevant oxygen exposure induces oxidative stress in leukocytes and platelets, which may influence the immune and clotting functions of these cells.

Conclusion (proposition de traduction) : L'exposition à l'oxygène cliniquement pertinente induit un stress oxydatif dans les leucocytes et les plaquettes, ce qui peut influencer les fonctions immunitaires et de coagulation de ces cellules.

Carotid Ultrasound in Assessing Fluid Responsiveness in Patients with Hypotension and Suspected Sepsis.
Liteplo AS, Schleifer J, Marill KA, Huang CK, Gouker SK, Ratanski D, Diamond E, Filbin MR, Shokoohi H. | Shock. 2021 Sep 1;56(3):419-424
DOI: https://doi.org/10.1097/shk.0000000000001755
Keywords: Aucun

Clinical Science Aspect

Introduction : We sought to assess whether ultrasound (US) measurements of carotid flow time (CFTc) and carotid blood flow (CBF) predict fluid responsiveness in patients with suspected sepsis.

Méthode : This was a prospective observational study of hypotensive (systolic blood pressure < 90) patients "at risk" for sepsis receiving intravenous fluids (IVF) in the emergency department. US measurements of CFTc and CBF were performed at time zero and upon completion of IVF. All US measurements were repeated after a passive leg raise (PLR) maneuver. Fluid responsiveness was defined as normalization of blood pressure without persistent hypotension or need for vasopressors.

Résultats : A convenience sample of 69 patients was enrolled. The mean age was 65; 49% were female. Fluid responders comprised 52% of the cohort. CFTc values increased significantly with both PLR (P = 0.047) and IVF administration (P = 0.003), but CBF values did not (P = 0.924 and P = 0.064 respectively). Neither absolute CFTc or CBF measures, nor changes in these values with PLR or IVF bolus, predicted fluid responsiveness, mortality, or the need for intensive care unit admission.

Conclusion : In patients with suspected sepsis, a fluid challenge resulted in a significant change in CFTc, but not CBF. Neither absolute measurement nor delta measurements with fluid challenge predicted clinical outcomes.

Conclusion (proposition de traduction) : Chez les patients suspectés de sepsis, un essai de remplissage a entraîné une modification significative du temps d'écoulement carotidien, mais pas du débit sanguin carotidien. Ni les mesures absolues ni les mesures delta avec remplissage vasculaire ne prédisaient les résultats cliniques.

Characterization of ketamine usage in a large tertiary-care emergency department.
McKinley K, Panakos P, Yousef D. | Am J Emerg Med. 2021 Sep;47:149-153
DOI: https://doi.org/10.1016/j.ajem.2021.03.074
Keywords: Agitated delirium; Agitation; Emergency department; Ketamine; Procedural sedation.

Research article

Introduction : Ketamine is a phencyclidine derivative first used in clinical practice in the 1970's. Specifically within the emergency department (ED), ketamine is utilized for a wide variety of indications including but not limited to procedural sedation, rapid sequence intubation, agitation, and pain. As providers continue to utilize ketamine more frequently and for additional indications, additional data describing its safety and efficacy in the ED setting is warranted.
Objectives : To describe current trends in ketamine usage within a large tertiary-care Emergency Department.

Méthode : All patients receiving intravenous (IV) or intramuscular (IM) ketamine within the Emergency Department between January 1, 2019 and December 31, 2019 were eligible for study inclusion. Patients were excluded from the study if they were less than 18 years of age, pregnant, or incarcerated. Data was collected using a report of ketamine removal from the ED automatic dispensing cabinets, with administration confirmed by electronic medical record review.

Résultats : During the study period, 170 patients received 195 doses of ketamine for the indications of agitation, procedural sedation, rapid sequence intubation, pain, sedation, seizure, status asthmaticus, and unknown. Patients were mostly male (74%) with a mean age of 45 years (range 20-97 years). The most common indications for ketamine administration were agitation and procedural sedation. For agitation, ketamine was utilized as first line therapy in 45% of patients. Seventy-seven percent of these patients did not require an additional sedative agent up to 60 min after ketamine administration. Procedural sedations were most commonly orthopedic reductions, and ketamine was given more frequently in combination with propofol than as monotherapy. Five percent of patients had an adverse event documented in the electronic medical record, with a single incidence of ketamine induced laryngospasm requiring intubation.

Conclusion : This descriptive review supports the versatility, safety, and efficacy of ketamine use within a large, tertiary-care, academic emergency department. Larger, prospective studies are warranted to draw further conclusions regarding ideal ketamine utilization within the emergency department.

Conclusion (proposition de traduction) : Cette revue descriptive soutient la polyvalence, l'innocuité et l'efficacité de l'utilisation de la kétamine dans un grand service d'urgence universitaire de soins tertiaires. Des études prospectives plus importantes sont justifiées pour tirer d'autres conclusions concernant l'utilisation idéale de la kétamine au sein du service d'urgence.

Lack of admission biomarkers' clinical utility in outcomes prediction in patients suspected with infection in the emergency department.
Gornet M, Leroux P, Ramont L, De Ruffi S, Giordano Orsini G, Losset X, Kanagaratnam L, Gennai S. | Am J Emerg Med. 2021 Sep;47:109-114
DOI: https://doi.org/10.1016/j.ajem.2021.03.050
Keywords: Emergency department; Infection; Lactate; Outcome prediction; Procalcitonin.

Research article

Introduction : Initial procalcitonin (PCT) levels may fail in mortality and septic shock prediction and raise cost-effectiveness issues. Since measurement of lactate, C-reactive protein (CRP), white blood cells and neutrophils is common in the emergency department (ED), we compared prediction abilities of these biomarkers to PCT.

Méthode : From January 1st to December 31st, 2018, an observational, single center, retrospective study was conducted in the adult ED of the Reims University Hospital (France). Endpoints were bacteremia, septic shock, and in-hospital mortality, related to the same ED visit.

Résultats : Over one year, 459 patients suspected with infection were included, of mean age 60.4 years (SD: 22.0), with 50.8% male, and 364 (79.3%) were hospitalized following ED visit. Overall, 45 (9.8%) patients had a bacteremia, 39 (8.5%) a septic shock and 54 (11.8%) died during their hospitalization. PCT and CRP showed the best discrimination for bacteremia, with an area under curve (AUC) of 0.68 for PCT and 0.65 for CRP. PCT and lactate showed similar good discriminative power for septic shock, with an AUC of 0.78 for both, and poor discrimination for in-hospital mortality, with an AUC of 0.62 for PCT and 0.69 for lactate. Systolic blood pressure and pulse oximetry showed similar discrimination for septic shock as PCT or lactate, while they showed higher discrimination for in-hospital mortality than PCT.

Conclusion : Usual admission biomarkers lack clinical utility in predicting septic shock or in-hospital mortality. CRP and PCT are poorly efficient in predicting bacteremia.

Conclusion (proposition de traduction) : Les biomarqueurs habituels à l'admission manquent d'utilité clinique pour prédire le choc septique ou la mortalité à l'hôpital. La CRP et la PCT sont peu efficaces pour prédire la bactériémie.

Cerebral venous thrombosis: Diagnosis and management in the emergency department setting.
Spadaro A, Scott KR, Koyfman A, Long B. | Am J Emerg Med. 2021 Sep;47:24-29
DOI: https://doi.org/10.1016/j.ajem.2021.03.040
Keywords: Cerebral venous thrombosis; Neurology; Thrombosis.

Review article

Introduction : Cerebral venous thrombosis (CVT) is an uncommon neurologic emergency associated with significant morbidity and mortality that can be difficult to differentiate from other conditions. It is important for the emergency clinician to be familiar with this disease as it requires a high index of suspicion, and early diagnosis and management can lead to improved outcomes.

Méthode : This narrative review provides an evidence-based update concerning the presentation, evaluation, and management of CVT for the emergency clinician.

Discussion : CVT is due to thrombosis of the cerebral veins resulting in obstruction of venous outflow and increased intracranial pressure. Early recognition is important but difficult as the clinical presentation can mimic more common disease patterns. The most common patient population affected includes women under the age of 50. Risk factors for CVT include pregnancy, medications (oral contraceptives), inherited thrombophilia, prior venous thromboembolic event, malignancy, recent infection, and neurosurgery. CVT can present in a variety of ways, but the most common symptom is headache, followed by focal neurologic deficit, seizure, and altered mental status. Imaging studies such as computed tomography (CT) venography or magnetic resonance (MR) venography should be obtained in patients with concern for CVT, as non-contrast CT will be normal or have non-specific findings in most patients. Treatment includes anticoagulation, treating seizures and elevated ICP aggressively, and neurosurgical or interventional radiology consultation in select cases.

Conclusion : CVT can be a challenging diagnosis. Knowledge of the risk factors, patient presentation, evaluation, and management can assist emergency clinicians.

Conclusion (proposition de traduction) : La thrombose veineuse cérébrale peut être un diagnostic difficile. La connaissance des facteurs de risque, de la présentation du patient, de l'évaluation et de la prise en charge peut aider les urgentistes.

Prehospital end-tidal carbon dioxide predicts hemorrhagic shock upon emergency department arrival.
Bulger N, Harrington B, Krieger J, Latimer A, Arbabi S, Counts CR, Sayre M, Maynard C, Bulger EM. | J Trauma Acute Care Surg. 2021 Sep 1;91(3):457-464
DOI: https://doi.org/10.1097/ta.0000000000003312
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : In addition to reflecting gas exchange within the lungs, end-tidal carbon dioxide (ETCO2) also reflects cardiac output based on CO2 delivery to the pulmonary parenchyma. We hypothesized that low prehospital ETCO2 values would be predictive of hemorrhagic shock in intubated trauma patients.

Méthode : A retrospective observational study of adult trauma patients intubated in the prehospital setting and transported to a single Level I trauma center from 2016 to 2019. Continuous prehospital ETCO2 data were linked with patient care registries. We developed a novel analytic approach that allows for reflection of prehospital ETCO2 over the entire prehospital course of care. The primary outcome was hemorrhagic shock on emergency department (ED) presentation, defined as either initial ED systolic blood pressure of 90 mm Hg or less or initial Shock Index (SI) > 0.9, and transfusion of at least one unit of blood product during their ED stay. Prehospital ETCO2 less than 25 mm Hg was evaluated for predictive value of hemorrhagic shock.

Résultats : Three hundred and seven patients (82% men, 34% penetrating injury, 42% in hemorrhagic shock on ED arrival, 27% mortality) were included in the study. Patients in hemorrhagic shock had lower median ETCO2 values (26.5 mm Hg vs. 32.5 mm Hg; p < 0.001) than those not in hemorrhagic shock. Patients with prehospital ETCO2 less than 25 mm Hg were 3.0 times (adjusted odds ratio = 3.0; 95% confidence interval, 1.1-7.9) more likely to be in hemorrhagic shock upon ED arrival than patients with ETCO2 ≥ 25 mm Hg.

Conclusion : Intubated patients with hemorrhagic shock upon ED arrival had significantly lower prehospital ETCO2 values. Incorporating ETCO2 assessment into prehospital care for trauma patients could support decisions regarding prehospital blood transfusion, and triage to higher-level trauma centers, and trauma team activation.

Conclusion (proposition de traduction) : Les patients intubés en choc hémorragique à leur arrivée aux urgences avaient des valeurs d'ETCO₂ préhospitalières significativement plus faibles. L'intégration de l'évaluation de l'ETCO₂ dans les soins préhospitaliers pour les patients traumatisés pourrait aider les décisions concernant la transfusion sanguine préhospitalière, le tri vers les centres de traumatologie de niveau supérieur et l'activation de l'équipe de traumatologie.

Fixed-dose combination therapies with and without aspirin for primary prevention of cardiovascular disease: an individual participant data meta-analysis.
Joseph P, Roshandel G, Gao P, Pais P, Lonn E, Xavier D, Avezum A, Zhu J, Liu L, Sliwa K, Gamra H, Bangdiwala SI, Teo K, Diaz R, Dans A, Lopez-Jaramillo P, Prabhakaran D, Castellano JM, Fuster V, Rodgers A, Huffman MD, Bosch J, Dagenais GR, Malekzadeh R, Yusuf S; Polypill Trialists' Collaboration. | Lancet. 2021 Sep 25;398(10306):1133-1146
DOI: https://doi.org/10.1016/s0140-6736(21)01827-4
Keywords: Aucun

Article

Introduction : In randomised controlled trials, fixed-dose combination treatments (or polypills) have been shown to reduce a composite of cardiovascular disease outcomes in primary prevention. However, whether or not aspirin should be included, effects on specific outcomes, and effects in key subgroups are unknown.

Méthode : We did an individual participant data meta-analysis of large randomised controlled trials (each with ≥1000 participants and ≥2 years of follow-up) of a fixed-dose combination treatment strategy versus control in a primary cardiovascular disease prevention population. We included trials that evaluated a fixed-dose combination strategy of at least two blood pressure lowering agents plus a statin (with or without aspirin), compared with a control strategy (either placebo or usual care). The primary outcome was time to first occurrence of a composite of cardiovascular death, myocardial infarction, stroke, or arterial revascularisation. Additional outcomes included individual cardiovascular outcomes and death from any cause. Outcomes were also evaluated in groups stratified by the inclusion of aspirin in the fixed-dose treatment strategy, and effect sizes were estimated in prespecified subgroups based on risk factors. Kaplan-Meier survival curves and Cox proportional hazard regression models were used to compare strategies.

Résultats : Three large randomised trials were included in the analysis (TIPS-3, HOPE-3, and PolyIran), with a total of 18 162 participants. Mean age was 63·0 years (SD 7·1), and 9038 (49·8%) participants were female. Estimated 10-year cardiovascular disease risk for the population was 17·7% (8·7). During a median follow-up of 5 years, the primary outcome occurred in 276 (3·0%) participants in the fixed-dose combination strategy group compared with 445 (4·9%) in the control group (hazard ratio 0·62, 95% CI 0·53-0·73, p<0·0001). Reductions were also observed for the separate components of the primary outcome: myocardial infarction (0·52, 0·38-0·70), revascularisation (0·54, 0·36-0·80), stroke (0·59, 0·45-0·78), and cardiovascular death (0·65, 0·52-0·81). Significant reductions in the primary outcome and its components were observed in the analyses of fixed-dose combination strategies with and without aspirin, with greater reductions for strategies including aspirin. Treatment effects were similar at different lipid and blood pressure levels, and in the presence or absence of diabetes, smoking, or obesity. Gastrointestinal bleeding was uncommon but slightly more frequent in the fixed-dose combination strategy with aspirin group versus control (19 [0·4%] vs 11 [0·2%], p=0·15). The frequencies of haemorrhagic stroke (10 [0·2%] vs 15 [0·3%]), fatal bleeding (two [<0·1%] vs four [0·1%]), and peptic ulcer disease (32 [0·7%] vs 34 [0·8%]) were low and did not differ significantly between groups. Dizziness was more common with fixed-dose combination treatment (1060 [11·7%] vs 834 [9·2%], p<0·0001).

Conclusion : Fixed-dose combination treatment strategies substantially reduce cardiovascular disease, myocardial infarction, stroke, revascularisation, and cardiovascular death in primary cardiovascular disease prevention. These benefits are consistent irrespective of cardiometabolic risk factors.

Conclusion (proposition de traduction) : Les stratégies de traitement combiné à dose fixe réduisent considérablement les maladies cardiovasculaires, l'infarctus du myocarde, les accidents vasculaires cérébraux, la revascularisation et les décès cardiovasculaires dans le cadre de la prévention primaire des maladies cardiovasculaires. Ces bénéfices sont constants quels que soient les facteurs de risque cardiométaboliques.

Comparing accuracy of bedside ultrasound examination with physical examination for detection of pleural effusion.
Walsh MH, Zhang KX, Cox EJ, Chen JM, Cowley NG, Oleynick CJ, Smyth LM, Ma IWY. | Ultrasound J. 2021 Sep 6;13(1):40
DOI: https://doi.org/10.1186/s13089-021-00241-7  | Télécharger l'article au format  
Keywords: Physical examination; Pleural effusion; Point-of-care ultrasound; Ultrasound.

Content type: Original article

Introduction : In detecting pleural effusion, bedside ultrasound (US) has been shown to be more accurate than auscultation. However, US has not been previously compared to the comprehensive physical examination. This study seeks to compare the accuracy of physical examination with bedside US in detecting pleural effusion.

Méthode : This study included a convenience sample of 34 medical inpatients from Calgary, Canada and Spokane, USA, with chest imaging performed within 24 h of recruitment. Imaging results served as the reference standard for pleural effusion. All patients underwent a comprehensive lung physical examination and a bedside US examination by two researchers blinded to the imaging results.

Résultats : Physical examination was less accurate than US (sensitivity of 44.0% [95% confidence interval (CI) 30.0-58.8%], specificity 88.9% (95% CI 65.3-98.6%), positive likelihood (LR) 3.96 (95% CI 1.03-15.18), negative LR 0.63 (95% CI 0.47-0.85) for physical examination; sensitivity 98% (95% CI 89.4-100%), specificity 94.4% (95% CI 72.7-99.9%), positive LR 17.6 (95% CI 2.6-118.6), negative LR 0.02 (95% CI 0.00-0.15) for US). The percentage of examinations rated with a confidence level of 4 or higher (out of 5) was higher for US (85% of the seated US examination and 94% of the supine US examination, compared to 35% of the PE, P < 0.001), and took less time to perform (P < 0.0001).

Conclusion : US examination for pleural effusion was more accurate than the physical examination, conferred higher confidence, and required less time to complete.

Conclusion (proposition de traduction) : L'examen échographique pour un épanchement pleural était plus précis que l'examen clinique, conférait une plus grande confiance et nécessitait moins de temps.

Recognizing electrocardiographically subtle occlusion myocardial infarction and differentiating it from mimics: Ten steps to or away from cath lab.
Aslanger EK, Meyers HP, Smith SW. | Turk Kardiyol Dern Ars. 2021 Sep;49(6):488-500
DOI: https://doi.org/10.5543/tkda.2021.21026  | Télécharger l'article au format  
Keywords:

Review

Editorial : It is increasingly evident that the ST-segment elevation (STE) myocardial infarction (MI)/non-STEMI paradigm that equates STEMI with acute coronary occlusion (ACO) is deceptive. This unfortunate paradigm, adhered to by the current guidelines, misses at least one-fourth of the ACOs, and unnecessarily over-triages a similar fraction of the patients to the catheterization laboratory. Accordingly, we have been calling for a new paradigm, the occlusion/nonocclusion MI (OMI/NOMI). Although this new OMI/NOMI paradigm is not limited to an electrocardiogram (ECG), the ECG will remain the cornerstone of this new paradigm because of its speed, repeatability, noninvasive nature, wide availability, and high diagnostic power for OMI. This review provides a step-by-step approach to ECG for the diagnosis of OMI.

Résultats : There are many ECG tools available beyond the STE criteria for recognizing OMI, and for differentiating OMI from OMI mimics. The entirety of the ECG must be assessed, including Q waves, R waves, S waves, ST segments, T waves, and the QT interval. The amplitude and width of all waves contribute to a nuanced interpretation of the ECG. This requires a significant investment in training, but in the future may be taught to deep convolutional neural networks. The diagnosis of OMI may be missed in the ECG especially in the hands of those who lack expertise, and even by experts at times. Thus, it is essential to remain humble when confronted with a patient who may be actively infarcting viable myocardium, and to use all the methods at one’s disposal to identify these patients expeditiously.

Discussion : Au-delà des critères de sus-décalage du segment ST, il existe de nombreux outils ECG permettant de reconnaître un infarctus du myocarde par occlusion et de différencier un infarctus du myocarde par occlusion d'une imitation d'infarctus du myocarde par occlusion. L'ensemble de l'ECG doit être évalué, y compris les ondes Q, les ondes R, les ondes S, les segments ST, les ondes T et l'intervalle QT. L'amplitude et la largeur de toutes les ondes contribuent à une interprétation nuancée de l'ECG. Cela nécessite un investissement important en termes de formation, mais à l'avenir, les réseaux neuronaux convolutionnels profonds pourront être utilisés pour l'apprentissage. Le diagnostic d'infarctus du myocarde par occlusion peut passer inaperçu sur l'ECG, surtout entre les mains de ceux qui manquent d'expertise, et même parfois d'experts. Il est donc essentiel de rester humain lorsqu'on est confronté à un patient qui peut être en train de faire un infarctus du myocarde viable et d'utiliser toutes les méthodes à sa disposition pour identifier ces patients rapidement.

Conclusion : Aucun