Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD² tests: A diagnostic cohort study.
Gerlier C, Hoarau M, Fels A, Vitaux H, Mousset C, Farhat W, Firmin M, Pouyet V, Paoli A, Chatellier G, Ganansia O. | Acad Emerg Med. 2021 Dec;28(12):1368-1378
DOI: https://doi.org/10.1111/acem.14337  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmologic examination HINTS performed by emergency physicians (EPs) is unknown. Our objective was to determine the accuracy of the HINTS examination performed by trained EPs for diagnosing central cause of acute vertigo and unsteadiness and to compare it with another bedside clinical tool, STANDING, and with the history-based score ABCD².

Méthode : This was a prospective diagnostic cohort study among patients with isolated vertigo and unsteadiness seen in a single emergency department (ED). Trained EPs performed HINTS and STANDING tests blinded to attending physicians. ABCD² ≥ 4 was used as the threshold and was calculated retrospectively. The criterion standard was diffusion-weighted brain magnetic resonance imaging (MRI). Peripheral diagnoses were established by a normal MRI, and etiologies were further refined by an otologic examination.

Résultats : We included 300 patients of whom 62 had a central lesion on neuroimaging including 49 strokes (79%). Of the 238 peripheral diagnoses, 159 were vestibulopathies, mainly benign paroxysmal positional vertigo (40%). HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD² score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+] = 3.71, negative likelihood ratio [LR-] = 0.09) than the HINTS test (67% and 44%, respectively; LR+ = 2.96, LR- = 0.04). The ABCD² score was specific (82%, LR+ = 3.04, LR- = 0.56) but had a very low PPV (44%).

Conclusion : In the hands of EPs, HINTS and STANDING tests outperformed ABCD² in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm is more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use.

Conclusion (proposition de traduction) : Quand ils sont utilisé par des urgentistes, les tests HINTS et STANDING ont surpassé ABCD² dans l'identification des causes centrales des vertiges. Pour diagnostiquer les troubles périphériques, l'algorithme STANDING est plus spécifique que le test HINTS. HINTS et STANDING pourraient être des outils utiles permettant d'économiser à la fois du temps et des coûts liés à l'utilisation inutile de la neuroimagerie.

Development and external validation of the KIIDS-TBI tool for managing children with mild traumatic brain injury and intracranial injuries.
Greenberg JK, Ahluwalia R, Hill M, Johnson G, Hale AT, Belal A, Baygani S, Olsen MA, Foraker RE, Carpenter CR, Yan Y, Ackerman L, Noje C, Jackson E, Burns E, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD Jr. | Acad Emerg Med. 2021 Dec;28(12):1409-1420
DOI: https://doi.org/10.1111/acem.14333
Keywords: Aucun

Original contribution

Introduction : Clinical decision support (CDS) may improve the postneuroimaging management of children with mild traumatic brain injuries (mTBI) and intracranial injuries. While the CHIIDA score has been proposed for this purpose, a more sensitive risk model may have broader use. Consequently, this study's objectives were to: (1) develop a new risk model with improved sensitivity compared to the CHIIDA model and (2) externally validate the new model and CHIIDA model in a multicenter data set.

Méthode : We analyzed children ≤18 years old with mTBI and intracranial injuries included in the PECARN head injury data set (2004-2006). We used binary recursive partitioning to predict the composite outcome of neurosurgical intervention, intubation for > 24 h due to TBI, or death due to TBI. The new model was externally validated in a separate data set that included children treated at any one of six centers from 2006 to 2019.

Résultats : Based on 839 patients from the PECARN data set, a new risk model, the KIIDS-TBI model, was developed that incorporated imaging (e.g., midline shift) and clinical (e.g., Glasgow Coma Scale score) findings. Based on the model-predicted probability of the composite outcome, three cutoffs were evaluated to classify patients as "high risk" for level of care decisions. In the external validation data set consisting of 1,630 patients, the most conservative cutoff (i.e., any predictor present) identified 119 of 119 children with the composite outcome (sensitivity = 100%), but had the lowest specificity (26.3%). The other two decision-making cutoffs had worse sensitivity (94.1%-96.6%) but improved specificity (67.4%-81.3%). The CHIIDA model lacked the most conservative cutoff and otherwise showed the same or slightly worse performance compared to the other two cutoffs.

Conclusion : The KIIDS-TBI model has high sensitivity and moderate specificity for risk stratifying children with mTBI and intracranial injuries. Use of this CDS tool may help improve the safe, resource-efficient management of this important patient population.

Conclusion (proposition de traduction) : Le modèle KIIDS-TBI a une sensibilité élevée et une spécificité modérée pour la stratification des risques chez les enfants victimes de lésions cérébrales traumatiques légères et de lésions intracrâniennes. L'utilisation de cet outil d'aide à la décision clinique peut aider à améliorer la gestion sûre et efficace des ressources de cette importante population de patients.

Rapid Sequence Induction With a Standard Intubation Dose of Rocuronium After Magnesium Pretreatment Compared With Succinylcholine: A Randomized Clinical Trial.
Czarnetzki C, Albrecht E, Masouyé P, Baeriswyl M, Poncet A, Robin M, Kern C, Tramèr MR. | Anesth Analg. 2021 Dec 1;133(6):1540-1549
DOI: https://doi.org/10.1213/ane.0000000000005324  | Télécharger l'article au format  
Keywords: Aucun

Original Clinical Research Report

Introduction : Succinylcholine remains the muscle relaxant of choice for rapid sequence induction (RSI) but has many adverse effects. High-dose rocuronium bromide may be an alternative to succinylcholine for RSI but recovery times are nearly doubled compared with a standard intubating dose of rocuronium. Magnesium sulfate significantly shortens the onset time of a standard intubating dose of rocuronium. We set out to investigate whether intravenous (IV) pretreatment with MgSO⁴ followed by a standard intubating dose of rocuronium achieved superior intubation conditions compared with succinylcholine.

Méthode : Adults were randomized to receive a 15-minute IV infusion of MgSO⁴ (60 mg·kg-1) immediately before RSI with propofol 2 mg·kg-1, sufentanil 0.2 μg·kg-1 and rocuronium 0.6 mg·kg-1, or a matching 15-minute IV infusion of saline immediately before an identical RSI, but with succinylcholine 1 mg·kg-1. Primary end point was the rate of excellent intubating conditions 60 seconds after administration of the neuromuscular blocking agent and compared between groups using multivariable log-binomial regression model. Secondary end points were blood pressure and heart rate before induction, before and after intubation, and adverse events up to 24 hours postoperatively.

Résultats : Among 280 randomized patients, intubating conditions could be analyzed in 259 (133 MgSO⁴-rocuronium and 126 saline-succinylcholine). The rate of excellent intubating conditions was 46% with MgSO⁴-rocuronium and 45% with saline-succinylcholine. The analysis adjusted for gender and center showed no superiority of MgSO⁴-rocuronium compared with saline-succinylcholine (relative risk [RR] 1.06, 95% confidence interval [CI], 0.81-1.39, P = .659). The rate of excellent intubating conditions was higher in women (54% [70 of 130]) compared with men (37% [48 of 129]; adjusted RR 1.42, 95% CI, 1.07-1.91, P = .017). No significant difference between groups was observed for systolic and diastolic blood pressures. Mean heart rate was significantly higher in the MgSO4-rocuronium group. The percentage of patients with at least 1 adverse event was lower with MgSO⁴-rocuronium (11%) compared with saline-succinylcholine (28%) (RR 0.38, 95% CI, 0.22-0.66, P < .001). With saline-succinylcholine, adverse events consisted mainly of postoperative muscle pain (n = 26 [19%]) and signs of histamine release (n = 13 [9%]). With MgSO⁴-rocuronium, few patients had pain on injection, nausea and vomiting, or skin rash during the MgSO⁴-infusion (n = 5 [4%]).

Conclusion : IV pretreatment with MgSO⁴ followed by a standard intubating dose of rocuronium did not provide superior intubation conditions to succinylcholine but had fewer adverse effects.

Conclusion (proposition de traduction) : Un prétraitement IV avec du MgSO⁴ suivi d'une dose standard de rocuronium pour l'intubation n'a pas fourni de conditions d'intubation supérieures à la succinylcholine mais a eu moins d'effets indésirables.

Engagement of the Median Glossoepiglottic Fold and Laryngeal View During Emergency Department Intubation.
Driver BE, Prekker ME, Levitan RM, Corajod J, Karl E, Smith AD, Reardon RF. | Ann Emerg Med. 2021 Dec;78(6):699-707
DOI: https://doi.org/10.1016/j.annemergmed.2021.04.024
Keywords: Aucun

Airway

Introduction : When using a standard geometry laryngoscope, experts recommend engaging the hyoepiglottic ligament-a ligament deep to the vallecula not visible to the intubator. The median glossoepiglottic fold (hereafter termed midline vallecular fold) is a superficial mucosal structure, visible to the intubator, that lies in the midline of the vallecula. We aimed to determine whether engaging the midline vallecular fold with a standard geometry blade tip during orotracheal intubation improved laryngeal visualization.

Méthode : We reviewed laryngoscopic videos from intubations by emergency physicians using standard geometry video laryngoscopes over a 2-year period. Two reviewers watched each video and recorded whether the blade tip engaged the midline vallecular fold (obscured the fold with the blade tip) and the best modified Cormack-Lehane grade and percent of glottic opening obtained. We compared laryngeal views in the presence and absence of fold engagement.

Résultats : We analyzed 183 discrete laryngoscopic episodes, including 113 instances in which the midline vallecular fold was engaged and 70 instances in which the fold was not engaged. The proportion with a Cormack-Lehane grade 1 or 2a was higher with fold engagement (96%) than without (87%) (absolute difference 9% [95% confidence interval (CI) 1 to 18%]). Ordinal logistic regression demonstrated that midline vallecular fold engagement was associated with a more favorable Cormack-Lehane grade (odds ratio 2.1 [95% CI 1.1 to 4.2]). The median percent of glottic opening score was 95% (interquartile range 90 to 100%) with fold engagement and 95% (65 to 100%) without engagement (median difference 0% [95% CI 0 to 5%]).

Conclusion : Engaging the midline vallecular fold with the laryngoscope blade tip during orotracheal intubation when using a standard geometry blade was associated with improved laryngeal visualization.

Conclusion (proposition de traduction) : La mobilisation du repli valléculaire médian avec la pointe de la lame du laryngoscope pendant l'intubation orotrachéale lors de l'utilisation d'une lame à géométrie standard a été associé à une meilleure visualisation du larynx.

Commentaire :  Repli glossoépiglottique médian (repli valléculaire médian).
A, Le sillon glosso-épiglottique médian superficiel (ici, appelé repli valléculaire médian) est surligné en vert (flèche supérieure). Le ligament hyoépiglottique plus profond, non visible à l'œil nu, est surligné en rose (flèche inférieure) ; la pression sur le ligament hyoépiglottique contribue également à l'élévation épiglottique.
B, Vue de l'opérateur du repli (flèche), un pli muqueux médian qui relie la base de la langue à l'épiglotte, lorsque la lame se rapproche de la vallécule.
C, La lame commence à s'engager dans le repli, ce qui peut aider indirectement à soulever l'épiglotte. L'opérateur doit placer la pointe de la lame profondément dans la vallécule et s'assurer que la pointe n'est pas trop peu profonde (sur la langue) ou trop profonde (sur l'épiglotte).
D, Vue laryngée après que l'épiglotte soit soulevée indirectement.

Illustrations publiées avec l'aimable autorisation du centre médical du comté de Hennepin.

Video Laryngoscopy Is Associated With First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry.
Trent SA, Kaji AH, Carlson JN, McCormick T, Haukoos JS, Brown CA 3rd; National Emergency Airway Registry Investigators. | Ann Emerg Med. 2021 Dec;78(6):708-719
DOI: https://doi.org/10.1016/j.annemergmed.2021.07.115
Keywords: Aucun

Airway

Introduction : We sought to (1) characterize emergency department (ED) intubations in trauma patients and estimate (2) first-pass success and (3) the association between patient and intubation characteristics and first-pass success.

Méthode : We performed a secondary analysis of a multicenter prospective observational cohort of ED intubations from the National Emergency Airway Registry (NEAR). Descriptive statistics were calculated for all patients who were intubated for trauma at 23 NEAR EDs between 2016 and 2018. We evaluated first-pass success in patients intubated by (1) emergency or pediatric emergency physicians, (2) using rapid sequence intubation or no medications, and (3) either direct laryngoscopy or video laryngoscopy. We used propensity score matching with a generalized linear mixed-effects model to estimate the associations between patient and intubation characteristics and first-pass success.

Résultats : Of the 19,071 intubations in NEAR, 4,449 (23%) were for trauma, and nearly all (88%) had at least one difficult airway characteristic. Prevalence of first-pass success was 86.8% (95% confidence interval [CI]: 83.3% to 90.3%). Most patients were intubated with video laryngoscopy, and patients were more likely to be intubated on first-pass with video laryngoscopy as compared to direct laryngoscopy (90% versus 79%). After propensity score matching, video laryngoscopy remained associated with first-pass success (adjusted risk difference 11%, 95% CI: 8% to 14%; and OR 2.2, 95% CI: 1.6 to 2.9). Additionally, an initial impression of difficult airway, blood/vomit in the airway, and use of external laryngeal manipulation were all associated with decreased odds of first-pass success.

Conclusion : Emergency physicians are successful at intubating patients in the setting of trauma, and video laryngoscopy is associated with twice the odds of first-pass success when compared to direct laryngoscopy.

Conclusion (proposition de traduction) : Les urgentistes réussissent à intuber les patients dans le cadre d'un traumatisme, et la laryngoscopie vidéo est associée à deux fois plus de chances de succès au premier essai par rapport à la laryngoscopie directe.

Commentaire : Matériel supplémentaire  

Etomidate Should be the Default Agent for Rapid Sequence Intubation in the Emergency Department.
April MD, Long B, Brown CA 3rd. | Ann Emerg Med. 2021 Dec;78(6):720-721
DOI: https://doi.org/10.1016/j.annemergmed.2021.05.018
Keywords: Aucun

Airway

Editorial : Rapid sequence intubation entails the simultaneous administration of induction and neuromuscular blocking agents.1 Peri-intubation hypotension is associated with increased mortality, suggesting that maintaining normal hemodynamics during intubation improves patient safety. Based on the lower risk of hemodynamic deterioration, etomidate should be the default agent for rapid sequence intubation in the emergency department (ED).

Conclusion : Until further data suggest otherwise, we contend that etomidate be the default sedative agent for rapid sequence intubation in the ED.

Conclusion (proposition de traduction) : Jusqu'à ce que de nouvelles données suggèrent le contraire, nous soutenons que l'étomidate soit l'agent hypnotique par défaut dans l'intubation à séquence rapide au service des urgences.

Ketamine Should be the Preferred Agent for Rapid Sequence Intubation.
Peksa GD, Gottlieb M. | Ann Emerg Med. 2021 Dec;78(6):722-723
DOI: https://doi.org/10.1016/j.annemergmed.2021.07.118
Keywords: Aucun

Airway

Editorial : Airway management in the emergency department (ED) is commonly performed using rapid sequence intubation. Rapid sequence intubation includes the administration ofan induction agent to rapidly induce unconsciousness, followed by the administration ofa neuromuscular blocking agent to facilitate laryngoscopy and tracheal intubation. Clinicians have several induction agents from which to choose, each with its own unique benefits and limitations. Although etomidate is commonly used, newer literature has supported the benefit ofketamine. In this Clinical Controversy article, we reviewed the literature supporting the advantages of ketamine over etomidate as a preferred agent for rapid sequence intubation

Conclusion : It is time to challenge the outdated practice of using etomidate in the ED for over 90% of intubations.12 Ketamine offers unique benefits in several important patient populations while avoiding the risk of adrenal suppression. Given the information currently available, we believe that it is justified to use ketamine as the preferred first-line induction agent for rapid sequence intubation.

Conclusion (proposition de traduction) : Il est temps de remettre en question la pratique obsolète consistant à utiliser l'étomidate aux urgences dans plus de 90 % des intubations. La kétamine offre des avantages uniques dans plusieurs populations importantes de patients tout en évitant le risque d'insuffisance surrénalienne. Compte tenu des informations actuellement disponibles, nous pensons qu'il est justifié d'utiliser la kétamine comme agent d'induction de première intention pour l'intubation à séquence rapide.

Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial.
Dove D, Fassassi C, Davis A, Drapkin J, Butt M, Hossain R, Kabariti S, Likourezos A, Gohel A, Favale P, Silver M, Marshall J, Motov S. | Ann Emerg Med. 2021 Dec;78(6):779-787
DOI: https://doi.org/10.1016/j.annemergmed.2021.04.031  | Télécharger l'article au format  
Keywords: Aucun

Pain Management and Sedation

Introduction : We aimed to assess and compare the analgesic efficacies and adverse effects of ketamine administered through a breath-actuated nebulizer at 3 different dosing regimens for emergency department patients presenting with acute and chronic painful conditions.

Méthode : This was a prospective, randomized, double-blinded trial comparing 3 doses of nebulized ketamine (0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg) administered through breath-actuated nebulizer in adult emergency department patients aged 18 years and older with moderate to severe acute and chronic pain. The primary outcome included the difference in pain scores on an 11-point numeric rating scale between all 3 groups at 30 minutes. Secondary outcomes included the need for rescue analgesia (additional doses of nebulized ketamine or intravenous morphine) and adverse events in each group at 30 and 60 minutes.

Résultats : We enrolled 120 subjects (40 per group). The difference in mean pain scores at 30 minutes between the 0.75 mg/kg and 1 mg/kg groups was 0.25 (95% confidence interval [CI] 1.28 to 1.78); between the 1 mg/kg and 1.5 mg/kg groups was -0.225 (95% CI -1.76 to 1.31); and between the 0.75 mg/kg and 1.5 mg/kg groups was 0.025 (95% CI -1.51 to 1.56). No clinically concerning changes in vital signs occurred. No serious adverse events occurred in any of the groups.

Conclusion : We found no difference between all 3 doses of ketamine administered through breath-actuated nebulizer for short-term treatment of moderate to severe pain in the emergency department.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune différence entre les 3 doses de kétamine administrées par nébuliseur actionné par la respiration pour le traitement à court terme de la douleur modérée à sévère au service des urgences.

Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial.
Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, Macewan B, Qian H, Wong H, Barbic SP, Honer WG. | Ann Emerg Med. 2021 Dec;78(6):788-795
DOI: https://doi.org/10.1016/j.annemergmed.2021.05.023  | Télécharger l'article au format  
Keywords: Aucun

Pain Management and Sedation

Introduction : We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation.

Méthode : We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events.

Résultats : Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]).

Conclusion : In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.

Conclusion (proposition de traduction) : Chez les patients des services d'urgence souffrant d'agitation sévère, la kétamine intramusculaire a fourni un temps significativement plus court pour une sédation adéquate qu'une combinaison de midazolam intramusculaire et d'halopéridol.

Gas conditioning during helmet noninvasive ventilation: effect on comfort, gas exchange, inspiratory effort, transpulmonary pressure and patient-ventilator interaction.
Bongiovanni F, Grieco DL, Anzellotti GM, Menga LS, Michi T, Cesarano M, Raggi V, De Bartolomeo C, Mura B, Mercurio G, D'Arrigo S, Bello G, Maviglia R, Pennisi MA, Antonelli M. | Ann Intensive Care. 2021 Dec 24;11(1):184
DOI: https://doi.org/10.1186/s13613-021-00972-9  | Télécharger l'article au format  
Keywords: Humidity; Noninvasive ventilation; Respiratory Insufficiency; Temperature.

Research

Introduction : There is growing interest towards the use of helmet noninvasive ventilation (NIV) for the management of acute hypoxemic respiratory failure. Gas conditioning through heat and moisture exchangers (HME) or heated humidifiers (HHs) is needed during facemask NIV to provide a minimum level of humidity in the inspired gas (15 mg H₂O/L). The optimal gas conditioning strategy during helmet NIV remains to be established.

Méthode : Twenty patients with acute hypoxemic respiratory failure (PaO₂/FiO₂ < 300 mmHg) underwent consecutive 1-h periods of helmet NIV (PEEP 12 cmH₂O, pressure support 12 cmH2O) with four humidification settings, applied in a random order: double-tube circuit with HHs and temperature set at 34 °C (HH34) and 37 °C (HH37); Y-piece circuit with HME; double-tube circuit with no humidification (NoH). Temperature and humidity of inhaled gas were measured through a capacitive hygrometer. Arterial blood gases, discomfort and dyspnea through visual analog scales (VAS), esophageal pressure swings (ΔP_ES) and simplified pressure-time product (PTP_ES), dynamic transpulmonary driving pressure (ΔP_L) and asynchrony index were measured in each step.

Résultats : Median [IqR] absolute humidity, temperature and VAS discomfort were significantly lower during NoH vs. HME, HH34 and HH37: absolute humidity (mgH2O/L) 16 [12-19] vs. 28 [23-31] vs. 28 [24-31] vs. 33 [29-38], p < 0.001; temperature (°C) 29 [28-30] vs. 30 [29-31] vs. 31 [29-32] vs 32. [31-33], p < 0.001; VAS discomfort 4 [2-6] vs. 6 [2-7] vs. 7 [4-8] vs. 8 [4-10], p = 0.03. VAS discomfort increased with higher absolute humidity (p < 0.01) and temperature (p = 0.007). Higher VAS discomfort was associated with increased VAS dyspnea (p = 0.001). Arterial blood gases, respiratory rate, ΔP_ES, PTP_ES and ΔP_L were similar in all conditions. Overall asynchrony index was similar in all steps, but autotriggering rate was lower during NoH and HME (p = 0.03).

Conclusion : During 1-h sessions of helmet NIV in patients with hypoxemic respiratory failure, a double-tube circuit with no humidification allowed adequate conditioning of inspired gas, optimized comfort and improved patient-ventilator interaction. Use of HHs or HME in this setting resulted in increased discomfort due to excessive heat and humidity in the interface, which was associated with more intense dyspnea.

Conclusion (proposition de traduction) : Lors de séances d'1h de VNI casque chez des patients souffrant d'insuffisance respiratoire hypoxémique, un circuit double sans humidification a permis un traitement adéquat du gaz inspiré, un confort optimisé et une meilleure interaction patient-ventilateur. L'utilisation d'humidificateurs chauffants ou d'échangeurs de chaleur et d'humidité dans ce cadre a entraîné une gêne accrue en raison d'une chaleur et d'une humidité excessives dans l'interface, ce qui a été associé à une dyspnée plus intense.

Commentaire : 

Awake prone position reduces work of breathing in patients with COVID-19 ARDS supported by CPAP.
Chiumello D, Chiodaroli E, Coppola S, Cappio Borlino S, Granata C, Pitimada M, Wendel Garcia PD. | Ann Intensive Care. 2021 Dec 20;11(1):179
DOI: https://doi.org/10.1186/s13613-021-00967-6  | Télécharger l'article au format  
Keywords: ARDS; Awake prone position; COVID-19; Continuous positive airway pressure; Helmet CPAP; Work of breathing.

Research

Introduction : The use of awake prone position concomitant to non-invasive mechanical ventilation in acute respiratory distress syndrome (ARDS) secondary to COVID-19 has shown to improve gas exchange, whereas its effect on the work of breathing remain unclear. The objective of this study was to evaluate the effects of awake prone position during helmet continuous positive airway pressure (CPAP) ventilation on inspiratory effort, gas exchange and comfort of breathing.

Méthode : Forty consecutive patients presenting with ARDS due to COVID-19 were prospectively enrolled. Gas exchange, esophageal pressure swing (ΔPes), dynamic transpulmonary pressure (dTPP), modified pressure time product (mPTP), work of breathing (WOB) and comfort of breathing, were recorded on supine position and after 3 h on prone position.

Résultats : The median applied PEEP with helmet CPAP was 10 [8-10] cmH2O. The PaO₂/FiO₂ was higher in prone compared to supine position (Supine: 166 [136-224] mmHg, Prone: 314 [232-398] mmHg, p < 0.001). Respiratory rate and minute ventilation decreased from supine to prone position from 20 [17-24] to 17 [15-19] b/min (p < 0.001) and from 8.6 [7.3-10.6] to 7.7 [6.6-8.6] L/min (p < 0.001), respectively. Prone position did not reduce ΔPes (Supine: - 7 [- 9 to - 5] cmH₂O, Prone: - 6 [- 9 to - 5] cmH₂O, p = 0.31) and dTPP (Supine: 17 [14-19] cmH2O, Prone: 16 [14-18] cmH₂O, p = 0.34). Conversely, mPTP and WOB decreased from 152 [104-197] to 118 [90-150] cmH₂O/min (p < 0.001) and from 146 [120-185] to 114 [95-151] cmH₂O L/min (p < 0.001), respectively. Twenty-six (65%) patients experienced a reduction in WOB of more than 10%. The overall sensation of dyspnea was lower in prone position (p = 0.005).

Conclusion : Awake prone position with helmet CPAP enables a reduction in the work of breathing and an improvement in oxygenation in COVID-19-associated ARDS.

Conclusion (proposition de traduction) : Le décubitus ventral vigile avec un casque de ventilation sous CPAP permet une réduction du travail respiratoire et une amélioration de l'oxygénation dans le SDRA associé au COVID-19.

Prognostic value of diagnostic scales in community-acquired sepsis mortality at an emergency service. Prognosis in community-adquired sepsis.
Clar J, Oltra MR, Benavent R, Pinto C, Ruiz A, Sanchez MT, Noceda J, Redon J, Forner MJ. | BMC Emerg Med. 2021 Dec 18;21(1):161
DOI: https://doi.org/10.1186/s12873-021-00532-1  | Télécharger l'article au format  
Keywords: Community-acquired sepsis; Diagnostic scales; Mortality; Prognosis; Sepsis.

Research

Introduction : To asses the prognostic value of diagnostic scales in mortality of community-adquired sepsis and added value of additional parameters.

Méthode : Prospective observational study of patients with community-adquired sepsis in the Emergency Room of University Hospital. The study population were patients presented in the Emergency Room with confirmed infection and practicians sepsis diagnosis. Demographics, triage vital signs, inhaled oxygen fraction, inflammatory markers, biochemistry, all-cause mortality during hospitalization and three months after were recorded. Prognostic value of qSOFA, NEWS, SOFA, SIRS, and amplified scales were calculated by using logistic regression and ROC curves.

Résultats : 201 patients, 54% male, average age 77±11,2 years were included. Sixty-three (31.5%) died during hospitalization and 24 (12%) three months after discharge. At the time of admission vital signs related with in-hospital mortality were Glasgow Coma Scale <13, respiratory rate ≥22 bpm, temperature, oxygen desaturation, high flow oxygen therapy and heart rate. Patients dead in-hospital had lower PaCO2, higher lactate, glucose and creatinine. Greater predictive capacity of the scales, from higher to lower, was: qSOFA, NEWS2, SOFA and SIRS. Amplified scales with lactate >2mg/dl, glucose, blood level >190mg/dl and PaCO2 <35mmHg improved predictive value.

Conclusion : Amplified-qSOFA and amplified-NEWS2 scales at Emergency Department may offer a better prognostic of septic patients mortality.

Conclusion (proposition de traduction) : Les échelles amplifiée-qSOFA et amplifiée-NEWS2 au service des urgences peuvent offrir un meilleur pronostic de la mortalité des patients septiques.

Towards enhanced telephone triage for chest pain: a Delphi study to define life-threatening conditions that must be identified.
Alotaibi A, Body R, Carley S, Pennington E. | BMC Emerg Med. 2021 Dec 15;21(1):158
DOI: https://doi.org/10.1186/s12873-021-00553-w  | Télécharger l'article au format  
Keywords: Chest pain; Dispatch; EMS; Life-threatening condition; Prehospital; Telephone-triage; Triage.

Research

Introduction : Improving telephone triage for patients with chest pain has been identified as a national research priority. However, there is a lack of strong evidence to define the life-threatening conditions (LTCs) that telephone triage ought to identify. Therefore, we aimed to build consensus for the LTCs associated with chest pain that ought to be identified during telephone triage for emergency calls.

Méthode : We conducted a Delphi study in three rounds. Twenty experts in pre-hospital care and emergency medicine experience from the UK were invited to participate. In round I, experts were asked to list all LTCs that would require priority 1, 2, and 4 ambulance responses. Round II was a ranking evaluation, and round III was a consensus round. Consensus level was predefined at > = 70%.

Résultats : A total of 15 participants responded to round one and 10 to rounds two and three. Of 185 conditions initially identified by the experts, 26 reached consensus in the final round. Ten conditions met consensus for requiring priority 1 response: oesophageal perforation/rupture; ST elevation myocardial infarction; non-ST elevation myocardial infarction with clinical compromise (defined, also by consensus, as oxygen saturation < 90%, heart rate < 40/min or systolic blood pressure < 90 mmHg); acute heart failure; cardiac tamponade; life-threatening asthma; cardiac arrest; tension pneumothorax and massive pulmonary embolism. An additional six conditions met consensus for priority 2 response, and three for priority 4 response.

Conclusion : Using expert consensus, we have defined the LTCs that may present with chest pain, which ought to receive a high-priority ambulance response. This list of conditions can now form a composite primary outcome for future studies to derive and validate clinical prediction models that will optimise telephone triage for patients with a primary complaint of chest pain.

Conclusion (proposition de traduction) : À l'aide d'un consensus d'experts, nous avons défini les conditions potentiellement mortelles qui peuvent se présenter avec des douleurs thoraciques, qui devraient recevoir une réponse de secours ambulancier hautement prioritaire. Cette liste de conditions peut maintenant former un résultat principal composite pour de futures études afin de dériver et de valider des modèles de prédiction clinique qui optimiseront le triage téléphonique pour les patients présentant une plainte principale de douleur thoracique.

Commentaire : Les dix conditions sont :
perforation/rupture de l'œsophage ; Infarctus du myocarde avec sus-décalage du segment ST ; infarctus du myocarde sans élévation du segment ST avec état clinique instable (défini, également par consensus, comme une saturation en oxygène < 90 %, une fréquence cardiaque < 40/min ou une pression artérielle systolique < 90 mmHg) ; insuffisance cardiaque aiguë; tamponnade cardiaque ; asthme potentiellement mortel ; arrêt cardiaque ; pneumothorax compressif et embolie pulmonaire massive.

Evaluating the transitions in care for children presenting with acute asthma to emergency departments: a retrospective cohort study.
Kroetch KR, Rowe BH, Rosychuk RJ. | BMC Emerg Med. 2021 Dec 7;21(1):153
DOI: https://doi.org/10.1186/s12873-021-00550-z  | Télécharger l'article au format  
Keywords: Administrative data; Asthma; Emergency department; Multistate models; Pediatrics.

Research

Introduction : Acute asthma is a common presentation to emergency departments (EDs) worldwide and, due to overcrowding, delays in treatment often occur. This study deconstructs the total ED length of stay into stages and estimates covariate effects on transition times for children presenting with asthma.

Méthode : We extracted ED presentations in 2019 made by children in Alberta, Canada for acute asthma. We used multivariable Cox regressions in a multistate model to model transition times among the stages of start, physician initial assessment (PIA), disposition decision, and ED departure.

Résultats : Data from 6598 patients on 8270 ED presentations were extracted. The individual PIA time was longer (i.e., HR < 1) when time to the crowding metric (hourly PIA) was above 1 h (HR = 0.32; 95% CI:0.30,0.34), for tertiary (HR = 0.65; 95% CI:0.61,0.70) and urban EDs (HR = 0.77; 95% CI:0.70,0.84), for younger patients (HR = 0.99 per year; 95% CI:0.99,1.00), and for patients triaged less urgent/non-urgent (HR = 0.89; 95% CI:0.84,0.95). It was shorter for patients arriving by ambulance (HR = 1.22; 95% CI:1.04,1.42). Times from PIA to disposition decision were longer for tertiary (HR = 0.47; 95% CI:0.44,0.51) and urban (HR = 0.69; 95% CI:0.63,0.75) EDs, for patients triaged as resuscitation/emergent (HR = 0.51; 95% CI:0.48,0.54), and for patients arriving by ambulance (HR = 0.78; 95% CI:0.70,0.87). Times from disposition decision to ED departure were longer for patients who were admitted (HR = 0.16; 95% CI:0.13,0.20) or transferred (HR = 0.42; 95% CI:0.35,0.50), and for tertiary EDs (HR = 0.93; 95% CI:0.92,0.94).

Conclusion : All transition times were impacted by ED presentation characteristics. The sole key patient characteristic was age and it only impacted time to PIA. ED crowding demonstrated strong effects of time to PIA but not for the transition times involving disposition decision and ED departure stages.

Conclusion (proposition de traduction) : Tous les temps de transition ont été influencés par les catégories de services d'urgence. La seule caractéristique clé du patient était l'âge et elle n'avait d'incidence que sur le délai avant l'évaluation initiale par le médecin. L'encombrement des services d'urgence a démontré des effets importants sur le temps jusqu'à l'évaluation initiale par le médecin, mais pas sur les temps de transition impliquant la décision d’orientation et les étapes de départ du service d'urgence.

Commentaire : Transitions des soins : une série d'actions conçues pour assurer la sécurité et l'efficacité de la coordination et de la continuité des soins lorsque l'état de santé du patient change ou que le patient a des besoins différents en matière de soins, de prestataires de soins de santé ou de lieu (à l'intérieur d'un même établissement ou entre établissements).

Intravenous infusion route in maternal resuscitation: a scoping review.
Nakamura E, Takahashi S, Matsunaga S, Tanaka H, Furuta M, Sakurai A; Japan Resuscitation Council (JRC), Guideline Editorial Committee. | BMC Emerg Med. 2021 Dec 3;21(1):151
DOI: https://doi.org/10.1186/s12873-021-00546-9  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Intravenous infusion; Pregnancy; Resuscitation; Scoping review.

Research

Introduction : The concept that upper extremities can be used as an infusion route during cardiopulmonary resuscitation in pregnant women is a reasonable recommendation considering the characteristic circulation of pregnant women; however, this method is not based on scientific evidence.

Méthode : We conducted a scoping review to determine whether the infusion route should be established above the diaphragm during cardiopulmonary resuscitation in a pregnant woman.

Discussion : We included randomized controlled trials (RCTs) and non-RCTs on the infusion of fluids in pregnant women after 20 weeks of gestation requiring establishment of an infusion route due to cardiac arrest, massive bleeding, intra-abdominal bleeding, cesarean section, severe infection, or thrombosis. In total, 3150 articles from electronic database were extracted, respectively. After title and abstract review, 265 articles were extracted, and 116 articles were extracted by full-text screening, which were included in the final analysis. The 116 articles included 78 studies on infusion for pregnant women. The location of the intravenous infusion route could be confirmed in only 17 studies, all of which used the upper extremity to secure the venous route.

Conclusion : Pregnant women undergo significant physiological changes that differ from those of normal adults, because of pressure and drainage of the inferior vena cava and pelvic veins by the enlarged uterus. Therefore, despite a lack of evidence, it seems logical to secure the infusion route above the diaphragm when resuscitating a pregnant woman.

Conclusion (proposition de traduction) : Les femmes enceintes subissent des changements physiologiques importants qui diffèrent de ceux des adultes normaux, en raison de la pression et du drainage de la veine cave inférieure et des veines pelviennes par l'utérus augmenté de volume. Ainsi, malgré le manque de preuves, il semble logique de sécuriser la voie de perfusion au-dessus du diaphragme lors de la réanimation d'une femme enceinte.

Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report.
Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. | Chest. 2021 Dec;160(6):e545-e608
DOI: https://doi.org/10.1016/j.chest.2021.07.055  | Télécharger l'article au format  
Keywords: DVT; antithrombotic therapy; guidelines; pulmonary embolism; thrombosis.

Pulmonary Vascular Guidelines and Consensus Statements

Introduction : This is the 2nd update to the 9th edition of these guidelines. We provide recommendations on 17 PICO (Population, Intervention, Comparator, Outcome) questions, four of which have not been addressed previously.

Méthode : We generate strong and weak recommendations based on high-, moderate-, and low-certainty evidence, using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.

Résultats : The panel generated 29 guidance statements, 13 of which are graded as strong recommendations, covering aspects of antithrombotic management of VTE from initial management through secondary prevention and risk reduction of postthrombotic syndrome. Four new guidance statements have been added that did not appear in the 9th edition (2012) or 1st update (2016). Eight statements have been substantially modified from the 1st update.

Conclusion : New evidence has emerged since 2016 that further informs the standard of care for patients with VTE. Substantial uncertainty remains regarding important management questions, particularly in limited disease and special patient populations.

Conclusion (proposition de traduction) : De nouvelles preuves sont apparues depuis 2016 qui éclairent davantage la norme de soins pour les patients présentant une maladie thromboembolique veineuse. Une incertitude substantielle demeure concernant les questions de gestion importantes, en particulier dans le cas de maladies limitées et de populations de patients particulières.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Update on Antithrombotic Therapy for VTE isease  . Rédigé par Clay Smith, le 26 Janvier 2022.
Proposition de traduction des 29 recommandations   (PDF, 201 Ko) avec les commentaires du site JournalFeed.

Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic.
Nauka PC, Chen JT, Shiloh AL, Eisen LA, Fein DG. | Chest. 2021 Dec;160(6):2112-2122
DOI: https://doi.org/10.1016/j.chest.2021.06.008  | Télécharger l'article au format  
Keywords: airway management; intratracheal; intubation; mechanical ventilation.

Research article

Introduction : For patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure.
Research question: For patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic?

Méthode : We conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables.

Résultats : One thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01).

Conclusion : Video laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.

Conclusion (proposition de traduction) : La vidéolaryngoscopie et la curarisation ont été de plus en plus utilisés pendant la pandémie de COVID-19. Malgré un taux plus élevé de réussite du premier essai pendant la pandémie, l'incidence des complications associées à la procédure était plus élevée.

Risks and Benefits of Fluid Administration as Assessed by Ultrasound.
Millington SJ, Wiskar K, Hobbs H, Koenig S. | Chest. 2021 Dec;160(6):2196-2208
DOI: https://doi.org/10.1016/j.chest.2021.06.041  | Télécharger l'article au format  
Keywords: medical education; resuscitation; shock; ultrasound.

How I Do It

Editorial : For patients in shock, decisions regarding administering or withholding IV fluids are both difficult and important. Although a strategy of relatively liberal fluid administration has traditionally been popular, recent trial results suggest that moving to a more fluid-restrictive approach may be prudent. The goal of this article was to outline how whole-body point-of-care ultrasound can help clarify both the possible benefits and the potential risks of fluid administration, aiding in the risk/benefit calculations that should always accompany fluid-related decisions.

Conclusion : The appropriate titration of fluid therapy is one of the most challenging aspects of caring for acutely unwell patients. Given the increasing recognition of the harms associated with over-resuscitation, clinicians must be thoughtful in their prescription of IV fluids. Three questions should be addressed sequentially: First, is the patient in a form of shock, with evidence of end-organ hypoxia, that would benefit from an increased cardiac output to increase tissue oxygen delivery? Second, is the patient in a fluid-responsive state whereby the administration of IV fluids and preload augmentation will in fact result in an increased in cardiac output? Finally, is there evidence of multiorgan venous congestion suggesting that fluid therapy could cause the patient harm?
Overall, the decision to give IV fluids, like any decision in medicine, comes back to careful consideration of the possible risks and benefits. By using POCUS to better understand the potential harms associated with fluid administration, we can make more informed clinical decisions and improve the care of acutely unwell patients.

Conclusion (proposition de traduction) : La titration appropriée du remplissage vasculaire est l'un des aspects les plus difficiles de la prise en charge des patients de réanimation. Compte tenu de l'identification croissante des effets indésirables associés à la sur-réanimation, les cliniciens doivent être réfléchis dans leur prescription de liquides IV. Trois questions doivent être posées séquentiellement : premièrement, le patient est-il en état de choc, présentant des signes d'hypoxie des organes cibles, qui bénéficierait d’une augmentation du débit cardiaque pour accroître l'apport d'oxygène tissulaire ? Deuxièmement, le patient est-il dans un état de réagir au solutés pour lequel l'administration du remplissage IV et l'augmentation de la précharge entraîneront en fait une augmentation du débit cardiaque ? Enfin, existe-t-il des preuves de congestion veineuse multiviscérale suggérant que le traitement par remplissage pourrait nuire au patient ?
Dans l'ensemble, la décision de remplissage IV, comme toute décision en médecine, revient à un examen attentif des risques et des avantages possibles. En utilisant l'échographie au point d'intervention pour mieux comprendre les dommages potentiels associés au remplissage, nous pouvons prendre des décisions cliniques plus éclairées et améliorer les soins aux patients de réanimation.

Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report.
Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. | Chest. 2021 Dec;160(6):e545-e608
DOI: https://doi.org/10.1016/j.chest.2021.07.055  | Télécharger l'article au format  
Keywords: DVT; antithrombotic therapy; guidelines; pulmonary embolism; thrombosis.

Guidelines and Consensus Statements

Introduction : This is the 2nd update to the 9th edition of these guidelines. We provide recommendations on 17 PICO (Population, Intervention, Comparator, Outcome) questions, four of which have not been addressed previously.

Méthode : We generate strong and weak recommendations based on high-, moderate-, and low-certainty evidence, using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.

Résultats : The panel generated 29 guidance statements, 13 of which are graded as strong recommendations, covering aspects of antithrombotic management of VTE from initial management through secondary prevention and risk reduction of postthrombotic syndrome. Four new guidance statements have been added that did not appear in the 9th edition (2012) or 1st update (2016). Eight statements have been substantially modified from the 1st update.

Conclusion : New evidence has emerged since 2016 that further informs the standard of care for patients with VTE. Substantial uncertainty remains regarding important management questions, particularly in limited disease and special patient populations.

Conclusion (proposition de traduction) : De nouvelles preuves sont apparues depuis 2016 qui éclairent davantage la norme de soins pour les patients présentant une maladie thromboembolique veineuse. Une incertitude substantielle demeure concernant les questions de gestion importantes, en particulier dans le cas de maladies limitées et de populations de patients particulières.

Anterior-Lateral Versus Anterior-Posterior Electrode Position for Cardioverting Atrial Fibrillation.
Schmidt AS, Lauridsen KG, Møller DS, Christensen PD, Dodt KK, Rickers H, Løfgren B, Albertsen AE. | Circulation. 2021 Dec 21;144(25):1995-2003
DOI: https://doi.org/10.1161/circulationaha.121.056301
Keywords: atrial fibrillation; electric countershock; electrodes.

Original Research Article

Introduction : Smaller randomized studies have reported conflicting results regarding the optimal electrode position for cardioverting atrial fibrillation. However, anterior-posterior electrode positioning is widely used as a standard and believed to be superior to anterior-lateral electrode positioning. Therefore, we aimed to compare anterior-lateral and anterior-posterior electrode positioning for cardioverting atrial fibrillation in a multicenter randomized trial.

Méthode : In this multicenter, investigator-initiated, open-label trial, we randomly assigned patients with atrial fibrillation scheduled for elective cardioversion to either anterior-lateral or anterior-posterior electrode positioning. The primary outcome was the proportion of patients in sinus rhythm after the first shock. The secondary outcome was the proportion of patients in sinus rhythm after up to 4 shocks escalating to maximum energy. Safety outcomes were any cases of arrhythmia during or after cardioversion, skin redness, and patient-reported periprocedural pain.

Résultats : We randomized 468 patients. The primary outcome occurred in 126 patients (54%) assigned to the anterior-lateral electrode position and in 77 patients (33%) assigned to the anterior-posterior electrode position (risk difference, 22 percentage points [95% CI, 13-30]; P<0.001). The number of patients in sinus rhythm after the final cardioversion shock was 216 (93%) assigned to anterior-lateral electrode positioning and 200 (85%) assigned to anterior-posterior electrode positioning (risk difference, 7 percentage points [95% CI, 2-12]). There were no significant differences between groups in any safety outcomes.

Conclusion : Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome.

Conclusion (proposition de traduction) : Le positionnement des électrodes antéro-latérales était plus efficace que le positionnement des électrodes antéro-postérieures pour la cardioversion de la fibrillation atriale avec une onde biphasique. Il n'y avait pas de différences significatives dans les résultats de sécurité.

Dangers of hyperoxia.
Singer M, Young PJ, Laffey JG, Asfar P, Taccone FS, Skrifvars MB, Meyhoff CS, Radermacher P. | Crit Care. 2021 Dec 19;25(1):440.
DOI: https://doi.org/10.1186/s13054-021-03815-y  | Télécharger l'article au format  
Keywords: ARDS; Acute ischaemic stroke; Cardiopulmonary resuscitation; Hyperoxaemia; Hyperoxia; Intracranial bleeding; Myocardial infarction; Reactive nitrogen species; Reactive oxygen species; Sepsis; Subarachnoidal bleeding; Surgical site infection; Trauma-and-haemorrhage; Traumatic brain injury.

Review

Editorial : Oxygen (O2) toxicity remains a concern, particularly to the lung. This is mainly related to excessive production of reactive oxygen species (ROS). Supplemental O2, i.e. inspiratory O2 concentrations (FIO2) > 0.21 may cause hyperoxaemia (i.e. arterial (a) PO2 > 100 mmHg) and, subsequently, hyperoxia (increased tissue O2 concentration), thereby enhancing ROS formation. Here, we review the pathophysiology of O2 toxicity and the potential harms of supplemental O2 in various ICU conditions. The current evidence base suggests that PaO2 > 300 mmHg (40 kPa) should be avoided, but it remains uncertain whether there is an "optimal level" which may vary for given clinical conditions. Since even moderately supra-physiological PaO2 may be associated with deleterious side effects, it seems advisable at present to titrate O2 to maintain PaO2 within the normal range, avoiding both hypoxaemia and excess hyperoxaemia.

Conclusion : So far, it appears prudent to target PaO2 values within the normal range, i.e. carefully titrating PaO2 to avoid both hypoxaemia and excess hyperoxaemia, particular as no clinically useful biomarker of O2 toxicity is available, and data on the effects of hyperoxia on markers of oxidative stress are equivocal.

Conclusion (proposition de traduction) : Jusqu'à présent, il semble prudent de cibler les valeurs de PaO2 dans la plage normale, c'est-à-dire de doser soigneusement la PaO2 pour éviter à la fois l'hypoxémie et l'excès d'hyperoxémie, d'autant plus qu'aucun biomarqueur cliniquement utile de la toxicité de l'O2 n'est disponible, et que des données sur les effets de l'hyperoxie sur les marqueurs de la toxicité oxydative stress sont équivoques.

The pain in the Emergency Department: Choosing and treating wisely before and during the COVID-19 era.
Poggiali, E, De Iaco, F. | Emerg Care J. 2021;17(4):9903
DOI: https://doi.org/10.4081/ecj.2021.9903  | Télécharger l'article au format  
Keywords: Pain; pain management; Emergency Department; COVID-19; pandemic.

Review

Editorial : Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria® to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of “pain”, “emergency”, “COVID19”, “elderly”, “palliative care”, “ketamine”, “dexmedetomidine”, and “post-traumatic stress disorder”. The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.

Conclusion : Despite the number of published manuscripts,management is complex and sometimes a challenge in the ED. Emergency clinicians should never underestimate pain and always consider a tailored approach for each patient, particularly COVID-19 patients. The long-term consequences of COVID-19 are still unknown and should be investigated on different levels, i.e., medical and psychological. The future health policies must develop strategies not only to avoid other pandemics, but also and above to encourage immediate and targeted treatment, including palliative care and chronic pain, to reduce serious consequences for the patients and the national health system with a great attention for the EDs and the healthcare workers.

Conclusion (proposition de traduction) : Malgré le grand nombre de manuscrits publiés, la gestion est complexe et parfois un défi à l'urgence. Les urgentistes ne doivent jamais sous-estimer la douleur et toujours envisager une approche adaptée à chaque patient, en particulier les patients COVID-19. Les conséquences à long terme de la COVID-19 sont encore inconnues et doivent être étudiées à différents niveaux, c'est-à-dire médical et psychologique. Les futures politiques de santé doivent développer des stratégies non seulement pour éviter d'autres pandémies, mais aussi et surtout pour encourager un traitement immédiat et ciblé, y compris les soins palliatifs et la douleur chronique, afin de réduire les conséquences graves pour les patients et le système de santé national avec une grande attention pour le les services d'urgence et les travailleurs de la santé.

Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients.
Turcato G, Zaboli A, Tenci A, Ricci G, Zannoni M, Scheurer C, Wieser A, Maccagnani A, Bonora A, Pfeifer N.. | Emerg Care J. 2021;17(4):10284
DOI: https://doi.org/10.4081/ecj.2021.10284  | Télécharger l'article au format  
Keywords: Falls in the elderly; intrathoracic hemorrhage; DOACs; VKA;, oral anticoagulant therapy; rib fractures

Original Article

Introduction : Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding.

Méthode : To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy.

Résultats : Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist.

Conclusion : Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.

Conclusion (proposition de traduction) : L'analyse de régression logistique n'a révélé aucune différence dans le risque d'hémorragies intrathoraciques entre les deux groupes étudiés. Le traitement par anticoagulants oraux directs présente un risque d'hémorragie intrathoracique post-traumatique comparable à celui des antivitamines K.

Association of advanced age with intubation-related adverse events in the emergency department: a multicentre prospective observational study.
Takahashi J, Goto T, Funakoshi H, Okamoto H, Hagiwara Y, Watase H, Hasegawa K; Japanese Emergency Medicine Network Investigators. | Emerg Med J. 2021 Dec;38(12):874-881
DOI: https://doi.org/10.1136/emermed-2020-209801
Keywords: airway; emergency departments; geriatrics.

GERIATRICS

Introduction : While the older population accounts for an increasing proportion of emergency department (ED), little is known about intubation-related adverse events in this high-risk population. We sought to determine whether advanced age is associated with a higher risk of intubation-related adverse events in the ED.

Méthode : This is an analysis of data from a prospective, 15-centre, observational study-the second Japanese Emergency Airway Network (JEAN-2) study. The current analysis included adult (aged ≥18 years) patients who underwent intubation in the ED between 2012 and 2018. The primary exposure was age (18-39, 40-64, 65-74, 75-84 and ≥85 years). The primary outcome was overall intubation-related adverse events during or immediately after an intubation. Adverse events were further categorised into major (hypotension, hypoxaemia, oesophageal intubation, cardiac arrest, dysrhythmia and death) and minor (endobronchial intubation, oesophageal intubation with early recognition, dental/lip trauma, airway trauma and regurgitation) adverse events. We constructed multivariable logistic regression models adjusting for seven potential confounders with generalised estimating equations that account for patients clustering within the ED.

Résultats : Among 9714 patients eligible for the analysis, 15% were aged ≥85 years, and 16% had adverse events. In the unadjusted models, advanced age was not significantly associated with the risk of overall adverse events. In the adjusted models, the association was significant (adjusted OR 1.41 in age ≥85 years (95% CI, 1.09 to 1.81) compared with age 18-39 years). Specifically, older patients had a significantly higher risk of major adverse events (adjusted OR in age ≥85 years 2.65 (95% CI, 1.78 to 3.94)), which was driven by the association of advanced age with an increased risk of hypotension (adjusted OR in ≥85 years, 5.69 (95% CI, 3.13 to 10.37)). By contrast, advanced age was not associated with minor adverse events.

Conclusion : Based on the data from a prospective multicentre study, advanced age was associated with higher risks of major adverse events.

Conclusion (proposition de traduction) : D'après les données d'une étude prospective multicentrique, l'âge avancé était associé à des risques plus élevés d'événements indésirables majeurs.

Commentaire : Les événements indésirables ont ensuite été classés en événements indésirables :
• majeurs : hypotension, hypoxémie, intubation œsophagienne, arrêt cardiaque, dysrythmie et décès ;
• mineurs : intubation endobronchique, intubation œsophagienne avec détection précoce, traumatisme dentaire/lèvre, traumatisme des voies respiratoires et régurgitation.

qSOFA as a new community-acquired pneumonia severity score in the emergency setting.
Spagnolello O, Ceccarelli G, Borrazzo C, Macrì A, Suppa M, Baldini E, Garramone A, Alessandri F, Celani L, Vullo F, Angeletti S, Ciccozzi M, Mastroianni C, Bertazzoni G, D'Ettorre G.. | Emerg Med J. 2021 Dec;38(12):906-912
DOI: https://doi.org/10.1136/emermed-2019-208789
Keywords: clinical assessment; death/mortality; emergency department; intensive care; pneumonia/infections.

RISK SCORES

Introduction : Quick Sequential Organ Failure Assessment (qSOFA) score is a bedside prognostic tool for patients with suspected infection outside the intensive care unit (ICU), which is particularly useful when laboratory analyses are not readily available. However, its performance in potentially septic patients with community-acquired pneumonia (CAP) needs to be examined further, especially in relation to early outcomes affecting acute management.
Objective: First, to compare the performance of qSOFA and CURB-65 in the prediction of mortality in the emergency department in patients presenting with CAP. Second, to study patients who required critical care support (CCS) and ICU admission.

Méthode : Between January and December 2017, a 1-year retrospective observational study was carried out of adult (≥18 years old) patients presenting to the emergency department (ED) of our hospital (Rome, Italy) with CAP. The accuracy of qSOFA, qSOFA-65 and CURB-65 was compared in predicting mortality in the ED, CCS requirement and ICU admission. The concordance among scores ≥2 was then assessed for 30-day estimated mortality prediction.

Résultats : 505 patients with CAP were enrolled. Median age was 71.0 years and mortality rate in the ED was 4.7%. The areas under the curve (AUCs) of qSOFA-65, CURB-65 and qSOFA in predicting mortality rate in the ED were 0.949 (95% CI 0.873 to 0.976), 0.923 (0.867 to 0.980) and 0.909 (0.847 to 0.971), respectively. The likelihood ratio of a patient having a qSOFA score ≥2 points was higher than for qSOFA-65 or CURB-65 (11 vs 7 vs 6.7). The AUCs of qSOFA, qSOFA-65 and CURB-65 in predicting CCS requirement were 0.862 (95% CI 0.802 to 0.923), 0.824 (0.758 to 0.890) and 0.821 (0.754 to 0.888), respectively. The AUCs of qSOFA-65, qSOFA and CURB-65 in predicting ICU admission were 0.593 (95% CI 0.511 to 0.676), 0.585 (0.503 to 0.667) and 0.570 (0.488 to 0.653), respectively. The concordance between qSOFA-65 and CURB-65 in 30-day estimated mortality prediction was 93%.

Conclusion : qSOFA is a valuable score for predicting mortality in the ED and for the prompt identification of patients with CAP requiring CCS. qSOFA-65 may further improve the performance of this useful score, showing also good concordance with CURB-65 in 30-day estimated mortality prediction.

Conclusion (proposition de traduction) : Le qSOFA est un score précieux pour prédire la mortalité aux urgences et pour l'identification rapide des patients présentant une pneumonie communautaire nécessitant une prise en charge en soins intensifs. Le qSOFA-65 peut encore améliorer les performances de ce score, montrant également une bonne concordance avec CURB-65 dans la prévision de la mortalité estimée à 30 jours.

Commentaire : Lee J, Song JU. Performance of a quick sofa-65 score as a rapid sepsis screening tool during initial emergency department assessment: A propensity score matching study. J Crit Care. 2020 Feb;55:1-8  .

Ultrasound in forearm fractures: a pragmatic study assessing the utility of Point of Care Ultrasound (PoCUS) in identifying and managing distal radius fractures.
Wood D, Reddy M, Postma I, Bromley P, Hambridge J, Wickramarachchi C, Hameed AS. | Emerg Radiol. 2021 Dec;28(6):1107-1112
DOI: https://doi.org/10.1007/s10140-021-01957-8
Keywords: Emergency department; Diagnosis; Fractures and dislocations; XRAY; Ultrasound

Original Article

Introduction : Point of Care Ultrasound (PoCUS) is a safe, non-invasive tool for identifying distal radius fractures and can potentially be utilised to assist clinicians to reduce displaced fractures. We aim to test whether PoCUS is accurate to identify distal radius fractures and to determine how PoCUS performs as a tool to confirm a successful fracture reduction.

Méthode : A pragmatic prospective observational study was done in adult patients presenting with forearm injuries resulting in Colle’s type distal radius fractures. Adults who presented to the emergency department (ED) with a suspected distal forearm fracture from August 2018 to July 2019 were conveniently sampled for inclusion into the study when a trained ED ultra-sonographer was available. PoCUS scans over the point of maximal tenderness were done using a high frequency linear transducer (7.5–10 mHz) prior to X-ray. Patients who required a manipulation of the fracture had a second ultrasound scan immediately after the procedure before the second X-ray was ordered. PoCUS scans were compared to X-rays for accuracy in both groups.

Résultats : Fractures were identified in 44 out of 47 included patients using both PoCUS and X-ray modalities. This showed a sensitivity of 100% (95% CI: 90–100%) and specificity of 100% (95% CI: 31–100%). Fracture manipulation was required in 35 out of 44 patients. The sensitivity and specificity of PoCUS in determining alignment accuracy when compared to X-ray were 100% (95% CI: 83–100%) and 64% (95% CI: 32–88%) respectively. The PPV and NPV were 86% (95% CI: 66–95%) and 100% (95% CI: 56–100%) respectively. Ten out of 44 (23%) patients with distal radius fractures ultimately required an Open Reduction and Internal Fixation (ORIF).

Conclusion : Our study supports the use of PoCUS for identifying distal radius forearm fractures and may have some value in assisting clinicians to determine post reduction success. We still advocate using standard X-ray radiographs to confirm successful or adequate cortical alignment following a manipulation.

Conclusion (proposition de traduction) : Notre étude soutient l'utilisation de l'échographie au point d'intervention pour identifier les fractures distales de l'avant-bras au niveau du radius et peut avoir une certaine valeur pour aider les cliniciens à déterminer le succès après la réduction. Nous préconisons toujours l'utilisation de radiographies standard à rayons X pour confirmer un alignement cortical réussi ou adéquat suite à une manipulation.

Commentaire :  Images échographiques et radiographiques du site de fracture distale du radius avant (a,b) et après (c,d) manipulation. Les flèches indiquent le site de la fracture

Out-of-hospital cardiac arrest: prehospital physician's role during CPR should be clarified.
SFMU Cardiac Arrest Board | Eur J Emerg Med. 2021 Dec 1;28(6):411-413
DOI: https://doi.org/10.1097/mej.0000000000000881
Keywords: Aucun

Perspective Article

Editorial : The European Resuscitation Council (ERC) 2021 Advanced Life Support (ALS) guidelines are on the basis of the assessment of cardiac rhythm, external electric shock, drug administration (adrenaline and amiodarone) and ventilation. Although the endotracheal intubation (ETI) success rate during resuscitation was higher when performed by physicians than paramedics, no clear benefit on neurological outcome compared to bagmask ventilation (BMV) or supraglottic airway (SGA) were observed in recent randomised clinical trials. Overall, the ALS algorithm proposed by the ERC is mainly on the basis of paramedical skills only. The specific role of the emergency physician (EP) is not clearly defined or highlighted. Although, Bötigger et al. found in their meta-analysis that the presence of an EP during out-of-hospital cardiac arrest (OHCA) resuscitation was associated with a better outcome. One explanation advanced by the authors is when an EP is present during cardiopulmonary resuscitation (CPR), the time for interrupting chest compressions is reduced and compliance with guidelines is higher, highlighting a better team leader role by the physician. Another interesting point was raised by Bjornsson et al., who found a higher rate of return of spontaneous circulation (ROSC) in subjects with pulseless electrical activity (PEA) when CPR was performed by a physician-staffed ambulance. Indeed, PEA is the most common rhythm found in reversible causes of cardiac arrest, and their identification and treatment by the EP during CPR is a plausible explanation for this result.
Therefore, the aim of this viewpoint is to discuss the main specific role of the EP during CPR, in relation to expertise, diagnostic and therapeutic skills.

Conclusion : The physician’s role in cardiac arrest resuscitation should focus on team management and early identification and treatment of reversible causes. Reversible causes are rare and the application of the proposed protocol will probably not radically improve outcomes, but it may save the lives of these particular subjects.

Conclusion (proposition de traduction) : Le rôle du médecin dans la réanimation en cas d'arrêt cardiaque doit se concentrer sur la gestion de l'équipe et l'identification et le traitement précoces des causes réversibles. Les causes réversibles sont rares et l'application du protocole proposé n'améliorera probablement pas radicalement les résultats, mais il peut sauver la vie de ces sujets particuliers.

Commentaire :  Algorithme proposé pour le rôle du médecin lors de la réanimation. RCP, réanimation cardiopulmonaire ; ECPR, réanimation cardiopulmonaire extracorporelle ; ETCO2, capnographie ; ETI, intubation endotrachéale ; SGA, dispositif supraglottique.

Targeted temperature management after resuscitation from cardiac arrest: the importance of emergency physicians.
Behringer W | Eur J Emerg Med. 2021 Dec 1;28(6):418-419
DOI: https://doi.org/10.1097/mej.0000000000000886
Keywords: Aucun

Perspective Article

Editorial : Sudden cardiac arrest is a major cause of death in Europe (incidence ranging from 27 to 91 per 100000 population per year) with high burden of disability. Targeted tem- perature management (TTM) became a recommended therapy for patients after successful resuscitation from cardiac arrest. However, the optimal temperature range, as well as time point to start, and the duration of cooling remain a matter of debate.

Conclusion : Emergency physicians as first treating physicians greatly influence the therapy and the outcome of patients. TTM at 32–34°C applied early and fast seems to be beneficial and should be considered in all patients resuscitated from cardiac arrest.

Conclusion (proposition de traduction) : Les médecins urgentistes en tant que premiers médecins traitants influencent grandement le traitement et le devenir des patients. Une gestion ciblée de la température à 32–34° C appliquée tôt et rapidement semble être bénéfique et doit être envisagée chez tous les patients réanimés après un arrêt cardiaque.

Guidelines for the management of status epilepticus.
Outin H, Lefort H, Peigne V; French Group for Status Epilepticus Guidelines. | Eur J Emerg Med. 2021 Dec 1;28(6):420-422
DOI: https://doi.org/10.1097/mej.0000000000000857
Keywords: Aucun

Viewpoint

Editorial : In 2019, The French Intensive Care Society (SRLF) and the French Society of Emergency Medicine (SFMU), along with the Francophone Group of Resuscitation and Paediatric Emergencies (GFRUP), have developed guidelines to respond to the practical questions raised by status epilepticus management in the prehospital setting, in the emergency department and in the ICU. Twenty-five experts analyzed the literature and formulated recommendations according to the Grade of Recommendation Assessment, Development and Evaluation methodology. This article reports the must-know summary of these guidelines for the initial management of generalized tonic-clonic status epilepticus (GTCSE) by emergency physicians. Additional specific recommendations about children and other types of status epilepticus are available in the electronic appendix, Supplemental digital content 1, http://links.lww.com/EJEM/A313  .

Conclusion : These new recommendations should allow better management of each status epilepticus patient by emergency physicians according to graduated and personalized protocols, modulated according to the type of status epilepticus and its etiology. These guidelines update European and American guidelines and are in accordance with the most recent works about emergency management of status epilepticus. Whether these recommendations may be applied in different settings in Europe is unknown and warrants further evaluations.

Conclusion (proposition de traduction) : Ces nouvelles recommandations doivent permettre une meilleure prise en charge de chaque patient en état de mal épileptique par les urgentistes selon des protocoles gradués et personnalisés, modulés selon le type d'état de mal épileptique et son étiologie. Ces recommandations mettent à jour les recommandations européennes et américaines et sont conformes aux travaux les plus récents sur la prise en charge en urgence de l'état de mal épileptique. On ne sait pas si ces recommandations peuvent être appliquées dans différents contextes en Europe et cela justifie des évaluations supplémentaires.

Commentaire :  Traitement de l'état de mal épileptique tonico-clonique généralisé. GTCSE, état de mal épileptique tonico-clonique généralisé ; IV, intraveineux ; IM, intramusculaire.

Effectiveness of the modified Valsalva manoeuvre in adults with supraventricular tachycardia: a systematic review and meta-analysis.
Lodewyckx E, Bergs J. | Eur J Emerg Med. 2021 Dec 1;28(6):432-439
DOI: https://doi.org/10.1097/mej.0000000000000862
Keywords: Aucun

Review

Introduction : Cardiac arrhythmia, specifically paroxysmal supraventricular tachycardia (SVT), accounts for a substantial proportion of emergency medical services resources utilisation. Reconversion requires increasing the atrioventricular node's refractoriness, which can be achieved by vagal manoeuvres, pharmacological agents or electrical cardioversion. There are multiple variants of vagal manoeuvres, including the Valsalva manoeuvre (VM). While the effectiveness of the standard VM has already been systematically reviewed, there has been no such analysis for the modified VM.
Objectives: Compare the effectiveness of the modified VM versus the standard VM in restoring the normal sinus rhythm in adult patients with supraventricular tachycardia.
Design: Systematic review with meta-analysis of published randomised controlled trials.

Méthode : The primary outcome was the reconversion to a sinus rhythm. Secondary outcomes included: medication use, adverse events, length of stay in the emergency department and hospital admission.

Résultats : Five randomised controlled trials were included, with a combined total of 1181 participants. The meta-analysis demonstrated a significantly higher success rate for reconversion to sinus rhythm when using the modified VM compared to the standard VM in patients with an SVT (odds ratio = 4.36; 95% confidence interval, 3.30-5.76; P < 0.001). More adverse events were reported in the modified VM group, although this difference is NS (risk ratio = 1.48; 95% confidence interval, 0.91-2.42; P = 0.11). The available evidence suggests that medication use was lower in the modified VM group than the standard VM group. However, medication use could not be generalised across the different studies. None of the included studies showed a significant difference in length of stay in the emergency department. Only one study reported on hospital admission, with no significant difference between the two groups.

Conclusion : The available evidence is highly suggestive to support the use of the modified VM compared to the standard VM in the treatment of adult patients with SVT. Meta-analysis showed a higher success rate, required less medication use, and resulted in an equal number of adverse events. However, these results cannot be regarded as definitive in the absence of higher-quality studies.

Conclusion (proposition de traduction) : Les preuves disponibles suggèrent fortement l'utilisation de la manœuvre de Valsalva modifiée par rapport à la manœuvre de Valsalva standard dans le traitement des patients adultes présentant une tachycardie supraventriculaire. La méta-analyse a montré un taux de réussite plus élevé, a nécessité moins de médicaments et a entraîné un nombre égal d'événements indésirables. Cependant, ces résultats ne peuvent être considérés comme définitifs en l'absence d'études de meilleure qualité.

The association of body temperature with antibiotic therapy and mortality in patients attending the emergency department with suspected infection.
Schuttevaer R, Brink A, Alsma J, de Steenwinkel JEM, Verbon A, Schuit SCE, Lingsma HF. | Eur J Emerg Med. 2021 Dec 1;28(6):440-447
DOI: https://doi.org/10.1097/mej.0000000000000817
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Previous studies found that septic patients with normothermia have higher mortality than patients with fever. We hypothesize that antibiotic therapy is less frequently initiated if infectious patients present with normothermia to the emergency department (ED).
Objectives: To examine the association of body temperature with the initiation of antibiotic therapy in patients attending the ED with suspected and proven infection. Additionally, the association of temperature with 30-day mortality was assessed.
Design, settings and participants: We conducted a retrospective cohort study between 2012 and 2016 at a tertiary university hospital. Adult patients attending the ED with a blood culture taken (i.e. suspected infection) and a positive blood culture (i.e. proven bacteremia) were included.
Exposure: Tympanic temperature at arrival was categorized as hypothermia (<36.1°C), normothermia (36.1-38.0°C) or hyperthermia (>38.0°C).

Méthode : Primary outcome was the initiation of antibiotic therapy. A secondary outcome was 30-day mortality. Multivariable logistic regression was used to control for covariates.

Résultats : Of 5997 patients with a suspected infection, 45.8% had normothermia, 44.6% hyperthermia and 5.6% hypothermia. Patients with hyperthermia received more often antibiotic therapy (53.5%) compared to normothermic patients (27.6%, adjusted odds ratio [95% confidence interval], 2.59 [2.27-2.95]). Patients with hyperthermia had lower mortality (4.7%) than those with normothermia (7.4%, adjusted odds ratio [95% confidence interval], 0.50 [0.39-0.64]). Sensitivity analyses in patients with proven bacteremia (n = 934) showed similar results.

Conclusion : Normothermia in patients presenting with infection was associated with receiving less antibiotic therapy in the ED compared to presentations with hyperthermia. Moreover, normothermia was associated with a higher mortality risk than hyperthermia.

Conclusion (proposition de traduction) : La normothermie chez les patients présentant une infection était associée à une diminution de l'antibiothérapie aux urgences par rapport aux patients présentant une hyperthermie. De plus, la normothermie était associée à un risque de mortalité plus élevé que l'hyperthermie.

Organ failure, aetiology and 7-day all-cause mortality among acute adult patients on arrival to an emergency department: a hospital-based cohort study.
Pedersen PB, Henriksen DP, Brabrand M, Lassen AT. | Eur J Emerg Med. 2021 Dec 1;28(6):448-455
DOI: https://doi.org/10.1097/mej.0000000000000841  | Télécharger l'article au format  
Keywords: Aucun

Original Article

Introduction : Organ failure is both a frequent and dangerous condition among adult patients on arrival to an emergency department (ED). The risk of an unfavourable outcome could depend on the underlying aetiology. Knowledge of the relation between aetiology and prognosis could improve the risk stratification at arrival.
Objectives: To describe the relation between organ failure, aetiology and prognosis through 7-day all-cause mortality.

Méthode : An observational three-year cohort study at the ED at Odense University Hospital, Denmark, including all acute adult patients.First-measured vital signs and laboratory values were included to evaluate the presence of the following organ failures: respiratory, coagulation, hepatic, circulatory, cerebral or renal.The primary outcome was 7-day all-cause mortality. Aetiological disease categories were based on primary discharge diagnoses. We described the association between 7-day mortality, aetiology category, site of organ failures and number of patients at risk.

Résultats : Of 40 423 patients with a first-time visit at the ED, 5883(14.6%) had an organ failure on arrival. The median age was 69 (IQR 54-80), and 50% were men. The most frequent aetiology was infection (1495, 25.4%). Seven-day all-cause mortality ranged between aetiologies from 0.0% (95% confidence interval [CI], 0.0-14.2) allergy) to 45.6% (95% CI, 41.3-50.0) (cardiac). Combining aetiology and site of organ failure, 7-day all-cause mortality was the highest in the cardiac category, from 14.8% (95% CI, 4.2-3.7) with hepatic failure to 79.2% (95% CI, 73.6-84.1) with cerebral failure. The combination of infection and respiratory failure characterised most patients (n = 949).

Conclusion : Infection was the most prevalent aetiology, and 7-day all-cause mortality was highly associated with the site of organ failure and aetiology.

Conclusion (proposition de traduction) : L'infection était l'étiologie la plus répandue, et la mortalité toutes causes confondues à 7 jours était fortement associée au site de la défaillance organique et à l'étiologie.

Effect of early hyperoxemia on mortality in mechanically ventilated septic shock patients according to Sepsis-3 criteria: analysis of the MIMIC-III database.
Popoff B, Besnier E, Dureuil B, Veber B, Clavier T. | Eur J Emerg Med. 2021 Dec 1;28(6):469-475
DOI: https://doi.org/10.1097/mej.0000000000000854
Keywords: Aucun

Original Article

Introduction :  Hyperoxemia may be associated with increased mortality in emergency room or ICU patients. However, its effect during septic shock is still debated.
Objective: To evaluate the effect of hyperoxemia on ICU mortality, during the first 24 h of ICU stay, in mechanically ventilated patients with septic shock according to SEPSIS-3 criteria.
Design, settings and participants: A retrospective cohort study of ICU admissions recorded in the Medical Information Mart for Intensive Care-III, a retrospective ICU database, was performed.

Méthode : Two oxygen exposures during the first 24 h were compared: average PaO2 (TWA-PaO2) between 70 and 120 mmHg in the normoxemia group and above 120 mmHg in the hyperoxemia group.
Outcome measures and analysis: The primary outcome was mortality during ICU stay.

Résultats : Four hundred eighty-eight ICU admissions met the inclusion criteria: 214 in the normoxemia group and 274 in the hyperoxemia group. The median TWA-PaO2 was 99.1 (88.9-107.6) mmHg in the normoxemia group and 151.5 (133.6-180.2) mmHg in the hyperoxemia group. ICU mortality was lower in the hyperoxemia group than in the normoxemia group in univariate analysis [29.6 vs. 39.7%, respectively; OR 0.64 (0.44-0.93); P = 0.024], but not in multivariate analysis [OR 0.98 (0.62-1.56); P = 0.93]. There was no difference between the two groups in ICU length of stay [8.0 (4.3-15.0) vs. 8.4 (4.7-15.0) days; P = 0.82].

Conclusion : We did not find any impact of early hyperoxemia on mortality in this population of mechanically ventilated patients with SEPSIS-3 septic shock criteria.

Conclusion (proposition de traduction) : Nous n'avons pas trouvé d'impact de l'hyperoxie précoce sur la mortalité dans cette population de patients ventilés mécaniquement avec des critères de choc septique SEPSIS-3.

Effect of early hyperoxemia on mortality in mechanically ventilated septic shock patients according to Sepsis-3 criteria: analysis of the MIMIC-III database.
Popoff B, Besnier E, Dureuil B, Veber B, Clavier T. | Eur J Emerg Med. 2021 Dec 1;28(6):469-475
DOI: https://doi.org/10.1097/mej.0000000000000854
Keywords: Aucun

Original Article

Introduction :  Hyperoxemia may be associated with increased mortality in emergency room or ICU patients. However, its effect during septic shock is still debated.
Objective: To evaluate the effect of hyperoxemia on ICU mortality, during the first 24 h of ICU stay, in mechanically ventilated patients with septic shock according to SEPSIS-3 criteria.
Design, settings and participants: A retrospective cohort study of ICU admissions recorded in the Medical Information Mart for Intensive Care-III, a retrospective ICU database, was performed.

Méthode : Two oxygen exposures during the first 24 h were compared: average PaO2 (TWA-PaO2) between 70 and 120 mmHg in the normoxemia group and above 120 mmHg in the hyperoxemia group.
Outcome measures and analysis: The primary outcome was mortality during ICU stay.

Résultats : Four hundred eighty-eight ICU admissions met the inclusion criteria: 214 in the normoxemia group and 274 in the hyperoxemia group. The median TWA-PaO2 was 99.1 (88.9-107.6) mmHg in the normoxemia group and 151.5 (133.6-180.2) mmHg in the hyperoxemia group. ICU mortality was lower in the hyperoxemia group than in the normoxemia group in univariate analysis [29.6 vs. 39.7%, respectively; OR 0.64 (0.44-0.93); P = 0.024], but not in multivariate analysis [OR 0.98 (0.62-1.56); P = 0.93]. There was no difference between the two groups in ICU length of stay [8.0 (4.3-15.0) vs. 8.4 (4.7-15.0) days; P = 0.82].

Conclusion : We did not find any impact of early hyperoxemia on mortality in this population of mechanically ventilated patients with SEPSIS-3 septic shock criteria.

Conclusion (proposition de traduction) : Nous n'avons pas trouvé d'impact de l'hyperoxie précoce sur la mortalité dans cette population de patients ventilés mécaniquement avec des critères de choc septique SEPSIS-3.

Effect of high versus low dose of dexamethasone on clinical worsening in patients hospitalised with moderate or severe COVID-19 Pneumonia: an open-label, randomised clinical trial.
Taboada M, Rodríguez N, Varela PM, Rodríguez MT, Abelleira R, González A, Casal A, Díaz Peromingo JA, Lama A, Domínguez MJ, Rábade C, Páez EM, Riveiro V, Pernas H, Del Carmen Beceiro M, Caruezo V, Naveira A, Cariñena A, Cabaleiro T, Estany-Gestal A, Zarra I, Pose A, Valdés L, Álvarez-Escudero J. | Eur Respir J. 2021 Dec 16:2102518
DOI: https://doi.org/10.1183/13993003.02518-2021  | Télécharger l'article au format  
Keywords: Aucun

Original research article

Introduction : Low dose dexamethasone demonstrated clinical improvement in patients with coronavirus disease 2019 (COVID-19) needing oxygen therapy; however, evidence on the efficacy of high dose of dexamethasone is limited.

Méthode : We performed a randomised, open-label, controlled trial involving hospitalised patients with confirmed COVID-19 pneumonia needing oxygen therapy. Patients were randomly assigned in a 1:1 ratio to receive low dose dexamethasone (6 mg once daily for 10 days) or high dose dexamethasone (20 mg once daily for 5 days, followed by 10 mg once daily for additional 5 days). The primary outcome was clinical worsening within 11 days since randomisation. Secondary outcomes included 28-day mortality, time to recovery, and clinical status at day 5, 11, 14 and 28 on an ordinal scale ranging from 1 (discharged) to 7 (death).

Résultats : A total of 200 patients (mean (sd) age, 64 (14) years; 62% male) were enrolled. Thirty-two patients of 102 (31.4%) enrolled in the low dose group and 16 of 98 (16.3%) in the high dose group showed clinical worsening within 11 days since randomisation (rate ratio, 0.427; 95% CI, 0.216-0.842; p=0.014). The 28-day mortality was 5.9% in the low dose group and 6.1% in the high dose group (p=0.844). There was no significant difference in time to recovery, and in the 7-point ordinal scale at day 5, 11, 14 and 28.

Conclusion : Among hospitalised COVID-19 patients needing oxygen therapy, high dose of dexamethasone reduced clinical worsening within 11 days after randomisation as compared with low dose.

Conclusion (proposition de traduction) : Parmi les patients hospitalisés COVID-19 nécessitant une oxygénothérapie, une dose élevée de dexaméthasone a réduit l'aggravation clinique dans les 11 jours suivant la randomisation par rapport à une faible dose.

Commentaire : Voir l'analyse de l'article sur :
Le masque et la plume  . Décembre 2021 par le Dr Vincent BALECH

Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine.
Robba C, Wong A, Poole D, Al Tayar A, Arntfield RT, Chew MS, Corradi F, Douflé G, Goffi A, Lamperti M, Mayo P, Messina A, Mongodi S, Narasimhan M, Puppo C, Sarwal A, Slama M, Taccone FS, Vignon P, Vieillard-Baron A; European Society of Intensive Care Medicine task force for critical care ultrasonography. | Intensive Care Med. 2021 Dec;47(12):1347-1367
DOI: https://doi.org/10.1007/s00134-021-06486-z  | Télécharger l'article au format  
Keywords: Aucun

Consensus and Expert Recommendation

Editorial : Ultrasonography is an evolving skill in critically ill patients. We pro‐ vide a large number of statements regarding the required ultrasono‐ graphic basic skills for the management of critically ill patients.

Conclusion : In this consensus, we provide a large number of statements intended to recommend those basic ultrasound skills that intensivists should possess/acquire for the evaluation and management of critically ill patients. Importantly, this should not be read as a potential medico-legal document describing what constitutes adequate management by an intensivist, but it rather should be considered as a guide for intensivists during their pursuit of competencies in basic critical care US. Also, this document could serve as a core for any courses or training program, at least endorsed by ESICM.

Conclusion (proposition de traduction) : 2 073 / 5 000 Résultats de traduction Dans ce consensus, nous fournissons un grand nombre de déclarations destinées à recommander les compétences de base en échographie que les intensivistes devraient posséder/acquérir pour l'évaluation et la prise en charge des patients gravement malades. Il est important de noter que cela ne doit pas être lu comme un document médico-légal potentiel décrivant ce qui constitue une prise en charge adéquate par un intensiviste, mais plutôt comme un guide pour les intensivistes dans leur quête de compétences en soins intensifs de base. En outre, ce document pourrait servir de base à tout cours ou programme de formation, au moins approuvé par l'ESICM.

Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine.
Aubron C, Duranteau J, Juffermans NP, Meier J, Murphy GJ, Abbasciano R, Müller MCA, Lance M, Nielsen ND, Schöchl H, Hunt BJ, Cecconi M, Oczkowski S. | Intensive Care Med. 2021 Dec;47(12):1368-1392
DOI: https://doi.org/10.1007/s00134-021-06531-x  | Télécharger l'article au format  
Keywords: Bleeding; Coagulopathy; Critically ill; Guideline; Intensive care; Plasma; Platelets; Point of care; Red blood cells; Tranexamic acid; Transfusion.

Guidelines

Introduction : To develop evidence-based clinical practice recommendations regarding transfusion practices and transfusion in bleeding critically ill adults.

Méthode : A taskforce involving 15 international experts and 2 methodologists used the GRADE approach to guideline development. The taskforce addressed three main topics: transfusion support in massively and non-massively bleeding critically ill patients (transfusion ratios, blood products, and point of care testing) and the use of tranexamic acid. The panel developed and answered structured guideline questions using population, intervention, comparison, and outcomes (PICO) format.

Résultats : The taskforce generated 26 clinical practice recommendations (2 strong recommendations, 13 conditional recommendations, 11 no recommendation), and identified 10 PICOs with insufficient evidence to make a recommendation.

Conclusion : This clinical practice guideline provides evidence-based recommendations for the management of massively and non-massively bleeding critically ill adult patients and identifies areas where further research is needed.

Conclusion (proposition de traduction) : Cette ligne directrice de pratique clinique fournit des recommandations fondées sur des données probantes pour la prise en charge des patients adultes gravement malades qui saignent massivement et non massivement et identifie les domaines dans lesquels des recherches supplémentaires sont nécessaires.

Commentaire : Voir la dernière recommandation formalisée d'experts de la SFAR/SRLF/SFMU/GEHT : Duranteau J, Asehnoune K, Pierre S and al. Recommandations sur la réanimation du choc hémorragique Anesth Reanim. 2015;1:62–74  .

Dautreppe C, Telion C. | J Eur des Urgences Réanimation. 2021 Dec;33(4):179-183
DOI: https://doi.org/10.1016/j.jeurea.2021.10.006
Keywords: Certification; Quality evaluation; Indicators; Other adverse event; Risk management; Declaration analysis; Monitoring; Team coordination; Users of healthcare system; Exceptional sanitary state

Article original

Editorial : Constituant la porte d’entrée du parcours de soins des patients, ce n’est que récemment que les Services d’aide médicale urgente (SAMU) ont introduit une démarche qualité dans leur organisation. Cet article présente le déploiement de cette démarche qualité mise en œuvre par le SAMU de Paris à travers le rôle clé de l’ingénieure qualité pour la réussite de la démarche. Il peut servir d’illustration de cette démarche pour les services qui auraient à s’y impliquer notamment dans le cadre de la future certification.

Conclusion (proposition de traduction) : Le déploiement d’une démarche qualité repose sur la théorie des petits pas : il s’agit d’un processus lent, qui doit reposer sur la confiance, la pertinence et l’appropriation de la démarche par les professionnels eux-mêmes. Un changement de culture doit s’opérer dans le service de façon favorable à la contribution des professionnels à la démarche en incitant à la participation à la rédaction de procédures ou au signalement des dysfonctionnements. Les enjeux de la démarche qualité dans un SAMU reposent également sur le fait de devoir maintenir les projets au long cours dans un service sans cesse bousculé par la traversée de crises, comme très récemment celle de la Covid-19. Enfin, la fonction d’un service qualité au sein d’un SAMU est novatrice : elle évolue en harmonie avec le service et crée, au gré de ses besoins, les outils nécessaires à une amélioration constante de la qualité de la régulation médicale.

Leroux C, Sahmi N, Nizard J, Telion C, Carli P. | J Eur des Urgences Réanimation. 2021 Dec;33(4):184–93
DOI: https://www.sciencedirect.com/science/article/pii/S2211423821000924
Keywords: Regulation; Call; Unexpected birth; Out of hospital; EMS

Article original

Editorial : Les appels pour accouchement inopiné extrahospitalier représentent 0,3 % des appels au Centre 15. Trois situations peuvent se présenter : l’accouchement est imminent, en cours ou déjà réalisé. Le médecin régulateur se doit de déterminer l’imminence de l’accouchement. Il peut s’aider de scores connus tels que le score de Malinas modifié et le score prédictif de l’imminence de l’accouchement. Le signe le plus pertinent reste malgré tout l’envie de pousser. Ce seul signe peut amener à engager une Unité mobile hospitalière (UMH). Les critères de gravité fœtale ou néonatale doivent être recherchés, comme une prématu- rité, un retard de croissance, un liquide amniotique méconial. Ces éléments doivent permettre d’engager une UMH pédiatrique avec incubateur. Le médecin régulateur détermine la pré- sence de facteurs de risque de l’hémorragie du post-partum. Il recherche donc des antécédents d’hémorragie du post-partum, une grossesse gémellaire ou une macrosomie, une grande mul- tiparité, un âge supérieur à 35 ans et un travail long. En cas de naissance réalisée, il évalue l’adaptabilité du nouveau-né à la vie extra-utérine et veille à la prévention de l’hypothermie. Le médecin régulateur doit, ensuite, suivant le bilan du premier effecteur, organiser le trans- fert vers la maternité la plus adaptée : soit celle du suivi initial, soit la plus proche ou celle possédant un plateau technique adapté en cas d’hémorragie du post-partum ou une maternité adaptée à l’âge gestationnel (maternité de type I, IIA, IIB, III). Trois situations nécessitent un transfert immédiat vers un bloc obstétrical : l’imminence de l’accouchement sur un placenta recouvrant, la procidence du cordon ou du bras.

Conclusion (proposition de traduction) : Certes peu fréquents, les appels pour menace d’accouchement inopiné ne sont, néanmoins, pas rares. La régulation de ces situations est un exercice difficile, puisqu’elle doit intégrer les complications liées à la mécanique obstétricale en elle-même, ainsi que celles liées à la mère et à l’enfant. Il faut savoir distinguer les signes orientant vers un accouchement imminent, ainsi que les facteurs de risque de complications fœtale ou maternelle afin de pouvoir anticiper sur l’évolution de la situation et envoyer les moyens adéquats nécessaires et suffisants. Il est fondamental de dépister, le plus en amont possible, les contre-indications à un accouchement voie basse afin de pouvoir anticiper et organiser rapidement une admission vers un bloc opératoire obstétrical pour une éventuelle césarienne en urgence.
Devant la particularité de cet exercice, des conférences d’experts recommandent la participation de sage-femmes et de néonatalogistes à la régulation au sein des SAMU-Centre 15.
L’hétérogénéité des réseaux de périnatalité sur le territoire national en termes de nombre, de répartition et d’offre globale de soins des établissements, ainsi que la disponibilité, variable en fonction des départements, des SMUR pédiatriques avec incubateur, influent beaucoup sur cette régulation qui varie donc d’une région à l’autre. Il est donc primordial pour les professionnels concernés d’avoir une bonne connaissance de l’offre de soins et de travailler conjointement avec les équipes d’obstétrique pour créer des parcours de soins optimisés. La rareté de la situation qui malgré tout n’est pas exceptionnelle impose à tous les acteurs de la régulation une maîtrise de cet interrogatoire (ARM, médecin) et donc une connaissance du risque lié à l’accouchement.

Practical guidelines for the response to perioperative anaphylaxis.
Takazawa T, Yamaura K, Hara T, Yorozu T, Mitsuhata H, Morimatsu H; Working Group for the Preparation of Practical Guidelines for the Response to Anaphylaxis, Safety Committee of the Japanese Society of Anesthesiologists. | J Anesth. 2021 Dec;35(6):778-793
DOI: https://doi.org/10.1007/s00540-021-03005-8
Keywords: Anaphylaxis; Anesthesia; Guideline; Shock.

Guideline

Editorial : Perioperative anaphylaxis is a severe adverse event during anesthesia that requires prompt diagnosis and treatment by physicians, including anesthesiologists. Muscle relaxants and antibiotics are the most common drugs that cause perioperative anaphylaxis in Japan, as in many countries. In addition, sugammadex appears to be a primary causative agent. Obtaining previous anesthesia records is necessary in a patient with a history of allergic reactions during anesthesia, whenever possible, to avoid recurrence of anaphylaxis. Although medical staff are likely to notice abnormal vital signs because of complete monitoring during anesthesia, surgical drapes make it difficult to notice the appearance of skin symptoms. Even if there are no skin symptoms, anaphylaxis should be suspected, especially when hypotension resistant to inotropes and vasopressors persists. For improving the diagnostic accuracy of anaphylaxis, it is helpful to collect blood samples to measure histamine/tryptase concentrations immediately after the events and at baseline. The first-line treatment for anaphylaxis is adrenaline. In the perioperative setting, adrenaline should be administered through the intravenous route, which has a faster effect onset and is secured in most cases. Adrenaline can cause serious complications including severe arrhythmias if the appropriate dose is not selected according to the severity of symptoms. The anesthesiologist should identify the causative agent after adverse events. The gold standard for identifying the causative agent is the skin test, but in vitro tests including specific IgE antibody measurements and basophil activation tests are also beneficial. The Working Group of the Japanese Society of Anesthesiologists has developed this practical guide to help appropriate prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia.Grade of recommendations and levels of evidence Anaphylaxis is a relatively rare condition with few controlled trials, and thus a so-called evidence-based scrutiny is difficult. Therefore, rather than showing evidence levels and indicating the level of recommendation, this practical guideline only describes the results of research available to date. The JSA will continue to investigate anaphylaxis during anesthesia, and the results may lead to an amendment of this practical guideline.

Conclusion : This guide is designed to provide anesthesiologists with useful information for the prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia. Many recommendations contained in this guide are based on expert opinion and case reports in the absence of high-quality evidence, because anaphylaxis is a relatively rare condition. This document aims to assist anesthesiologists’ decision making in clinical settings, and these guidelines are not recommended to general physicians.

Conclusion (proposition de traduction) : Ce guide est conçu pour fournir aux anesthésistes des informations utiles pour la prévention, le diagnostic et le traitement précoces, ainsi que le diagnostic postopératoire de l'anaphylaxie pendant l'anesthésie. De nombreuses recommandations contenues dans ce guide sont basées sur des avis d'experts et des rapports de cas en l'absence de preuves de haute qualité, car l'anaphylaxie est une maladie relativement rare. Ce document vise à aider la prise de décision des anesthésistes en milieu clinique, et ces lignes directrices ne sont pas recommandées aux médecins généralistes.

Commentaire :  Flowchart of the differential diagnosis upon onset of the reaction

Pour le traitement, les experts considèrent que :
Le médicament clé pour le traitement de l'anaphylaxie est l'adrénaline.
La voie et la dose d'adrénaline varient en fonction de la recommandation. Dans ce guide pratique, la voie intraveineuse est considérée par défaut, car la plupart des patients sont placés sous anesthésie, et la voie intraveineuse est donc déjà sécurisée.
Si une voie veineuse ne peut être sécurisée, l'adrénaline doit être administrée par injection intramusculaire (à la dose de 0,3 mg, soit une posologie moindre que la recommandation française de 0,5 mg).

Documents à consulter :
• Gloaguen A and al. Prise en charge de l’anaphylaxie en médecine d’urgence. Recommandations de la Société française de médecine d’urgence (SFMU) en partenariat avec la Société française d’allergologie (SFA) et le Groupe francophone de réanimation et d’urgences pédiatriques (GFRUP), et le soutien de la Société pédiatrique de pneumologie et d’allergologie (SP2A). Ann. Fr. Med. Urgence 2016;6:342-364  .
• Prise en charge d'un choc anaphylactique. Recommandations pour la pratique clinique  . SFAR 2010.
• Choc anaphylactique au bloc opératoire - Grades ≥ II. Aides cognitives en anesthésie réanimation - La SFAR  . Réalisée en 2016 et mise à jour en 2022 par le CAMR.

Central venous catheterization site choice based on anatomical landmark technique: a systematic review and meta-analysis.
Gu Y, Min K, Zhang Q, Chen Z, Feng D, Wei J, Jin X, Zhou H, Song J, Lv X. | J Anesth. 2021 Dec;35(6):801-810
DOI: https://doi.org/10.1007/s00540-021-02976-y
Keywords: Anatomy; Catheterization; Jugular vein; Subclavian vein.

Original Article

Introduction : Internal jugular vein catheterization (IJVC) and subclavian vein catheterization (SCVC) have been the most preferred central venous catheterizations (CVC) clinically. Individual preference and institutional routine dominate the traditional CVC choice; however, it is lack of high-level evidence. We sought to provide better clinical strategy for CVC site choice based on anatomical landmark technique between IJVC and SCVC.

Méthode : We systematically reviewed eligible studies from PubMed, OVID, Cochrane and ClinicalTrials.Gov till February 2020. The primary outcomes were catheterization time and overall success rate, and the secondary outcomes were the first-attempt success rate and the instant mechanical complications. Ethical problems are not applicable.

Résultats : A total of 3378 patients from 7 studies were included in the analyses. Neither difference was found on the catheterization time (SMD 95% CI: -0.095-0.124, p = 0.792), nor any difference on the overall success rate (RR = 1.017, 95% CI: 0.927-1.117, p = 0.721, I2 = 89.6%) between the 2 procedures. However, subgroup analyses showed overall success rate of IJVC was significantly lower than that of SCVC (RR = 0.906, 95% CI: 0.850-0.965, p = 0.002) in adults. The first-attempt success rate of IJVC group was higher in the adults (RR = 1.472, 95% CI: 1.004-2.156, p = 0.047). No significance was detected in arterial injury (RR = 1.137, 95% CI: 0.541-2.387, p = 0.735) and pneumothorax (RR = 0.600, 95% CI: 0.32-1.126, p = 0.112) between the two procedures. Hematoma was significantly more in IJVC group than that in SCVC group (RR = 2.824, 95% CI: 1.181-6.751, p = 0.02).

Conclusion : Compared with IJVC, SCVC shows a higher overall success rate while a lower first-attempt success rate in adults, and has involved with less hematoma.

Conclusion (proposition de traduction) : Comparé au cathétérisme de la veine jugulaire interne, le cathétérisme de la veine sous-clavière présente un taux de réussite global plus élevé, tandis qu'un taux de réussite à la première tentative plus faible chez les adultes, et a impliqué moins d'hématomes.

A two-handed airway maneuver of mandibular advancement and mouth opening in the neutral neck position for immobilization of the cervical spine.
Sawada A, Ochiai G, Yamakage M. | J Anesth. 2021 Dec;35(6):811-817
DOI: https://doi.org/10.1007/s00540-021-02981-1  | Télécharger l'article au format  
Keywords: Mandibular advancement; Mouth opening; Neutral neck position; Two-handed airway maneuver.

Original Article

Introduction : Immobilization of the cervical spine after trauma is recommended as standard care to prevent secondary injury. We tested the hypothesis that a two-handed airway maneuver, consisting of mandibular advancement and mouth opening in the neutral neck position, would minimize changes in the angle of the cervical vertebrae at the C0/4 level and tidal volume in non-obese patients under anesthesia with neuromuscular blockade.

Méthode : Twenty consecutive patients without cervical spine injury undergoing general anesthesia were enrolled and evaluated. The primary variable was change in the angle of the cervical vertebrae at the C0/4 level during mask ventilation using the modified two-handed technique. Secondary variables included changes in the angles of the cervical vertebrae at each level between C0 and C4, anterior movement of the vertebral bodies, change in the angle between the head and neck, change in the pharyngeal airway space, and tidal volume during mask ventilation.

Résultats : The two-handed airway maneuver of mandibular advancement and mouth opening resulted in statistically significant changes in the angle of the cervical spine at the C0/4 level (3.2 ± 3.0 degrees, P < 0.001) and the C3/4 level (1.4 ± 2.2 degrees, P = 0.01). The two-handed airway maneuver provided adequate mask ventilation without anterior movement of the vertebral bodies.

Conclusion : Our study suggests that a two-handed airway maneuver of mandibular advancement and mouth opening in the neutral neck position results in only slight change in the cervical vertebral angle at the C0/4 level in non-obese patients under general anesthesia with neuromuscular blockade.

Conclusion (proposition de traduction) : Notre étude suggère que la maintien du masque facial à deux mains avec subluxation de la mandibulaire et l'ouverture de la bouche dans la position neutre du cou n'entraîne qu'une légère modification de l'angle vertébral cervical au niveau C0/4 chez les patients non obèses sous anesthésie générale curarisés.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Writing Committee Members, Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. | J Cardiovasc Comput Tomogr. 2021 Dec 1:S1934-5925(21)00469-X
DOI: https://doi.org/10.1016/j.jcct.2021.11.009  | Télécharger l'article au format  
Keywords: ACC/AHA Clinical Practice Guidelines; accelerated diagnostic pathway; acute coronary syndrome; angina; biomarkers; cardiac imaging; chest pain; chest pain syndromes; clinical decision pathway; coronary artery disease; myocardial infarction; myocardial injury; myocardial ischemia; noncardiac; noncardiac chest pain; sex differences; shared decision-making; troponins.

PRACTICE GUIDELINES

Introduction : This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

Méthode : A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

Conclusion : Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Conclusion (proposition de traduction) : La douleur thoracique est une cause fréquente de consultation aux urgences aux États-Unis. La « 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain » fournit des recommandations basées sur des preuves contemporaines sur le bilan et l'évaluation de la douleur thoracique. Cette ligne directrice présente une approche fondée sur des preuves pour la stratification du risque et le bilan diagnostique pour l'évaluation de la douleur thoracique. Des considérations de rapport coût-efficacité ont été intégrées aux tests diagnostiques, et il est recommandé de partager la prise de décision avec les patients.

Commentaire :  Messages à retenir pour l'évaluation et le diagnostic de la douleur thoracique

ROX index as a good predictor of high flow nasal cannula failure in COVID-19 patients with acute hypoxemic respiratory failure: A systematic review and meta-analysis.
Prakash J, Bhattacharya PK, Yadav AK, Kumar A, Tudu LC, Prasad K. | J Crit Care. 2021 Dec;66:102-108
DOI: https://doi.org/10.1016/j.jcrc.2021.08.012  | Télécharger l'article au format  
Keywords: Acute hypoxemic respiratory failure; COVID-19; High flow nasal cannula; ROX index.

Research article

Introduction : Prediction of high flow nasal cannula (HFNC) failure in COVID-19 patients with acute hypoxemic respiratory failure (AHRF) may improve clinical management and stratification of patients for optimal treatment. We performed a systematic review and meta-analysis to determine performance of ROX index as a predictor of HFNC failure.

Méthode : Systematic search was performed in electronic databases (PubMed, Google Scholar, Web of Science and Cochrane Library) for articles published till 15 June 2021 investigating ROX index as a predictor for HFNC failure. Quality In Prognosis Studies (QUIPS) tool was used to analyze risk of bias for prognostic factors, by two independent authors.

Résultats : Eight retrospective or prospective cohort studies involving 1301 patients showed a good discriminatory value, summary area under the curve (sAUC) 0.81 (95% CI, 0.77-0.84) with sensitivity of 0.70 (95% CI, 0.59-0.80) and specificity of 0.79 (95% CI, 0.67-0.88) for predicting HNFC failure. The positive and negative likelihood ratio were 3.0 (95% CI, 2.2-5.3) and 0.37 (95% CI, 0.28-0.50) respectively, and was strongly associated with a promising predictive accuracy (Diagnostic odds ratio (DOR) 9, 95% CI, 5-16).

Conclusion : This meta-analysis suggests ROX index has good discriminating power for prediction of HFNC failure in COVID-19 patients with AHRF.

Conclusion (proposition de traduction) : Cette méta-analyse suggère que l'indice ROX a un bon pouvoir discriminant pour la prédiction de l'échec de l'oxygénothérapie nasale à haut débit chez les patients COVID-19 présentant une insuffisance respiratoire hypoxémique aiguë.

Effect of rapid fluid administration on the prognosis of septic shock patients with isolated hyperlactatemia: A prospective multicenter observational study.
Lee H, Choi SH, Kim K, Shin TG, Park YS, Ryoo SM, Suh GJ, Kwon WY, Lim TH, Son D, Kim WY, Ko BS; Korean Shock Society (KoSS) Investigators. | J Crit Care. 2021 Dec;66:154-159
DOI: https://doi.org/10.1016/j.jcrc.2021.07.003
Keywords: Fluid resuscitation; Hyperlactatemia; Mortality; Septic shock.

Research article

Introduction : We aimed to investigate the association between initial fluid resuscitation in septic shock patients with isolated hyperlactatemia and outcomes.

Méthode : This multicenter prospective study was conducted using the data from the Korean Shock Society registry. Patients diagnosed with isolated hyperlactatemia between October 2015 and December 2018 were included and divided into those who received 30 mL/kg of fluid within 3 or 6 h and those who did not receive. The primary outcome was in-hospital mortality; the secondary outcomes were intensive care unit (ICU) admission, length of ICU stay, mechanical ventilation, and renal replacement therapy (RRT).

Résultats : A total of 608 patients were included in our analysis. The administration of 30 mL/kg crystalloid within 3 or 6 h was not significantly associated with in-hospital mortality in multivariable logistic regression analysis ([OR, 0.8; 95% CI, 0.52-1.23, p = 0.31], [OR, 0.96; 95% CI, 0.59-1.57, p = 0.88], respectively). The administration of 30 mL/kg crystalloid within 3-h was not significantly associated with mechanical ventilation and RRT ([OR, 1.19; 95% CI, 0.77-1.84, p = 0.44], [OR, 1.2; 95% CI, 0.7-2.04, p = 0.5], respectively). However, the administration of 30 mL/kg crystalloid within 6 h was associated with higher ICU admission and RRT ([OR, 1.57; 95% CI, 1.07-2.28, p = 0.02], [OR, 2.08; 95% CI, 1.19-3.66, p = 0.01], respectively).

Conclusion : Initial fluid resuscitation of 30 mL/kg within 3 or 6 h was neither associated with an increased or decreased in-hospital mortality in septic shock patients with isolated hyperlactatemia.

Conclusion (proposition de traduction) : Le remplissage vasculaire initiale de 30 mL/kg en 3 ou 6 h n'a été associée ni à une augmentation ni à une diminution de la mortalité hospitalière chez les patients en choc septique avec hyperlactatémie isolée.

Trauma in Obstetrical Patients.
Keneally RJ, Cyr KL, Sherman M, Vincent A, Chu E, Berger JS, Chow JH. | J Emerg Trauma Shock. 2021 Oct-Dec;14(4):216-221
DOI: https://doi.org/10.4103/jets.jets_176_20  | Télécharger l'article au format  
Keywords: Anesthesia; mortality; obstetrics; trauma.

Original Article

Introduction : Pregnant trauma patients are an underdescribed cohort in the medical literature. Noting injury patterns and contributors to mortality may lead to improved care.

Méthode : Female patients between 14 and 49 years of age were identified among entries in the 2017 National Trauma Data Bank. Data points were compared using Chi-square test, Fisher's exact test, Student's t-test, Mann-Whitney rank-sum, or multiple logistic regression as appropriate. P < 0.05 was used to determine the findings of significance.

Résultats : There were 569 pregnant trauma patients identified, which was 0.54% of the 105,507 women identified. Overall, mortality was low among all women and not different between groups (1.2% for pregnant women vs. 2.2% for nonpregnant, P = 0.12). Pregnant women with head injuries had a higher mortality rate than pregnant women without (4.2% vs. 0.47%, P < 0.01). Head injuries (Abbreviated Injury Severity Score [AIS] head >1) were associated with an increased risk for mortality (odds ratio: 3.33, 95% confidence interval: 3.0-3.7, P < 0.01).

Conclusion : There was no increase in mortality for trauma patients who are pregnant when controlling for covariates. Factors such as head injuries, the need for blood, and comorbid diseases appear to have a more significant contribution to mortality. We also report the prevalence of head, cervical spine, and extremity injuries in pregnant trauma patients. Multidisciplinary simulation, jointly crafted protocols, and expanding training in regional anesthesia may be the next steps to improving care for pregnant trauma patients.

Conclusion (proposition de traduction) : Il n'y a pas eu d'augmentation de la mortalité chez les patientes enceintes traumatisées lors du contrôle des covariables. Des facteurs tels que les traumatismes crâniens, le besoin de transfusion et les comorbidités semblent avoir une contribution plus importante à la mortalité. Nous rapportons également la prévalence des blessures à la tête, au rachis cervical et aux extrémités chez les patientes enceintes traumatisées. La simulation multidisciplinaire, les protocoles élaborés conjointement et l'élargissement de la formation en anesthésie loco-régionale pourraient être les prochaines étapes pour améliorer les soins aux patientes enceintes traumatisées.

Treatment Outcomes of Epinephrine for Traumatic Out-of-hospital Cardiac Arrest: A Systematic Review and Meta-analysis.
Wongtanasarasin W, Thepchinda T, Kasirawat C, Saetiao S, Leungvorawat J, Kittivorakanchai N. | J Emerg Trauma Shock. 2021 Oct-Dec;14(4):195-200
DOI: https://doi.org/10.4103/jets.jets_35_21  | Télécharger l'article au format  
Keywords: Epinephrine; out-of-hospital cardiac arrest; survival; trauma.

Original article

Introduction : Despite the standard guidelines stating that giving epinephrine for patients with cardiac arrest is recommended, the clinical benefits of epinephrine for patients with traumatic out-of-hospital cardiac arrest (OHCA) are still limited. This study aims to evaluate the benefits of epinephrine administration in traumatic OHCA patients.

Méthode : We searched four electronic databases up to June 30, 2020, without any language restriction in research sources. Studies comparing epinephrine administration for traumatic OHCA patients were included. Two independent authors performed the selection of relevant studies, data extraction, and assessment of the risk of bias. The primary outcome was inhospital survival rate. Secondary outcomes included prehospital return of spontaneous circulation (ROSC), short-term survival, and favorable neurological outcome. We calculated the odds ratios (ORs) of those outcomes using the Mantel-Haenszel model and assessed the heterogeneity using the I² statistic.

Résultats : Four studies were included. The risk of bias of the included studies was low, except for one study in which the risk of bias was fair. All included studies reported the inhospital survival rate. Epinephrine administration during traumatic OHCA might not demonstrate a benefit for inhospital survival (OR: 0.61, 95% confidence interval [CI]: 0.11-3.37). Epinephrine showed no significant improvement in prehospital ROSC (OR: 4.67, 95% CI: 0.66-32.81). In addition, epinephrine might not increase the chance of short-term survival (OR: 1.41, 95% CI: 0.53-3.79).

Conclusion : The use of epinephrine for traumatic OHCA may not improve either inhospital survival or prehospital ROSC and short-term survival. Epinephrine administration as indicated in standard advanced life support algorithms might not be routinely used in traumatic OHCA.

Conclusion (proposition de traduction) : L'utilisation d'adrénaline dans l'arrêt cardiaque traumatique en dehors de l'hôpital peut ne pas améliorer la survie à l'hôpital ou le retour préhospitalier à une circulation spontanée et la survie à court terme. L'administration d'adrénaline telle qu'indiquée dans les algorithmes standard avancés de réanimation peut ne pas être utilisée en routine dans les cas d'arrêt cardiaque traumatique hors hôpital.

Hydrocortisone, ascorbic acid, and thiamine (HAT) for sepsis and septic shock: a meta-analysis with sequential trial analysis.
Na W, Shen H, Li Y, Qu D. | J Intensive Care. 2021 Dec 18;9(1):75
DOI: https://doi.org/10.1186/s40560-021-00589-x  | Télécharger l'article au format  
Keywords: Ascorbic acid; Hydrocortisone; Meta-analysis; Sepsis; Thiamine.

Research

Introduction : Sepsis is a primary global health threat and costs a lot, requiring effective and affordable treatments. We performed this meta-analysis to explore the treatment of hydrocortisone, ascorbic acid, and thiamine (HAT) in sepsis and septic shock.

Méthode : We searched Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to August 14, 2021. We included randomized controlled trials (RCTs) that evaluated the HAT treatments in sepsis and septic shock. The primary outcome was the change in SOFA score over the 72 h. The second outcomes were the hospital, and 28-/30-day mortality, the duration of vasopressors, PCT clearance, hospital length of stay (LOS), and ICU LOS. We performed a subgroup analysis and a trial sequential analysis (TSA). The Der Simonian-Laird random-effects models were used to report the pooled risk ratios (RR) or mean difference (MD) with confidence intervals (CI).

Résultats : Nine RCTs, enrolling 1427 patients of sepsis and septic shock treated with HAT (717) or only standard care (710), were included. There was a significant difference between the two groups in the change in SOFA score over the first 72 h (MD 0.65, 95% CI 0.30 to 1.00), the duration of vasopressors (MD - 18.16, 95% CI - 25.65 to - 10.68) and the PCT clearance (MD 14.54, 95% CI 0.64 to 28.43). In addition, there was no significant difference in the hospital mortality (RR 1.07, 95% CI 0.85 to 1.34), the 28-/30-day mortality (RR 0.96, 95% CI 0.80 to 1.15), the hospital LOS (MD 0.78, 95% CI - 0.30 to 1.86), and ICU LOS (MD 0.12, 95% CI - 0.53 to 0.78).

Conclusion : The HAT combination improves the SOFA score in the first 72 h and reduces the duration of vasopressors in patients with sepsis. Given the minor mean difference of the change in SOFA score, the mortality benefit has not been observed.

Conclusion (proposition de traduction) : L'association HAT améliore le score SOFA dans les 72 premières heures et réduit la durée d'utilisation des vasopresseurs chez les patients présentant un sepsis. Compte tenu de la différence moyenne mineure de la variation du score SOFA, le bénéfice sur la mortalité n'a pas été observé.

The Impact of Nighttime on First Pass Success During the Emergent Endotracheal Intubation of Critically Ill Patients.
Fein DG, Zhao D, Swartz K, Nauka P, Andrea L, Aboodi M, Shiloh AL, Eisen LA. | J Intensive Care Med. 2021 Dec;36(12):1498-1506
DOI: https://doi.org/10.1177/0885066620965166
Keywords: ICU outcomes; anesthesia; complications; endotracheal intubation; respiratory failure; resuscitation; safety.

Original Research

Introduction : While numerous investigations have described worse outcomes for patients undergoing emergent procedures at night, few studies have investigated the impact of nighttime on the outcomes of emergent endotracheal intubation (EEI). We hypothesized that for patients requiring EEI at night, the outcome of first pass success would be lower as compared to during the day.

Méthode : We performed a retrospective cohort study of all patients admitted to our institution between January 1st, 2016 and July 17st, 2019 who underwent EEI outside of an emergency department or operating room. Nighttime was defined as between 7:00 pm and 6:59 am. The primary outcome was the rate of first pass success. Logistic regression was utilized with adjustment for demographic, morbidity and procedure related covariables.

Résultats : The final examined cohort included 1,674 EEI during the day and 1,229 EEI at night. The unadjusted rate of first pass success was not different between the day and night (77.5% vs. 74.6%, unadjusted odds ratio (OR): 0.85; 95% confidence interval (CI): 0.72, 1.0; P = 0.073 though following adjustment for prespecified covariables the odds of first pass success was lower at night (adjusted OR: 0.83, 95% CI: 0.69, 0.99; P = 0.042. Obesity was found to be an effect modifier on first pass success rate for day vs. night intubations. In obese patients, nighttime intubations had significantly lower odds of first pass success (adjusted OR: 0.71, 95% CI: 0.52, 0.98; P = 0.037).

Conclusion : After adjustment for patient and procedure related factors, we have found that the odds of first pass success is lower at night as compared to the day. This finding was, to some degree, driven by obesity which was found to be a significant effect modifier in this relationship.

Conclusion (proposition de traduction) : Après ajustement pour les facteurs liés au patient et à la procédure, nous avons constaté que les chances de réussite au premier essai étaient plus faibles la nuit que le jour. Cette constatation s’explique, dans une certaine mesure, par l’obésité, qui s’est avérée être un modificateur important de cette relation.

N-Terminal Pro-B-Type Natriuretic Peptide as a Biomarker for the Severity and Outcomes With COVID-19 in a Nationwide Hospitalized Cohort.
O'Donnell C, Ashland MD, Vasti EC, Lu Y, Chang AY, Wang P, Daniels LB, de Lemos JA, Morrow DA, Rodriguez F, O'Brien CG. | J Am Heart Assoc. 2021 Dec 21;10(24):e022913
DOI: https://doi.org/10.1161/jaha.121.022913  | Télécharger l'article au format  
Keywords: COVID‐19; NT‐proBNP; biomarker; critical care; mortality/survival.

ORIGINAL RESEARCH

Introduction : Currently, there is limited research on the prognostic value of NT-proBNP (N-terminal pro-B-type natriuretic peptide) as a biomarker in COVID-19. We proposed the a priori hypothesis that an elevated NT-proBNP concentration at admission is associated with increased in-hospital mortality.

Méthode : In this prospective, observational cohort study of the American Heart Association's COVID-19 Cardiovascular Disease Registry, 4675 patients hospitalized with COVID-19 were divided into normal and elevated NT-proBNP cohorts by standard age-adjusted heart failure thresholds, as well as separated by quintiles

Résultats : Patients with elevated NT-proBNP (n=1344; 28.7%) were older, with more cardiovascular risk factors, and had a significantly higher rate of in-hospital mortality (37% versus 16%; P<0.001) and shorter median time to death (7 versus 9 days; P<0.001) than those with normal values. Analysis by quintile of NT-proBNP revealed a steep graded relationship with mortality (7.1%-40.2%; P<0.001). NT-proBNP was also associated with major adverse cardiac events, intensive care unit admission, intubation, shock, and cardiac arrest (P<0.001 for each). In subgroup analyses, NT-proBNP, but not prior heart failure, was associated with increased risk of in-hospital mortality. Adjusting for cardiovascular risk factors with presenting vital signs, an elevated NT-proBNP was associated with 2-fold higher adjusted odds of death (adjusted odds ratio [OR], 2.23; 95% CI, 1.80-2.76), and the log-transformed NT-proBNP with other biomarkers projected a 21% increased risk of death for each 2-fold increase (adjusted OR, 1.21; 95% CI, 1.08-1.34).

Conclusion : Elevated NT-proBNP levels on admission for COVID-19 are associated with an increased risk of in-hospital mortality and other complications in patients with and without heart failure.

Conclusion (proposition de traduction) : Des niveaux élevés de NT-proBNP à l'admission pour la COVID-19 sont associés à un risque accru de mortalité à l'hôpital et d'autres complications chez les patients avec et sans insuffisance cardiaque.

Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial.
Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F, Gorlicki J, Chouihed T, Goulet H, Montassier E, Dumont M, Lozano Polo L, Le Borgne P, Khellaf M, Bouzid D, Raynal PA, Abdessaied N, Laribi S, Guenezan J, Ganansia O, Bloom B, Miró O, Cachanado M, Simon T. | JAMA. 2021 Dec 7;326(21):2141-2149
DOI: https://doi.org/10.1001/jama.2021.20750
Keywords: Aucun

Original Investigation

Introduction : Uncontrolled studies suggest that pulmonary embolism (PE) can be safely ruled out using the YEARS rule, a diagnostic strategy that uses varying D-dimer thresholds.
Objective: To prospectively validate the safety of a strategy that combines the YEARS rule with the pulmonary embolism rule-out criteria (PERC) rule and an age-adjusted D-dimer threshold.
Design, settings, and participants: A cluster-randomized, crossover, noninferiority trial in 18 emergency departments (EDs) in France and Spain. Patients (N = 1414) who had a low clinical risk of PE not excluded by the PERC rule or a subjective clinical intermediate risk of PE were included from October 2019 to June 2020, and followed up until October 2020.

Méthode : Each center was randomized for the sequence of intervention periods. In the intervention period (726 patients), PE was excluded without chest imaging in patients with no YEARS criteria and a D-dimer level less than 1000 ng/mL and in patients with 1 or more YEARS criteria and a D-dimer level less than the age-adjusted threshold (500 ng/mL if age <50 years or age in years × 10 in patients ≥50 years). In the control period (688 patients), PE was excluded without chest imaging if the D-dimer level was less than the age-adjusted threshold.
Main outcomes and measures: The primary end point was venous thromboembolism (VTE) at 3 months. The noninferiority margin was set at 1.35%. There were 8 secondary end points, including chest imaging, ED length of stay, hospital admission, nonindicated anticoagulation treatment, all-cause death, and all-cause readmission at 3 months.

Résultats : Of the 1414 included patients (mean age, 55 years; 58% female), 1217 (86%) were analyzed in the per-protocol analysis. PE was diagnosed in the ED in 100 patients (7.1%). At 3 months, VTE was diagnosed in 1 patient in the intervention group (0.15% [95% CI, 0.0% to 0.86%]) vs 5 patients in the control group (0.80% [95% CI, 0.26% to 1.86%]) (adjusted difference, -0.64% [1-sided 97.5% CI, -∞ to 0.21%], within the noninferiority margin). Of the 6 analyzed secondary end points, only 2 showed a statistically significant difference in the intervention group compared with the control group: chest imaging (30.4% vs 40.0%; adjusted difference, -8.7% [95% CI, -13.8% to -3.5%]) and ED median length of stay (6 hours [IQR, 4 to 8 hours] vs 6 hours [IQR, 5 to 9 hours]; adjusted difference, -1.6 hours [95% CI, -2.3 to -0.9]).

Conclusion : Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a conventional diagnostic strategy, did not result in an inferior rate of thromboembolic events.

Conclusion (proposition de traduction) : Chez les patients à l'urgence avec suspicion d'EP, l'utilisation de la règle YEARS associée au seuil de D-dimères ajusté selon l'âge chez les patients positifs aux critères d'exclusion de l'embolie pulmonaire, par rapport à une stratégie diagnostique conventionnelle, n'a pas entraîné un taux inférieur de thromboembolie événements.

Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial.
Ospina-Tascón GA, Calderón-Tapia LE, García AF, Zarama V, Gómez-Álvarez F, Álvarez-Saa T, Pardo-Otálvaro S, Bautista-Rincón DF, Vargas MP, Aldana-Díaz JL, Marulanda Á, Gutiérrez A, Varón J, Gómez M, Ochoa ME, Escobar E, Umaña M, Díez J, Tobón GJ, Albornoz LL, Celemín Flórez CA, Ruiz GO, Cáceres EL, Reyes LF, Damiani LP, Cavalcanti AB; HiFLo-Covid Investigators. | JAMA. 2021 Dec 7;326(21):2161-2171
DOI: https://doi.org/10.1001/jama.2021.20714
Keywords: Aucun

Original investigation

Introduction : The effect of high-flow oxygen therapy vs conventional oxygen therapy has not been established in the setting of severe COVID-19.
Objective: To determine the effect of high-flow oxygen therapy through a nasal cannula compared with conventional oxygen therapy on need for endotracheal intubation and clinical recovery in severe COVID-19.
Design, setting, and participants: Randomized, open-label clinical trial conducted in emergency and intensive care units in 3 hospitals in Colombia. A total of 220 adults with respiratory distress and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 200 due to COVID-19 were randomized from August 2020 to January 2021, with last follow-up on February 10, 2021.

Méthode : Patients were randomly assigned to receive high-flow oxygen through a nasal cannula (n = 109) or conventional oxygen therapy (n = 111).
Main outcomes and measures: The co-primary outcomes were need for intubation and time to clinical recovery until day 28 as assessed by a 7-category ordinal scale (range, 1-7, with higher scores indicating a worse condition). Effects of treatments were calculated with a Cox proportional hazards model adjusted for hypoxemia severity, age, and comorbidities.

Résultats : Among 220 randomized patients, 199 were included in the analysis (median age, 60 years; n = 65 women [32.7%]). Intubation occurred in 34 (34.3%) randomized to high-flow oxygen therapy and in 51 (51.0%) randomized to conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). The median time to clinical recovery within 28 days was 11 (IQR, 9-14) days in patients randomized to high-flow oxygen therapy vs 14 (IQR, 11-19) days in those randomized to conventional oxygen therapy (hazard ratio, 1.39; 95% CI, 1.00-1.92; P = .047). Suspected bacterial pneumonia occurred in 13 patients (13.1%) randomized to high-flow oxygen and in 17 (17.0%) of those randomized to conventional oxygen therapy, while bacteremia was detected in 7 (7.1%) vs 11 (11.0%), respectively.

Conclusion : Among patients with severe COVID-19, use of high-flow oxygen through a nasal cannula significantly decreased need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen therapy.

Conclusion (proposition de traduction) : Chez les patients présentant une COVID-19 sévère, l'utilisation d'oxygène à haut débit via une canule nasale a considérablement réduit le besoin d'assistance par ventilation mécanique et le temps de récupération clinique par rapport à l'oxygénothérapie conventionnelle à faible débit.

Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.
Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. | JAMA. 2021 Dec 14;326(22):2268-2276
DOI: https://doi.org/10.1001/jama.2021.20929
Keywords: Aucun

Original contribution

Introduction :  It is unclear whether administration of calcium has a beneficial effect in patients with cardiac arrest.
Objective : To determine whether administration of calcium during out-of-hospital cardiac arrest improves return of spontaneous circulation in adults.
Design, setting, and participants: This double-blind, placebo-controlled randomized clinical trial included 397 adult patients with out-of-hospital cardiac arrest and was conducted in the Central Denmark Region between January 20, 2020, and April 15, 2021. The last 90-day follow-up was on July 15, 2021.

Méthode : The intervention consisted of up to 2 intravenous or intraosseous doses with 5 mmol of calcium chloride (n = 197) or saline (n = 200). The first dose was administered immediately after the first dose of epinephrine.
Main outcomes and measures: The primary outcome was sustained return of spontaneous circulation. The secondary outcomes included survival and a favorable neurological outcome (modified Rankin Scale score of 0-3) at 30 days and 90 days.

Résultats : Based on a planned interim analysis of 383 patients, the steering committee stopped the trial early due to concerns about harm in the calcium group. Of 397 adult patients randomized, 391 were included in the analyses (193 in the calcium group and 198 in the saline group; mean age, 68 [SD, 14] years; 114 [29%] were female). There was no loss to follow-up. There were 37 patients (19%) in the calcium group who had sustained return of spontaneous circulation compared with 53 patients (27%) in the saline group (risk ratio, 0.72 [95% CI, 0.49 to 1.03]; risk difference, -7.6% [95% CI, -16% to 0.8%]; P = .09). At 30 days, 10 patients (5.2%) in the calcium group and 18 patients (9.1%) in the saline group were alive (risk ratio, 0.57 [95% CI, 0.27 to 1.18]; risk difference, -3.9% [95% CI, -9.4% to 1.3%]; P = .17). A favorable neurological outcome at 30 days was observed in 7 patients (3.6%) in the calcium group and in 15 patients (7.6%) in the saline group (risk ratio, 0.48 [95% CI, 0.20 to 1.12]; risk difference, -4.0% [95% CI, -8.9% to 0.7%]; P = .12). Among the patients with calcium values measured who had return of spontaneous circulation, 26 (74%) in the calcium group and 1 (2%) in the saline group had hypercalcemia.

Conclusion : Among adults with out-of-hospital cardiac arrest, treatment with intravenous or intraosseous calcium compared with saline did not significantly improve sustained return of spontaneous circulation. These results do not support the administration of calcium during out-of-hospital cardiac arrest in adults.

Conclusion (proposition de traduction) : Chez les adultes en un arrêt cardiaque en dehors de l'hôpital, le traitement au calcium intraveineux ou intraosseux par rapport à la solution saline n'a pas amélioré de manière significative le retour soutenu de la circulation spontanée. Ces résultats ne sont pas en faveur de l'administration de calcium lors d'un arrêt cardiaque extra-hospitalier chez l'adulte.

Diagnosis and Management of Acute Appendicitis in Adults: A Review.
Moris D, Paulson EK, Pappas TN. | JAMA. 2021 Dec 14;326(22):2299-2311
DOI: https://doi.org/10.1001/jama.2021.20502
Keywords: Aucun

Review

Introduction : Acute appendicitis is the most common abdominal surgical emergency in the world, with an annual incidence of 96.5 to 100 cases per 100 000 adults.

Résultats : The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging. Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever. The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms. Laparoscopic appendectomy remains the most common treatment. However, increasing evidence suggests that broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, successfully treats uncomplicated acute appendicitis in approximately 70% of patients. Specific imaging findings on computed tomography (CT), such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, defined as the conglomeration of feces in the appendiceal lumen, identify patients for whom an antibiotics-first management strategy is more likely to fail. CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach. Therefore, surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy. In unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended, and surgery may be considered if antibiotic treatment fails. In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered.

Conclusion : Acute appendicitis affects 96.5 to 100 people per 100 000 adults per year worldwide. Appendectomy remains first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis.

Conclusion (proposition de traduction) : L'appendicite aiguë touche 96,5 à 100 personnes pour 100 000 adultes par an dans le monde. L'appendicectomie reste le traitement de première intention de l'appendicite aiguë, mais un traitement antibiotique plutôt que chirurgical est approprié chez certains patients atteints d'appendicite non compliquée.

Association of Rivaroxaban vs Apixaban With Major Ischemic or Hemorrhagic Events in Patients With Atrial Fibrillation.
Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. | JAMA. 2021 Dec 21;326(23):2395-2404
DOI: https://doi.org/10.1001/jama.2021.21222
Keywords: Aucun

Original contribution

Introduction : The comparative effectiveness of rivaroxaban and apixaban, the most frequently prescribed oral anticoagulants for ischemic stroke prevention in patients with atrial fibrillation, is uncertain.
Objective : To compare major ischemic and hemorrhagic outcomes in patients with atrial fibrillation treated with rivaroxaban or apixaban.

Méthode : Retrospective cohort study using computerized enrollment and claims files for US Medicare beneficiaries 65 years or older. Between January 1, 2013, and November 30, 2018, a total of 581 451 patients with atrial fibrillation began rivaroxaban or apixaban treatment and were followed up for 4 years, through November 30, 2018.
Exposures : Rivaroxaban (n = 227 572) and apixaban (n = 353 879), either standard or reduced dose.
Main outcomes and measures: The primary outcome was a composite of major ischemic (stroke/systemic embolism) and hemorrhagic (intracerebral hemorrhage/other intracranial bleeding/fatal extracranial bleeding) events. Secondary outcomes were nonfatal extracranial bleeding and total mortality (fatal ischemic/hemorrhagic event or other death during follow-up). Rates, hazard ratios (HRs), and rate differences (RDs) were adjusted for baseline differences in comorbidity with inverse probability of treatment weighting.

Résultats : Study patients (mean age, 77.0 years; 291 966 [50.2%] women; 134 393 [23.1%] receiving reduced dose) had 474 605 person-years of follow-up (median [IQR] of 174 [62-397] days). The adjusted primary outcome rate for rivaroxaban was 16.1 per 1000 person-years vs 13.4 per 1000 person-years for apixaban (RD, 2.7 [95% CI, 1.9-3.5]; HR, 1.18 [95% CI, 1.12-1.24]). The rivaroxaban group had increased risk for both major ischemic events (8.6 vs 7.6 per 1000 person-years; RD, 1.1 [95% CI, 0.5-1.7]; HR, 1.12 [95% CI, 1.04-1.20]) and hemorrhagic events (7.5 vs 5.9 per 1000 person-years; RD, 1.6 [95% CI, 1.1-2.1]; HR, 1.26 [95% CI, 1.16-1.36]), including fatal extracranial bleeding (1.4 vs 1.0 per 1000 person-years; RD, 0.4 [95% CI, 0.2-0.7]; HR, 1.41 [95% CI, 1.18-1.70]). Patients receiving rivaroxaban had increased risk of nonfatal extracranial bleeding (39.7 vs 18.5 per 1000 person-years; RD, 21.1 [95% CI, 20.0-22.3]; HR, 2.07 [95% CI, 1.99-2.15]), fatal ischemic/hemorrhagic events (4.5 vs 3.3 per 1000 person-years; RD, 1.2 [95% CI, 0.8-1.6]; HR, 1.34 [95% CI, 1.21-1.48]), and total mortality (44.2 vs 41.0 per 1000 person-years; RD, 3.1 [95% CI, 1.8-4.5]; HR, 1.06 [95% CI, 1.02-1.09]). The risk of the primary outcome was increased for rivaroxaban in both those receiving the reduced dose (27.4 vs 21.0 per 1000 person-years; RD, 6.4 [95% CI, 4.1-8.7]; HR, 1.28 [95% CI, 1.16-1.40]) and the standard dose (13.2 vs 11.4 per 1000 person-years; RD, 1.8 [95% CI, 1.0-2.6]; HR, 1.13 [95% CI, 1.06-1.21]) groups.

Conclusion : Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.

Conclusion (proposition de traduction) : Parmi les bénéficiaires de Medicare âgés de 65 ans ou plus présentant une fibrillation atriale, le traitement par rivaroxaban par rapport à apixaban a été associé à un risque significativement accru d'événements ischémiques ou hémorragiques majeurs.

Commentaire : Medicare est une assurance maladie réservée aux personnes âgées et aux invalides, aux Etats-Unis.

Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial.
Driver BE, Semler MW, Self WH, Ginde AA, Trent SA, Gandotra S, Smith LM, Page DB, Vonderhaar DJ, West JR, Joffe AM, Mitchell SH, Doerschug KC, Hughes CG, High K, Landsperger JS, Jackson KE, Howell MP, Robison SW, Gaillard JP, Whitson MR, Barnes CM, Latimer AJ, Koppurapu VS, Alvis BD, Russell DW, Gibbs KW, Wang L, Lindsell CJ, Janz DR, Rice TW, Prekker ME, Casey JD; BOUGIE Investigators and the Pragmatic Critical Care Research Group. | JAMA. 2021 Dec 28;326(24):2488-2497
DOI: https://doi.org/10.1001/jama.2021.22002
Keywords: Aucun

Original contribution

Introduction : For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.
Objective: To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.

Méthode : The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.
Interventions: Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).
Main outcomes and measures: The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.

Résultats : Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, -2.6 percentage points [95% CI, -7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, -1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.

Conclusion : Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

Conclusion (proposition de traduction) : Chez les adultes gravement malades bénéficiant d'une intubation endotrachéale, l'utilisation d'un mandrin long béquillé n'a pas augmenté de manière significative l'incidence de réussite de l'intubation au premier essai par rapport à l'utilisation d'une sonde endotrachéale avec mandrin souple malléable.

Vacheron CH, David JS, Piriou V, Friggeri A. | Prat Anesth Rea. 2021 December;25(6):263-268
DOI: https://doi.org/10.1016/j.pratan.2021.10.007
Keywords: Tranexamic acid; Narrative review

Mise au point

Editorial : L'acide tranexamique est une molécule ancienne, synthétisée par un couple japonais dans les années 60. Initialement boudée par la communauté médicale, son utilisation est en plein essor depuis son utilisation dans le polytraumatisé et l'étude CRASH 2 en 2010. Dans cette revue narrative de la littérature, nous reviendrons sur l'utilisation de l'acide tranexamique au cours des hémorragies graves non prévues.

Conclusion (proposition de traduction) : Lors de la première présentation de l’acide tranexamique à un congrès d’obstétrique par Utako Okamoto, à la fin de sa présentation, ses interlocuteurs obstétriciens lui ont demandé de danser plutôt que de porter un intérêt sur cette molécule. Il fallut attendre 2010 pour que la communauté médicale retrouve son importance, avec des preuves de son efficacité se multipliant au cours des années. Avec un médicament au très faible coût, la World Health Organisation a finalement ajouté l’acide tranexamique a sa liste de médicaments essentiels initialement confiné au seul contexte d’hémorragie traumatique. C’est en 2019, 3 ans après le décès de sa créatrice, que l’acide tranexamique fut finalement inscrit a la liste des médicaments essentiels pour les hémorragies du post-partum.

Pediatric Abdominal Pain in Children Presenting to the Emergency Department.
Lee WH, O'Brien S, Skarin D, Cheek JA, Deitch J, Nataraja R, Craig S, Borland ML; PREDICT. | Pediatr Emerg Care. 2021 Dec 1;37(12):593-598
DOI: https://doi.org/10.1097/pec.0000000000001789
Keywords: Aucun

Original Article

Introduction : Undifferentiated abdominal pain is a common pediatric presentation to the emergency department (ED).
Objectives: The objective of this study was to describe the prevalence of clinically significant abdominal pathology (CSAP) including appendicitis, patterns of imaging and pathology tests, and management and outcomes of children with abdominal pain in ED.

Méthode : A prospective multicenter observational cohort pilot study of children under the age of 16 years presenting to 4 Australian EDs with abdominal pain was performed for a 1-month period at each site. The primary outcome was to describe the prevalence of CSAP and appendicitis. Age, sex, length of stay, surgery or interventional procedure, investigations, and analgesia use were recorded.

Résultats : There were 555 presentations with abdominal pain during the study period with a median age of 9 years (interquartile range, 6-12 years). Eighty-two patients (14.8%; 95% confidence interval, 11.8-17.7) had CSAP, of which 41 (7.4%, 5.2-9.6) had appendicitis. Three hundred forty-eight (62.7%, 58.7-66.7) were discharged directly from ED, and 207 (37.3%, 33.2-41.3) were admitted. Two hundred fifty-five (45.9%, 41.8-50.1) had pathology tests, and 173 (31.2%, 27.3-35.1) had imaging tests in ED. Of those contacted for telephone follow-up, 100 (50.5%, 43.5-57.5) of 198 reported ongoing pain after discharge, and 13.1% (8.4-17.8) had missed over a week of school due to abdominal pain.

Conclusion : The prevalence of CSAP and appendicitis in our study was 14.8% (11.8-17.7) and 7.4% (5.2-9.6), respectively. Fewer than half of patients received blood tests, and a third received imaging during their ED attendance. The presentation of abdominal pain conveys a significant health burden on families with time off school and ongoing symptoms of pain.

Conclusion (proposition de traduction) : La prévalence de la pathologie abdominale cliniquement significative et de l'appendicite dans notre étude était de 14,8 % (11,8-17,7) et 7,4 % (5,2-9,6), respectivement. Moins de la moitié des patients ont bénéficié d'un bilan biologique et un tiers ont bénéficié d'une imagerie lors de leur visite aux urgences. La présentation des douleurs abdominales entraîne un coût de santé important pour les familles qui ont des congés scolaires et des symptômes de douleur persistants.

Predictors for Acute Appendicitis in Children.
Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. | Pediatr Emerg Care. 2021 Dec 1;37(12):e962-e968
DOI: https://doi.org/10.1097/pec.0000000000001840
Keywords: Aucun

Original article

Introduction : Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children.

Méthode : The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US.

Résultats : A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology.

Conclusion : There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%.

Conclusion (proposition de traduction) : Lorsque l'appendice est vu à l'échographie mais que le diagnostic d'appendicite est remis en question, l'absence de modification des paramètres inflammatoires, le nombre de globules blancs inférieur à 10 000/μL et un diamètre de l'appendice de 7 mm ou moins devraient diminuer la suspicion d'appendicite.

Use of Intranasal Ketamine in Pediatric Patients in the Emergency Department.
Guthrie AM, Baum RA, Carter C, Dugan A, Jones L, Tackett T, Bailey AM. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1001-e1007
DOI: https://doi.org/10.1097/pec.0000000000001863
Keywords: Aucun

Original article

Introduction : Ketamine is a safe and widely used sedative and analgesic in the pediatric emergency department (ED). The use of intranasal (IN) ketamine in exchange for the administration of intravenous sedatives or analgesics for procedural sedation in pediatric patients is not commonplace. The goal of this study was to evaluate provider perceptions and patient outcomes at varying doses of IN ketamine for anxiolysis, agitation, or analgesia.

Méthode : From January 2018 to May 2018, we performed a prospective survey and chart review of pediatric patients receiving IN ketamine. The primary outcome was to determine provider satisfaction with using IN ketamine. Secondary objectives included comparing outcomes stratified by dose, adverse events, assessing for treatment failure, and ED length of stay (LOS). As a secondary comparison, patients receiving IN ketamine whom otherwise would have required procedural sedation with intravenous sedatives or analgesics were placed into a subgroup. This subgroup of patients was compared with a cohort who received intravenous sedatives or analgesics for procedural sedation during a similar period the preceding year (January 2017 to June 2017).

Résultats : Of the 196 cases, 100% of the providers were comfortable using IN ketamine. The median overall provider satisfaction was 90 out of 100, the perception of patient comfort was 75 out of 100, and perceived patient comfort was maximized when using doses between 3 and 5 mg/kg. There were 15 (7.7%) patients who experienced ketamine treatment failure. Overall, the rate of adverse events was 6%, but were considered minor [nausea (n = 3; 1.5%), dizziness (n = 2; 1%), and drowsiness (n = 2; 1%)]. No patients required respiratory support or intubation. The mean LOS was 237.9 minutes, compared with those who underwent procedural sedation with an LOS of 332.4 minutes (P < 0.001).

Conclusion : This study demonstrates that IN ketamine was able to provide safe and successful analgesia and anxiolysis in pediatric patients in an ED setting. In addition, providers expressed a high degree of satisfaction with using IN ketamine (90 out of 100) in addition to a high degree of patient comfort during the procedure (75 out of 100). Intranasal ketamine provides an alternative to intravenous medication normally requiring more resource-intensive monitoring. Procedural sedations are resource and time intensive activities that increase ED LOS. Intranasal ketamine used for anxiolysis and analgesia offers the benefits of freeing up resources of staff and monitoring while enhancing overall throughput through a pediatric ED.

Conclusion (proposition de traduction) : Cette étude démontre que la kétamine intranasale a pu fournir une analgésie et une anxiolyse sûres et efficaces chez les patients pédiatriques dans un service d'urgence. En outre, les utilisateurs ont exprimé un degré élevé de satisfaction à l'égard de l'utilisation de la kétamine intranasale (90 sur 100) en plus d'un degré élevé de confort du patient pendant la procédure (75 sur 100). La kétamine intranasale offre une alternative aux médicaments intraveineux nécessitant normalement une surveillance plus gourmande en ressources. La sédation procédurale est une activité gourmande en ressources et en temps qui augmentent la durée du séjour aux urgences. La kétamine intranasale utilisée pour l'anxiolyse et l'analgésie offre l'avantage de libérer des ressources en personnel et en surveillance tout en améliorant le débit global dans un service d'urgence pédiatrique.

Reevaluation of FAST (Focused Assessment with Sonography in Trauma) Sensitivity in Pediatric Blunt Abdominal Trauma Patients: Should We Redefine the Qualitative Threshold for Significant Hemoperitoneum?.
Riera A, Hayward H, Torres Silva C, Chen L. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1012-e1019
DOI: https://doi.org/10.1097/pec.0000000000001877
Keywords: Aucun

Original article

Introduction : The utility of the focused assessment with sonography in trauma (FAST) examination in hemodynamically stable pediatric blunt abdominal trauma (BAT) patients is controversial.We report our 3-year experience with FAST performance to detect greater than physiologic amounts of intraperitoneal fluid after BAT.

Méthode : We performed a retrospective chart review of all FAST examinations performed from July 2015 to June 2018 at a level I pediatric trauma center. The main outcome of interest was the performance of a concerning FAST (cFAST) compared with a computed tomography scan diagnosis for greater than physiologic levels of free fluid (FF) and clinical follow-up. A cFAST was defined by the presence of any FF in the upper abdomen or by a moderate to large amount of FF present in the pelvis. The interobserver reliability of cFASTwas assessed with Cohen κ coefficient. Locations of FF were assessed.

Résultats : A total of 448 FAST cases were eligible for review. The median age was 11 years with 64% male. Thirty-one FAST examinations (6.9%) were positive for some amount of FF; 18 (4.0%) were cFASTs. In the cFAST group, 11 patients (61%) were hemodynamically stable. The cFAST had a sensitivity of 89% (95% confidence interval [CI], 65%-99%), specificity of 99% (95% CI, 98%-100%), positive predictive value of 89% (95% CI, 67%-97%), and negative predictive value of 99% (95% CI, 98%-100%). The positive and negative likelihood ratios were 191 (95% CI, 47-769) and 0.11 (95% CI, 0.03-0.41). The κ coefficient for cFASTwas 0.72 with 86% agreement. Free fluid on cFAST cases was observed in the pelvis (78%), right upper quadrant (44%), and left upper quadrant (44%).

Conclusion : In pediatric BAT patients, a cFAST has acceptable sensitivity and remains a highly specific test to rule in greater than physiologic quantities of FF with confidence.

Conclusion (proposition de traduction) : Chez les patients pédiatriques présentant un traumatisme abdominal contondant, l'échographie de type FAST (Focused Assessment with Sonography in Trauma) préoccupant a une sensibilité acceptable et reste un examen hautement spécifique pour déterminer avec confiance des quantités de liquide libre, supérieures à la physiologie.

Microhematuria as an Indicator of Significant Abdominal Injury.
Ohana-Sarna-Cahan L, Levin Y, Gross I, Hassidim A, Yuval JB, Hess A, Bala M, Hashavya S. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1020-e1025
DOI: https://doi.org/10.1097/pec.0000000000001878
Keywords: Aucun

Original article

Introduction : Trauma is one of the leading causes of morbidity and mortality in the pediatric population. In many centers, microhematuria is used as a screening tool for the presence of significant abdominal injury and as an indication for further imaging. Our objective was to evaluate the role of microhematuria by dipstick as an indicator of significant abdominal injury in children.

Méthode : A retrospective review of children aged 0 to 16 years admitted for a motor vehicle accident or a fall from 2007 to 2017 who had urinalyses performed.

Résultats : The charts of 655 children were reviewed. Microhematuria was found in 100 children, of whom 49 (49%), 28 (28%), and 23 (23%) had small, moderate, and large amounts of hematuria, respectively. Of the children who had microhematuria, 41 underwent a computed tomography scan. Positive findings were recorded in 16 (39%) of these patients. There was a clear association between microhematuria as detected by the urine dipstick and a significant finding on the computed tomography scan (P = 0.002). The sensitivity of microhematuria for significant abdominal pathology on imaging was 66.6% and the specificity was 68.3% (positive predictive value, 39%; negative predictive value, 87.1%). Microhematuria was associated with increased length of stay in the hospital (P < 0.001), surgical interventions (P = 0.036), and admission to the pediatric intensive care unit (P < 0.001).

Conclusion : The diagnostic role of dipstick urine analysis in the assessment of intra-abdominal injury has low sensitivity and specificity. Nevertheless, it is still a valuable screening tool for the evaluation of the severity of injury.

Conclusion (proposition de traduction) : Le rôle diagnostique de l'analyse d'urine sur bandelette réactive dans l'évaluation des lésions intra-abdominales a une faible sensibilité et une faible spécificité. Néanmoins, il reste un outil de dépistage précieux pour l'évaluation de la gravité des blessures.

Validation of an Assessment Instrument for Pediatric Basic Life Support.
Binkhorst M, Hogeveen M, Benthem Y, van de Pol EM, van Heijst AFJ, Draaisma JMT. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1057-e1064
DOI: https://doi.org/10.1097/pec.0000000000001899
Keywords: Aucun

Original article

Introduction : To develop a valid and reliable instrument for the assessment of pediatric basic life support (PBLS).

Méthode : An assessment instrument for PBLS was developed, based on 3 existing scoring systems and the European Resuscitation Council PBLS guideline. We tested if experienced PBLS instructors performed better than medical students on a standard PBLS examination on a low-fidelity pediatric manikin (construct validity). To pass the examination, 15 penalty points or less were required. The examinations were videotaped. One researcher assessed all videos once, and approximately half of them twice (intrarater reliability). A second researcher independently assessed part of the videos (interrater reliability). The time needed to assess 1 examination was determined.

Résultats : Face and content validity were established, because PBLS experts reached consensus on the instrument and because the instrument incorporated all items of the European Resuscitation Council algorithm. Of the 157 medical students that were scored, 98 (62.4%) passed the examination. Fourteen PBLS instructors were scored; all passed (100%). Pass rate (62.4% vs 100%) and median penalty points (15 [interquartile range, 10-22.5] vs 7.5 [interquartile range, 1.25-10]) were significantly different between students and instructors (P = 0.005 and <0.001, respectively). Reassessment demonstrated a κ for intrarater reliability of 0.62 (95% confidence interval, 0.45-0.81) (substantial agreement); κ for interrater reliability was 0.51 (95% confidence interval, 0.09-0.93) (moderate agreement). It took approximately 3 minutes to assess 1 videotaped examination.

Conclusion : Our instrument for the (video-based) assessment of PBLS is valid and sufficiently reliable. It is also designed to be practical, time-efficient, and applicable in various settings, including resource limited.

Conclusion (proposition de traduction) : Notre instrument pour l'évaluation (basée sur la vidéo) de la réanimation pédiatrique de base est valide et suffisamment fiable. Il est également conçu pour être pratique, rapide et applicable dans divers contextes, y compris les ressources limitées.

Impact of Ondansetron Prescription on Return Emergency Department Visits Among Children with Acute Gastroenteritis.
McLaren SH, Yim RB, Fleegler EW. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1087-e1092
DOI: https://doi.org/10.1097/pec.0000000000001907
Keywords: Aucun

Original article

Introduction : The objective of this study was to determine if providing ondansetron prescription to children with acute gastroenteritis seen in the emergency department (ED) is associated with reduced unscheduled ED revisits.

Méthode : This was a retrospective comparative cohort study conducted in a tertiary urban pediatric ED. We evaluated otherwise healthy children 6 months to 18 years old who presented to the ED between 2010 and 2015 and were discharged home with acute gastroenteritis diagnosis. Illness severity was determined using dehydration score, emergency severity index, and presenting symptoms. The incidence of unscheduled 72-hour ED revisit among patients discharged home with ondansetron prescription was compared with those without a prescription.

Résultats : Of the 11,785 eligible patients, 35.5% (N = 4,187) of patients were discharged home with ondansetron prescription. After adjustment for emergency severity index, age, insurance source, race, time of index visit registration, intravenous fluid use, and ED-administered ondansetron, there were no differences in the rates of ED revisit (adjusted odds ratio [aOR] = 1.12 [0.92, 1.33]) or admission after ED revisit (aOR = 0.81 [0.51, 1.27]) among children with versus without ondansetron prescription. No difference was found in the proportion of alternative diagnoses among returning patients with versus without ondansetron prescription (aOR = 0.56 [0.20, 1.59]).

Conclusion : There was no association between ondansetron prescription and ED revisit among children seen in the ED with suspected acute gastroenteritis. In the appropriate setting, however, physicians may consider prescribing ondansetron for symptom control in conjunction with careful discharge instructions.

Conclusion (proposition de traduction) : Il n'y avait aucune association entre la prescription d'ondansétron et la reconsultation aux urgences chez les enfants vus aux urgences pour suspicion de gastro-entérite aiguë. Dans le contexte approprié, cependant, les médecins peuvent envisager de prescrire de l'ondansétron pour contrôler les symptômes avec des instructions de sortie prudentes.

Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period.
Pacheco GS, Patanwala AE, Mendelson JS, Sakles JC. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1098-e1103
DOI: https://doi.org/10.1097/pec.0000000000001911
Keywords: Aucun

Original article

Introduction : There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED.

Méthode : This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age.

Résultats : During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]).

Conclusion : In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.

Conclusion (proposition de traduction) : Dans cette étude portant sur des enfants intubés aux urgences pédiatriques, par rapport à la laryngoscopie directe, le CMAC a été associé à un succès accru au premier essai sans événements indésirables, mais pas le GlideScope.

Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis.
Elkhunovich MA, Wang VJ, Pham P, Arpilleda JC, Clingenpeel JM, Mansour K, Riech T, Yen K, Liu DR. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1104-e1109
DOI: https://doi.org/10.1097/pec.0000000000001912
Keywords: Aucun

Original Article

Introduction : The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate.
Objective: The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population.

Méthode : This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status.

Résultats : A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64).

Conclusion : Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

Conclusion (proposition de traduction) : Les nourrissons fébriles âgés de 2 à 12 mois présentant une bronchiolite ont une incidence cliniquement significative d'infection urinaire, ce qui suggère que l'évaluation de l'infection urinaire devrait être envisagée chez ces patients.

Dexamethasone Versus Prednisone or Prednisolone for Acute Pediatric Asthma Exacerbations in the Emergency Department: A Meta-Analysis.
Cai KJ, Su SQ, Wang YG, Zeng YM. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1139-e1144
DOI: https://doi.org/10.1097/pec.0000000000001926
Keywords: Aucun

Original article

Introduction : This study evaluates the efficacy and tolerability of dexamethasone (DEX) as an alternative to prednisone/prednisolone (PRED) for the treatment of pediatric asthma exacerbations in emergency department (ED).

Méthode : Fixed-effects meta-analyses of selected endpoints were performed by using data taken from relevant studies identified by following a priori eligibility criteria after a comprehensive literature search in several electronic databases.

Résultats : Data from 10 studies (3208 pediatric asthma patients [1616 DEX treated and 1592 PRED treated], 4.77 years [95% confidence interval, 3.80-5.56 years], 63% [57.76%-62.68%] males) were used. Risk of vomiting drug was significantly lower in DEX group than in PRED group (risk ratio, 0.29 [0.18-0.48]; P ˂ 0.00001). Emergency department stay between DEX and PRED treated patients was statistically different (0.16 [0.03-0.40] hours; P = 0.02) but may not be clinically meaningful. The number of β-agonist therapies received by DEX- and PRED-treated patients was similar. Treatments with both DEX and PRED were associated with improvement in asthma status assessment scores, and there was no significant difference between the groups. There were also no differences between the groups in hospitalization rate, ED revisit rate, and hospital admission rate after relapse.

Conclusion : Dexamethasone is a suitable alternative to PRED for the treatment of pediatric asthma exacerbation in ED.

Conclusion (proposition de traduction) : La dexaméthasone est une alternative appropriée à la prednisone/prednisolone pour le traitement de l'exacerbation d'asthme au service des urgences pédiatrique.

Validity Analysis on the Findings of Dehydration in 2 to 24-Month-Old Children With Acute Diarrhea.
Vatandas NS, Yurdakok K, Yalcin SS, Celik M. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1227-e1232
DOI: https://doi.org/10.1097/pec.0000000000001980
Keywords: Aucun

Original article

Introduction : The most common cause of diarrheal mortality in children is dehydration. In this study, we aimed to assess the validity (sensitivity and specificity) of history and the clinical and laboratory findings in in the diagnosis of dehydration in children younger than 2 years with acute diarrhea.

Méthode : One hundred twenty-six 2 to 24-month-old children with acute diarrhea, who were admitted to Hacettepe University Ihsan Dogramaci Children's Hospital's Diarrheal Diseases Treatment and Training Unit, were included. The patients were examined on admission for clinical findings of dehydration. Percent weight loss on admission was calculated by using the weight on admission and the weight after the diarrhea resolution and was used as the golden standard for analyzing the validity of clinical and laboratory findings.

Résultats : Compared with the golden standard, dehydration was overestimated in 13% of the cases and underestimated in 7% when using only the World Health Organization criteria. Dehydrated children had higher diarrheal frequency and longer anuria time. Thirst, weakness, sunken fontanelle, sunken eyes, decreased tears, dry mucous membranes, and dry lip were detected in children with 2% or greater of weight loss. The most valid laboratory findings were low serum pH (<7.30), low bicarbonate (<15 mmol/L), and hyperurisemia (>5.8 mg/dL). In multivariate analysis, physical findings, such as thirst, dry mucous membranes, weakness, sunken eyes, hoarse crying, and low pH, were found to be significant for the diagnosis of dehydration.

Conclusion : In children with acute diarrhea, diarrheal frequency and last urination time should be asked, thirst, dry mucous membranes, weakness, sunken eyes, and hoarse crying should be examined.

Conclusion (proposition de traduction) : Chez les enfants souffrant de diarrhée aiguë, la fréquence de la diarrhée et l'heure de la dernière miction doivent être demandées, la soif, les sécheresse des muqueuses, l'asthénie, les yeux enfoncés et les pleurs rauques doivent être examinés.

Seymour Fractures: A Retrospective Review of Infection Rates, Treatment and Timing of Antibiotic Administration.
Rask DMG, Wingfield J, Elrick B, Chen C, Lalka A, Sibbel SE, Scott FA. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1299-e1302
DOI: https://doi.org/10.1097/pec.0000000000002009
Keywords: Aucun

Original article

Introduction : Seymour fractures are important to recognize and treat promptly because injuries may result in growth disturbance, nail deformity, or infection. We hypothesize that the administration of antibiotics within 24 hours of injury will be associated with a decreased rate of infection.

Méthode : Patients younger than 18 years were included if clinical examination and radiographs demonstrated a Seymour fracture. The timing of antibiotic administration and treatment details were reviewed. The presence of superficial infections or radiographic evidence of osteomyelitis was recorded.

Résultats : A total of 52 patients with 54 fracture that had greater than 30 days of follow-up and were included in data analysis. The average age at the time of injury was 10.2 years. Thirty-four (63%) of 54 patients were most commonly injured secondary to a crush type mechanism. The overall infection rate was 27.3% (15/54 fractures). Among the 29 fractures that received antibiotics within 24 hours of injury, 2 infections (6.9%) were noted at final follow-up. Delayed administration of antibiotics beyond 24 hours postinjury was observed in 17 fractures and was associated with an increased infection rate of 76.5% (13/17, P = 0.000).

Conclusion : Early administration of antibiotics within 24 hours of injury is associated with a reduction in the development of infections. Patients with delayed antibiotic administration may be at high risk for early superficial infection or osteomyelitis. This study highlights the importance of early identification and appropriate treatment of Seymour fractures including the prompt administration of antibiotics following injury.

Conclusion (proposition de traduction) : L'administration précoce des antibiotiques dans les 24 heures suivant la blessure est associée à une réduction du développement des infections. Les patients dont l'administration d'antibiotiques est retardée peuvent présenter un risque élevé d'infection superficielle précoce ou d'ostéomyélite. Cette étude souligne l'importance d'une identification précoce et d'un traitement approprié des fractures de type Seymour, y compris l'administration rapide d'antibiotiques après cette blessure.

Commentaire : Les fractures type Seymour sont des fractures juxtaépiphysaires ouvertes, retrouvées habituellement chez l’enfant et l’adolescent. Plus récemment, ce type de fracture a été décrite chez l’adulte (encore moins fréquentes).
Il s’agit le plus souvent de traumatismes directs, écrasement par portes ou portières, chute, choc direct contre un objet lourd. Le plus souvent sont atteints le troisième doigt, puis le pouce, le cinquième, le quatrième et enfin le deuxième. L’aspect clinique est celui d’un doigt en maillet, ouvert.
La radio met toujours en évidence une fracture extraarticulaire de la base de la phalange distale. Il ne s’agit pas toujours d’un décollement épiphysaire, type 1 ou 2 de Salter, mais parfois d’une fracture métaphysaire siégeant 1 à 2 mm distalement par rapport à la plaque de conjugaison.
Le traitement est la réduction puis l'ostéosynthèse chirurgicale et la fixation de l’ongle pour préserver l’ongle (et diminuer le risque d'instabilité du foyer de fracture). Un traitement antibiotique de couverture doit être institué. La sortie du service se fait dès le lendemain. Une attelle en hyperextension peut être proposée avec surveillance rigoureuse chez un patient des plus prudents et ce pour une durée de quatre semaines.


Seymour N. Juxta epiphysal fracture of the terminal phalanx of the finger. J Bone Joint Surg 1966;48B:347–9  .

Pediatric Difficult Airway Response Team Utilization in the Emergency Department: A Case Series.
Kelly GS, Deanehan JK, Dalesio NM. | Pediatr Emerg Care. 2021 Dec 1;37(12):e1462-e1467
DOI: https://doi.org/10.1097/pec.0000000000002073
Keywords: Aucun

Original article

Introduction : A multidisciplinary pediatric difficult airway team was created at our institution to respond to hospital-wide airway emergencies. We report the characteristics, indications, and outcomes of these activations that occur in the pediatric emergency department (PED).

Méthode : Retrospective, single-center cohort study comprised all difficult airway team activations occurring in the PED from the program's inception in 2008 to 2018. Ages of ≤18 years were included. For each case, detailed information was abstracted, including patient factors, PED context and milieu, airway interventions, and airway outcomes.

Résultats : There were 15 difficult airway response team activations in the PED during the study period, or 1.4 activations per year. The most common indications for activation were contaminated airways (n = 7; 47%) and history of difficult intubation (n = 4; 27%). Definitive airway management was successful in all cases, except for a single case where intervention was unnecessary. The most commonly performed definitive airway intervention was direct laryngoscopy (n = 6; 40%). There were no instances of emergency front-of-neck access.

Conclusion : Difficult airways in the PED were uncommon. Most cases were resolved with familiar equipment including direct laryngoscopy, video laryngoscopy, and supraglottic airways.

Conclusion (proposition de traduction) : L'intubation difficile au service des urgences pédiatriques étaient rares. La plupart des cas ont été résolus avec un équipement habituel, notamment la laryngoscopie directe, la vidéolaryngoscopie et les dispositifs supraglottiques.

Prehospital Ketamine Administration for Excited Delirium with Illicit Substance Co-Ingestion and Subsequent Intubation in the Emergency Department.
Solano JJ, Clayton LM, Parks DJ, Polley SE, Hughes PG, Hennekens CH, Shih RD, Alter SM. | Prehosp Disaster Med. 2021 Dec;36(6):697-701
DOI: https://doi.org/10.1017/s1049023x21000935  | Télécharger l'article au format  
Keywords: cocaine; delirium; excited delirium; intratracheal; intubation; ketamine.

Original Research

Introduction : Excited delirium, which has been defined as combativeness, agitation, and altered sensorium, requires immediate treatment in prehospital or emergency department (ED) settings for the safety of both patients and caregivers. Prehospital ketamine use is prevalent, although the evidence on safety and efficacy is limited. Many patients with excited delirium are intoxicated with illicit substances. This investigation explores whether patients treated with prehospital ketamine for excited delirium with concomitant substance intoxication have higher rates of subsequent intubation in the ED compared to those without confirmed substance usage.

Méthode : Over 28 months at two large community hospitals, all medical records were retrospectively searched for all patients age 18 years or greater with prehospital ketamine intramuscular (IM) administration for excited delirium and identified illicit and prescription substance co-ingestions. Trained abstractors collected demographic characteristics, history of present illness (HPI), urine drug screens (UDS), alcohol levels, and noted additional sedative administrations. Substance intoxication was determined by UDS and alcohol positivity or negativity, as well as physician HPI. Patients without toxicological testing or documentation of substance intoxication, or who may have tested positive due to ED sedation, were excluded from relevant analyses. Subsequent ED intubation was the primary pre-specified outcome. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare variables.

Résultats : Among 86 patients given prehospital ketamine IM for excited delirium, baseline characteristics including age, ketamine dose, and body mass index were similar between those who did or did not undergo intubation. Men had higher intubation rates. Patients testing positive for alcohol, amphetamines, barbiturates, benzodiazepines, ecstasy, marijuana, opiates, and synthetic cathinones, both bath salts and flakka, had similar rates of intubation compared to those negative for these substances. Of 27 patients with excited delirium and concomitant cocaine intoxication, nine (33%) were intubated compared with four of 50 (8%) without cocaine intoxication, yielding a 5.75 OR (95%, CI 1.57 to 21.05; P = .009).

Conclusion : Patients treated with ketamine IM for excited delirium with concomitant cocaine intoxication had a statistically significant 5.75-fold increased rate of subsequent intubation in the ED. Amongst other substances, no other trends with intubation were noted, but further study is warranted.

Conclusion (proposition de traduction) : Les patients traités par de la kétamine IM pour un délire agité avec intoxication concomitante à la cocaïne présentaient un taux statistiquement significatif de 5,75 fois plus élevé d'intubation ultérieure aux urgences. Parmi les autres substances, aucune autre tendance à l'intubation n'a été notée, mais une étude plus approfondie est justifiée.

A Change from a Spinal Immobilization to a Spinal Motion Restriction Protocol was Not Associated with an Increase in Disabling Spinal Cord Injuries.
Clemency BM, Natalzia P, Innes J, Guarino S, Welch JV, Haghdel A, Noyes E, Jordan J, Lindstrom HA, Lerner EB. | Prehosp Disaster Med. 2021 Dec;36(6):708-712
DOI: https://doi.org/10.1017/s1049023x21001187
Keywords: backboard; significant disability; spinal immobilization; spinal motion restriction; spine injury.

Original research

Introduction : Over the past decade, Emergency Medical Service (EMS) systems decreased backboard use as they transition from spinal immobilization (SI) protocols to spinal motion restriction (SMR) protocols. Since this change, no study has examined its effect on the neurologic outcomes of patients with spine injuries.
Objectives: The object of this study is to determine if a state-wide protocol change from an SI to an SMR protocol had an effect on the incidence of disabling spinal cord injuries.

Méthode : This was a retrospective review of patients in a single Level I trauma center before and after a change in spinal injury protocols. A two-step review of the record was used to classify spinal cord injuries as disabling or not disabling. A binary logistic regression was used to determine the effects of protocol, gender, age, level of injury, and mechanism of injury (MOI) on the incidence of significant disability from a spinal cord injury.

Résultats : A total of 549 patients in the SI period and 623 patients in the SMR period were included in the analysis. In the logistic regression, the change from an SI protocol to an SMR protocol did not demonstrate a significant effect on the incidence of disabling spinal injuries (OR: 0.78; 95% CI, 0.44 - 1.36).

Conclusion : This study did not demonstrate an increase in disabling spinal cord injuries after a shift from an SI protocol to an SMR protocol. This finding, in addition to existing literature, supports the introduction of SMR protocols and the decreased use of the backboard.

Conclusion (proposition de traduction) : Cette étude n'a pas démontré d'augmentation des lésions invalidantes de la moelle épinière après le passage d'un protocole d'immobilisation de la colonne vertébrale à un protocole de restriction des mouvements de la colonne vertébrale. Cette découverte, en plus de la littérature existante, soutient l'introduction de protocoles de restriction des mouvements de la colonne vertébrale et la diminution de l'utilisation du plan dur.

Commentaire : Restriction des mouvements spinaux (RMS) = limiter au maximum les mouvements spinaux, sans utilisation d’outil mécanique, autre que le collier cervical (Spinal Motion Restriction, en anglais [SMR]) pendant le transport du patient. La planche dorsale et le KED ne servant qu'à l'évacuation/extraction.
Pour les patients de plus de 8 ans, c'est notamment l'abandon du plan dur au profit du brancard avec matelas et collier cervical et l'indication de ne pas bouger, avec utilisation d'un matelas à dépression, si nécessaire.

Improved Out-of-Hospital Cardiac Arrest Survival with a Comprehensive Dispatcher-Assisted CPR Program in a Developing Emergency Care System.
Pek PP, Lim JYY, Leong BS, Mao DR, Chia MY, Cheah SO, Gan HN, Ng YY, Tham LP, Arulanandam S, Shahidah N, Lin X, Ho AFW, Ong MEH. | Prehosp Emerg Care.. 2021 Nov-Dec;25(6):802-811
DOI: https://doi.org/10.1080/10903127.2020.1846824
Keywords: bystander CPR; cardiopulmonary resuscitation; dispatcher-assisted CPR; out-of-hospital cardiac arrest; telephone CPR.

Article

Introduction : Out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Studies have demonstrated improved survival with early bystander cardiopulmonary resuscitation (BCPR). This study evaluated the impact of a dispatcher-assisted CPR (DA-CPR) program on BCPR rate and outcomes of OHCA in a developing emergency medical services (EMS) system setting.

Méthode : Data were extracted from the national cardiac arrest registry. A before-after analysis was performed between OHCA cases with cardiac etiology conveyed by EMS from April 2010-June 2012 (pre-intervention) and July 2012-December 2015 (post-intervention). Primary outcomes were survival-to-discharge/30 days post-arrest and favorable cerebral performance (Glasgow-Pittsburgh cerebral performance categories 1 and 2).

Résultats : 6365 OHCA cases were analyzed with 2129 in the pre-intervention and 4236 in the post-intervention group. In the post-intervention group, there was an increase in BCPR rates from 24.8% to 53.8% (p < 0.001), adjusted OR 3.67 (aOR; 95%CI: 3.26-4.13). OHCA outcomes also improved with survival-to-discharge rates increasing from 3.0%-4.5% (p < 0.01), aOR 2.10 (95%CI: 1.40-3.17) and favorable cerebral performance increasing from 1.6% to 2.7% (p < 0.05), aOR 2.82 (95%CI: 1.65-4.82). In patients with initial shockable rhythm, BCPR without dispatcher assistance was associated with significantly higher odds of survival-to-discharge (aOR 1.67, 95%CI: 1.06-2.64) and favorable cerebral performance (aOR 2.32, 95%CI: 1.26-4.27) compared to no BCPR.

Conclusion : Our study showed that a simplified DA-CPR program can be successfully implemented in a developing EMS system and can contribute to higher BCPR rate and in turn, improve OHCA survival. Future studies can examine bystanders' characteristics and quality of the CPR performed to understand their impact on survival.

Conclusion (proposition de traduction) : Notre étude a montré qu'un programme simplifié de réanimation cardio-pulmonaire assistée par un répartiteur peut être mis en œuvre avec succès dans un système de services médicaux d'urgence en développement et peut contribuer à un taux de réanimation cardio-pulmonaire plus élevé et, à son tour, améliorer la survie à l'arrêt cardiaque hors de l'hôpital. De futures études pourront examiner les caractéristiques des témoins et la qualité de la réanimation cardiorespiratoire effectuée pour comprendre leur impact sur la survie.

Safety of mechanical and manual chest compressions in cardiac arrest patients: A systematic review and meta-analysis.
Gao Y, Sun T, Yuan D, Liang H, Wan Y, Yuan B, Zhu C, Li Y, Yu Y.. | Resuscitation. 2021 Dec;169:124-135
DOI: https://doi.org/10.1016/j.resuscitation.2021.10.028  | Télécharger l'article au format  
Keywords: Cardiac arrest; Injury; Manual chest compressions; Mechanical chest compressions.

Reviews

Introduction : Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients.

Méthode : Two investigators separately screened the articles of EMBASE, PubMed, and Cochrane Central databases. Cohort studies and randomized clinical trials (RCTs) that evaluated the safety of mechanical (LUCAS or AutoPulse) and manual chest compressions in cardiac arrest patients were included. A meta-analysis was performed using a random effects model to calculate the pooled odds ratios (ORs) and their 95% confidence intervals (CIs). The primary outcome was the rate of overall compression-induced injuries. The secondary outcomes included the incidence of life-threatening injuries, skeletal fractures, visceral injuries, and other soft tissue injuries.

Résultats : The meta-analysis included 11 trials involving 2,818 patients. A significantly higher rate of overall compression-induced injuries was found for mechanical compressions than manual compressions (OR, 1.29; 95% CI, 1.19-1.41), while there was no significant difference between the two groups in respect of the rate of life-threatening injuries. Furthermore, both modalities shared similar incidences of sternal fractures, vertebral fractures, lung, spleen, and kidney injuries. However, compared to mechanical compressions, manual compressions were shown to present a reduced risk of posterior rib fractures, and heart and liver lesions.

Conclusion : The findings suggested that manual compressions could decrease the risk of compression-induced injuries compared to mechanical compressions in cardiac arrest patients. Interestingly, mechanical compressions have not increased the risk of life-threatening injuries, whereas additional high-quality RCTs are needed to further verify the safety of mechanical chest devices.

Conclusion (proposition de traduction) : Les résultats suggèrent que les compressions manuelles pourraient réduire le risque de blessures induites par la compression par rapport aux compressions mécaniques chez les patients en arrêt cardiaque. Fait intéressant, les compressions mécaniques n'ont pas augmenté le risque de blessures potentiellement mortelles, alors que des essai contrôlé randomisé supplémentaires de haute qualité sont nécessaires pour vérifier davantage la sécurité des dispositifs thoraciques mécaniques.

Pre-charging the defibrillator before rhythm analysis reduces hands-off time in patients with out-of-hospital cardiac arrest with shockable rhythm.
Iversen BN, Meilandt C, Væggemose U, Terkelsen CJ, Kirkegaard H, Fjølner J. | Resuscitation. 2021 Dec;169:23-30
DOI: https://doi.org/10.1016/j.resuscitation.2021.09.037  | Télécharger l'article au format  
Keywords: Advanced life support; Cardiac arrest; Cardiopulmonary resuscitation; Defibrillation; Pre-charging; Shockable rhythm.

Clinical Paper

Introduction : To evaluate the effect of pre-charging the defibrillator before rhythm analysis on hands-off time in patients suffering from out-of-hospital cardiac arrest with shockable rhythm.

Méthode : Pre-charging was implemented in the Emergency Medical Service in the Central Denmark Region in June 2018. Training consisted of hands-on simulation scenarios, e-learning material, and written instructions. Data were extracted from the Danish Cardiac Arrest Registry for a 14-month period spanning the implementation of pre-charging. Patients having received at least one shock were included. Transthoracic impedance data were analysed. We recorded hands-off time and peri-shock pauses for all defibrillation procedures and the total hands-off fraction for all cardiac arrests.

Résultats : Impedance and outcome data were available for 178 patients. 523 defibrillation procedures were analysed. The pre-charge method was associated with shorter median hands-off time per defibrillation procedure (7.6 (IQR 5.8-9.9) vs. 12.6 (IQR 10-16.4) seconds, p < 0.001) but longer pre-shock pause (4 (IQR 2.7-6.1) vs 1.7 (IQR 1.2-3) seconds, p < 0.001) when compared to the current guideline-recommended defibrillation method. The total hands-off fraction per cardiac arrest was reduced after implementation of the pre-charge method (16.5% vs. 20.4%, p = 0.003). No increase in shocks to non-shockable rhythms or personnel was registered. Patients who received only pre-charge defibrillations had an increased odds ratio of return of spontaneous circulation (aOR 2.91; 95%CI 1.09-7.8, p = 0.03).

Conclusion : Pre-charging the defibrillator reduced hands-off time during defibrillation procedures, reduces the total hands-off fraction and may be associated with increased return of spontaneous circulation in out-of-hospital cardiac arrest with shockable rhythm.

Conclusion (proposition de traduction) : La pré-charge du défibrillateur réduit le temps de non-intervention pendant les procédures de défibrillation, réduit la fraction totale de non-intervention et peut être associée à un retour accru à une circulation spontanée en cas d'arrêt cardiaque extra-hospitalier avec rythme choquable.

Change in out-of-hospital 12-lead ECG diagnostic classification following resuscitation from cardiac arrest.
Aufderheide TP, Engel TW 2nd, Saleh HO, Gutterman DD, Weston BW, Pepe PE, Baker JE, Labinski J, Debaty G, Tang L, Szabo A, Kalra R, Yannopoulos D, Colella MR. | Resuscitation. 2021 Dec;169:45-52
DOI: https://doi.org/10.1016/j.resuscitation.2021.10.012
Keywords: 12-lead electrocardiogram; Acute myocardial infarction; Cardiac arrest; Emergency medical services; Out-of-hospital; Resuscitation.

Clinical paper

Introduction : We evaluated the incidence of change in serial 12-lead electrocardiogram (ECG) diagnostic classifications in patients resuscitated from out-of-hospital (OH) cardiac arrest (OHCA) comparing OH to emergency department (ED) ECGs.

Méthode : This retrospective case series included: 1) adults (≥ 18 years old), 2) resuscitated from OHCA, 3) ≥ 1 OH and 1 ED ECG/patient, and 4) emergency medical services (EMS) transport to the study hospital. OH and ED ECGs were classified as: 1) STEMI (ST-segment Elevation Myocardial Infarction), 2) Ischemic, and 3) Non-ischemic. Two ED physicians and one cardiologist independently classified all ECGs, then generated a consensus opinion classification for each ECG based on American Heart Association's 2018 Expert Consensus criteria. The most ischemic OH ECG classification was compared with the last ED ECG classification.

Résultats : From 7/27/12 to 7/18/19, 176 patients were entered with a mean age of 61.2 ± 16.6 years; 102/176 (58%) were male. Overall, 504 OH and ED 12-lead ECGs were acquired (2.9 ECGs/patient). ECG classification inter-rater reliability kappa score was 0.63 ± 0.02 (substantial agreement). Overall, 86/176 (49%) changed ECG classification from the OH to ED setting; 69/86 (80%) of these ECGs changed from more to less ischemic classifications. Of 49 OH STEMI ECG classifications, 33/49 (67%) changed to a less ischemic (non-STEMI) ED ECG classification.

Conclusion : Change in 12-lead ECG classification from OH to ED setting in patients resuscitated from OHCA was common (49%). The OH STEMI classification changed to a less ischemic (non-STEMI) ED classification in 67% of cases.

Conclusion (proposition de traduction) : Le changement du classement diagnostic de l'ECG 12 dérivations de l'extérieur de l'hôpital au service des urgences chez les patients réanimés après un arrêt cardiaque en dehors de l'hôpital était courant (49 %). La classification des infarctus du myocarde avec élévation du segment ST en dehors de l'hôpital a été remplacée par une classification des services d'urgence moins ischémique (infarctus du myocarde sans élévation du segment ST) dans 67 % des cas.

Commentaire : Les ECG ont été classés comme :
1) STEMI (infarctus du myocarde avec élévation du segment ST) ;
2) ischémique ;
3) non ischémique.

Effectiveness of near-infrared spectroscopy-guided continuous chest compression resuscitation without rhythm check in patients with out-of-hospital cardiac arrest: The prospective multicenter TripleCPR 16 study.
Takegawa R, Taniuchi S, Ohnishi M, Muroya T, Hayakawa K, Tachino J, Hirose T, Nakao S, Muratsu A, Sakai T, Hayashida K, Shintani A, Becker LB, Shimazu T, Shiozaki T. | Resuscitation. 2021 Dec;169:146-153
DOI: https://doi.org/10.1016/j.resuscitation.2021.09.006  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Cerebral oximetry; Continuous chest compression; Heart arrest; Near-infrared spectroscopy; Regional cerebral oxygen saturation; Return of spontaneous circulation; Timing of rhythm check.

Clinical paper

Introduction : The proportion of adult patients with return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) remains unchanged since 2012. A better resuscitation strategy is needed. This study evaluated the effectiveness of a regional cerebral oxygen saturation (rSO₂)-guided resuscitation protocol without rhythm check based on our previous study.

Méthode : Because defibrillation is the definitive therapy that should be performed without delay for shockable rhythm, the study subjects were OHCA patients with non-shockable rhythm on hospital arrival at three emergency departments. They were divided into three groups based on their baseline rSO₂ value (%): ≥50, ≥40 to <50, or <40. Continuous chest compression without rhythm checks was performed for 16 minutes or until a maximum increase in rSO₂ of 10%, 20%, or 35% was achieved in each group, respectively. This intervention cohort was compared with a historical control cohort regarding the probability of ROSC using inverse probability of treatment weighting (IPTW) with propensity score.

Résultats : The control and intervention cohorts respectively included 86 and 225 patients. The rate of ROSC was not significantly different between the groups (adjusted OR 0.91 [95% CI, 0.64-1.29], P = 0.60), but no serious adverse events occurred. Sensitivity analyses 1 and 2 showed a significant difference or positive tendency for higher probability of ROSC (adjusted OR 1.63 [95% CI, 1.22-2.17], P < 0.001) (adjusted OR 1.25 [95% CI, 0.95-1.63], P = 0.11).

Conclusion : This trial suggested that a new cardiopulmonary resuscitation protocol with different rhythm check timing could be created using the rSO₂ value.

Conclusion (proposition de traduction) : Cet essai suggére qu'un nouveau protocole de réanimation cardiopulmonaire avec un temps différé pour la vérification du rythme pourrait être créé en utilisant la valeur de rSO₂ (saturation en oxygène des tissus cérébraux ou oxymétrie régionale cérébrale).

Pulse oximetry waveform: A non-invasive physiological predictor for the return of spontaneous circulation in cardiac arrest patients ---- A multicenter, prospective observational study.
Xu J, Li C, Tang H, Tan D, Fu Y, Zong L, Jing D, Ding B, Cao Y, Lu Z, Tian Y, Chai Y, Meng Y, Wang Z, Zheng YA, Zhao X, Zhang X, Liang L, Zeng Z, Li Y, Walline JH, Song PP, Zheng L, Sun F, Shao S, Sun M, Huang M, Zeng R, Zhang S, Yang X, Yao D, Yu M, Liao H, Xiong Y, Zheng K, Qin Y, An Y, Liu Y, Chen K, Zhu H, Yu X, Du B. | Resuscitation. 2021 Dec;169:189-197
DOI: https://doi.org/10.1016/j.resuscitation.2021.09.032
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Oximetry; Plethysmography; Return of spontaneous circulation.

Clinical paper

Introduction : This study aimed to investigate the predictive value of pulse oximetry plethysmography (POP) for the return of spontaneous circulation (ROSC) in cardiac arrest (CA) patients.

Méthode : This was a multicenter, observational, prospective cohort study of patients hospitalized with cardiac arrest at 14 teaching hospitals cross China from December 2013 through November 2014. The study endpoint was ROSC, defined as the restoration of a palpable pulse and an autonomous cardiac rhythm lasting for at least 20 minutes after the completion or cessation of CPR.

Résultats : 150 out-of-hospital cardiac arrest (OHCA) patients and 291 in-hospital cardiac arrest (IHCA) patients were enrolled prospectively. ROSC was achieved in 20 (13.3%) and 64 (22.0%) patients in these cohorts, respectively. In patients with complete end-tidal carbon dioxide (ETCO₂) and POP data, patients with ROSC had significantly higher levels of POP area under the curve (AUCp), wave amplitude (Amp) and ETCO₂ level during CPR than those without ROSC (all p < 0.05). Pairwise comparison of receiver operating characteristic (ROC) curve analysis indicated no significant difference was observed between ETCO₂ and Amp (p = 0.204) or AUCp (p = 0.588) during the first two minutes of resuscitation.

Conclusion : POP may be a novel and effective method for predicting ROSC during resuscitation, with a prognostic value similar to ETCO₂ at early stage.

Conclusion (proposition de traduction) : La pléthysmographie par oxymétrie de pouls peut être une méthode nouvelle et efficace pour prédire le retour de la circulation spontanée pendant la réanimation, avec une valeur pronostique similaire à l'ETCO₂ à un stade précoce.

Intraosseous fluid resuscitation causes systemic fat emboli in a porcine hemorrhagic shock model.
Kristiansen S, Storm B, Dahle D, Domaas Josefsen T, Dybwik K, Nilsen BA, Waage-Nielsen E. | Scand J Trauma Resusc Emerg Med. 2021 Dec 20;29(1):172
DOI: https://doi.org/10.1186/s13049-021-00986-z  | Télécharger l'article au format  
Keywords: Coronary fat embolism; Fat embolism; Fat embolism syndrome; Intraosseous cannulation; Open chest conditions; Systemic embolization.

Original research

Introduction : Intraosseous cannulation can be life-saving when intravenous access cannot be readily achieved. However, it has been shown that the procedure may cause fat emboli to the lungs and brain. Fat embolization may cause serious respiratory failure and fat embolism syndrome. We investigated whether intraosseous fluid resuscitation in pigs in hemorrhagic shock caused pulmonary or systemic embolization to the heart, brain, or kidneys and if this was enhanced by open chest conditions.

Méthode : We induced hemorrhagic shock in anesthetized pigs followed by fluid-resuscitation through bilaterally placed tibial (hind leg) intraosseous cannulas. The fluid-resuscitation was limited to intraosseous or i.v. fluid therapy, and did not involve cardiopulmonary resuscitation or other interventions. A subgroup underwent median sternotomy with pericardiectomy and pleurotomy before hemorrhagic shock was induced. We used invasive hemodynamic and respiratory monitoring including Swan Ganz pulmonary artery catheter and transesophageal echocardiography and obtained biopsies from the lungs, heart, brain, and left kidney postmortem.

Résultats : All pigs exposed to intraosseous infusion had pulmonary fat emboli in postmortem biopsies. Additionally, seven of twenty-one pigs had coronary fat emboli. None of the pigs with open chest had fat emboli in postmortem lung, heart, or kidney biopsies. During intraosseous fluid-resuscitation, three pigs developed significant ST-elevations on ECG; all of these animals had coronary fat emboli on postmortem biopsies.

Conclusion : Systemic fat embolism occurred in the form of coronary fat emboli in a third of the animals who underwent intraosseous fluid resuscitation. Open chest conditions did not increase the incidence of systemic fat embolization.

Conclusion (proposition de traduction) : L'embolie graisseuse systémique s'est produite sous la forme d'emboles graisseux coronaires chez un tiers des animaux ayant subi une réanimation par remplissage intra-osseux. La sternotomie n'a pas augmenté l'incidence de l'embolie graisseuse systémique.

Comparison of Clinical Outcomes with Initial Norepinephrine or Epinephrine for Hemodynamic Support After Return of Spontaneous Circulation.
Weiss A, Dang C, Mabrey D, Stanton M, Feih J, Rein L, Feldman R. | Shock. 2021 Dec 1;56(6):988-993
DOI: https://doi.org/10.1097/shk.0000000000001830
Keywords: Aucun

Clinical Science Aspects

Introduction : The optimal vasoactive agent for management of patients with return of spontaneous circulation (ROSC) after cardiac arrest has not yet been identified. The Advanced Cardiac Life Support guidelines recommend initiation of either norepinephrine (NE), epinephrine (EPI), or dopamine (DA) to maintain adequate hemodynamics after ROSC is achieved. The goal of this study is to retrospectively assess the impact of initial vasopressor agent on incidence rate of rearrest, death, or need for additional vasopressor in post-cardiac arrest emergency department (ED) patients.

Méthode : A retrospective review of electronic medical records was conducted at a tertiary care, academic medical center over a 32-month period. Inclusion criteria were any patient who received vasopressors in the ED after achieving ROSC from out-of-hospital cardiac arrest, or in ED cardiac arrest. The incidence of the primary outcome was assessed during care within the ED, at 6 h regardless of location (early resuscitation period), and throughout the entire hospitalization. Secondary outcomes included incidence of tachyarrhythmia while on vasopressor, type of additional therapy needed for refractory shock, and functional status at discharge as determined by discharge location (discharged home without assistance, or discharged to long-term care facility, subacute rehabilitation, or assisted living).

Résultats : A total of 93 patients were included for analysis; 45 received NE, 42 EPI, and six DA. Due to small sample size, DA was excluded from reporting post hoc. Significantly more EPI patients met the primary outcome of refractory hypotension, rearrest, or death in the emergency department (EPI 21/42, 50% vs. NE 10/45, 22.2%; P = 0.008). The incidence was no longer significantly different during the early resuscitation period of 6 h (EPI 30/42, 71.4% vs. NE 25/45, 55.6%; P = 0.182), or during the entire hospitalization (EPI 40/42, 95.2% vs. NE 36/45, 80.0%; P = 0.051). Notably, the EPI group had higher rates of rearrest prior to vasopressor initiation, potentially signaling more severe illness despite other prognostic variables being similarly distributed. In an adjusted regression model, which included adjustment for rearrest prior to vasopressor initiation, the odds of reaching the primary outcome in the ED were 3.94 [95%CI 1.38-12.2] (P = 0.013) times higher in the EPI group compared to NE treated patients. No difference in tachyarrhythmia or functional status at discharge was detected between groups.

Conclusion : These data suggest prospective study of initial vasopressors used for hemodynamic support after ROSC may be warranted. Rates of intra-emergency department refractory shock, rearrest, or death were higher among epinephrine treated patients compared to norepinephrine treated patients in this population. However, inability to control for potential confounding variables in retrospective studies limits the findings. These results are hypothesis generating and further study is warranted.

Conclusion (proposition de traduction) : Ces données suggèrent qu'une étude prospective sur les inotropes prescrits initialement dans le maintien de l'état hémodynamique après RACS peut être justifiée. Les taux de choc réfractaire, de nouvel arrêt cardiaque ou de décès au service des urgences étaient plus élevés chez les patients traités par l'adrénaline que chez les patients traités par la noradrénaline dans cette population. Cependant, l'incapacité de contrôler les variables confusionnelles potentielles dans les études rétrospectives limite les résultats. Ces résultats sont générateurs d'hypothèses et une étude plus approfondie est justifiée.

Impact of COVID-19 Infection on the Outcome of Patients With Ischemic Stroke.
Martí-Fàbregas J, Guisado-Alonso D, Delgado-Mederos R and al.; COVICTUS Collaborators. | Stroke. 2021 Dec;52(12):3908-3917
DOI: https://doi.org/10.1161/strokeaha.121.034883  | Télécharger l'article au format  
Keywords: cerebrovascular disease; coronavirus; pandemics; prognosis; reperfusion; stroke; thrombectomy.

CLINICAL AND POPULATION SCIENCES

Introduction : We evaluated whether stroke severity, functional outcome, and mortality are different in patients with ischemic stroke with or without coronavirus disease 2019 (COVID-19) infection.

Méthode : A prospective, observational, multicentre cohort study in Catalonia, Spain. Recruitment was consecutive from mid-March to mid-May 2020. Patients had an acute ischemic stroke within 48 hours and a previous modified Rankin Scale (mRS) score of 0 to 3. We collected demographic data, vascular risk factors, prior mRS score, National Institutes of Health Stroke Scale score, rate of reperfusion therapies, logistics, and metrics. Primary end point was functional outcome at 3 months. Favourable outcome was defined depending on the previous mRS score. Secondary outcome was mortality at 3 months. We performed mRS shift and multivariable analyses.

Résultats : We evaluated 701 patients (mean age 72.3±13.3 years, 60.5% men) and 91 (13%) had COVID-19 infection. Median baseline National Institutes of Health Stroke Scale score was higher in patients with COVID-19 compared with patients without COVID-19 (8 [3–18] versus 6 [2–14], P=0.049). Proportion of patients with a favourable functional outcome was 33.7% in the COVID-19 and 47% in the non-COVID-19 group. However, after a multivariable logistic regression analysis, COVID-19 infection did not increase the probability of unfavourable functional outcome. Mortality rate was 39.3% among patients with COVID-19 and 16.1% in the non-COVID-19 group. In the multivariable logistic regression analysis, COVID-19 infection was a risk factor for mortality (hazard ratio, 3.14 [95% CI, 2.10–4.71]; P<0.001).

Conclusion : Patients with ischemic stroke and COVID-19 infection have more severe strokes and a higher mortality than patients with stroke without COVID-19 infection. However, functional outcome is comparable in both groups.

Conclusion (proposition de traduction) : Les patients ayant subi un AVC ischémique et une infection à la COVID-19 ont des AVC plus graves et une mortalité plus élevée que les patients ayant subi un AVC sans infection à la COVID-19. Cependant, le résultat fonctionnel est comparable dans les deux groupes.

Early versus delayed administration of intravenous magnesium sulfate for pediatric asthma.
DeLaroche AM, Mowbray FI, Bohsaghcheghazel M, Zalewski K, Obudzinski K. | Am J Emerg Med. 2021 Dec;50:36-40
DOI: https://doi.org/10.1016/j.ajem.2021.07.003
Keywords: Asthma; Magnesium sulfate; Pediatrics.

Research article

Introduction : This study aims to describe and examine the factors associated with the early administration of intravenous magnesium sulfate (IV Mg) in children presenting to the pediatric emergency department (ED) for an asthma exacerbation.

Méthode : Retrospective cohort study of children aged 5-11 years who received IV Mg in the pediatric ED between September 1, 2018 and August 31, 2019 for management of an asthma exacerbation. Primary outcome was administration of IV Mg in ≤60 min from ED triage ('early administration'). Comparison of clinical management and therapies in children who received early versus delayed IV Mg and the factors associated with early administration of IV Mg were examined.

Résultats : Early (n = 90; 31.6%) IV Mg was associated with more timely bronchodilators (47 versus 68 min; p ≤ 0.001) and systemic corticosteroids (36 versus 46.5 min; p ≤ 0.001). There was no difference between the two cohorts in returns to the ED within 72 h (1.1% versus 2.1%; p = .99) or readmissions within 1 week one week (2.2% versus 0.5%; p = .2). Hypoxia (aOR = 3.76; 95% CI = 2.02-7.1), respiratory rate (aOR = 1.04; 95% CI = 1.02-1.07), retractions (aOR = 2.21; 95% CI = 1.25-3.94), and prior hospital use for asthma-related complaints (aOR = 2.1; 95% CI = 1.16-3.84) were significantly associated with early IV Mg.

Conclusion : Early administration of IV Mg was associated with more timely delivery of first-line asthma therapies, was safe, and improved ED throughput without increasing return ED visits or hospitalizations for asthma.

Conclusion (proposition de traduction) : L’administration précoce de Mg IV a été associée à l’administration plus rapide des traitements de première intention contre l’asthme, s’est avérée sécuritaire et a amélioré le débit des urgences sans augmenter le nombre de visites supplémentaires aux urgences ou d’hospitalisations pour l’asthme.

Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers.
Rimbaldo KM, Fauteux-Lamarre E, Babl FE, Kollias C, Hopper SM. | Am J Emerg Med. 2021 Dec;50:59-65
DOI: https://doi.org/10.1016/j.ajem.2021.06.073
Keywords: Forearm fracture; Fracture morphology; Fracture treatment; Pediatric.

Research article

Introduction : Forearm fractures are common pediatric injuries. Most displaced or angulated fractures can be managed via closed reduction in the operating room or in the Emergency Department (ED). Previous research has shown that emergency physicians can successfully perform closed reduction within ED; however, the fracture morphology amendable to ED physician reduction is unclear. The aim of this study is to detail the fracture characteristics associated with successful reduction by ED physicians.

Méthode : We conducted a retrospective study of children (aged <18 years) presenting to the ED of a tertiary care children's hospital (annual census 90,000) between January 2018 and December 2018 with closed distal and midshaft forearm fractures requiring reduction. Data collected included patient demographics, fracture morphology, management, and complications. Successful ED physician reduction was based on predefined criteria. Orthopedic referrals included those patients sent directly to the operating room, closed reductions performed by orthopedic trainees within the ED, and patients requiring orthopedic consultation after failed ED reduction.

Résultats : A total of 340 patients with forearm fractures were included in the study. ED clinicians attempted to reduce 274 (80.6%) of these fractures and were successful in 256/274 (93.4%) cases. Of the 84 orthopedic referrals, 18 were after failed ED clinician attempt, and 66 were ab initio managed by orthopedics (37 in the operating room and 29 in ED). Compared to the fractures with successful ED reduction (n = 256), factors associated with orthopedic referral (n = 84) included: increasing age, midshaft location, higher degree of angulation, and completely displaced fractures. Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians. There were no difference in complication rates between the two groups.

Conclusion : In this series, fractures most amenable to reduction by ED clinicians include distal greenstick fractures, whereas midshaft and completely displaced fractures are more likely to need treatment by orthopedics.

Conclusion (proposition de traduction) : Dans cette série, les fractures les plus susceptibles d'être réduites par les urgentistes comprennent les fractures distales en bois vert, tandis que les fractures médianes et complètement déplacées sont plus susceptibles de nécessiter un traitement orthopédique.

Admission SpO₂ and ROX index predict outcome in patients with COVID-19.
Mukhtar A, Rady A, Hasanin A, Lotfy A, El Adawy A, Hussein A, El-Hefnawy I, Hassan M, Mostafa H. | Am J Emerg Med. 2021 Dec;50:106-110
DOI: https://doi.org/10.1016/j.ajem.2021.07.049  | Télécharger l'article au format  
Keywords: COVID-19; Mechanical ventilatory support; Peripheral oxygen saturation; ROX index.

Research article

Introduction : This study aimed to evaluate the accuracy of pulse oximetry-derived oxygen saturation (SpO₂) on room air, determined at hospital admission, as a predictor for the need for mechanical ventilatory support in patients with Coronavirus Disease-2019 (COVID-19).

Méthode : In this retrospective observational study, demographic and clinical details of the patients were obtained during ICU admission. SpO2 and respiratory rate (RR) on room air were determined within the first 6 h of hospital admission. As all measurements were obtained on room air, we calculated the simplified respiratory rate‑oxygenation (ROX) index by dividing the SpO₂ by the RR. Based on the use of any assistance of mechanical ventilator (invasive or noninvasive), patients were divided into mechanical ventilation (MV) group and oxygen therapy group. The accuracy of the SpO₂, CT score, and ROX index to predict the need to MV were determined using the Area under receiver operating curve (AUC).

Résultats : We included 72 critically ill patients who tested COVID-19-positive. SpO₂ on the room air could predict any MV requirement (AUC [95% confidence interval]: 0.9 [0.8-0.96], sensitivity: 70%, specificity 100%, cut-off value ≤78%, P < 0.001). Within the MV group, the use of noninvasive ventilation (NIV) was successful in 37 (74%) patients, whereas 13 patients (26%) required endotracheal intubation. The cut-off ROX value for predicting early NIV failure was ≤1.4, with a sensitivity of 85%, a specificity of 86%, and an AUC of 0.86 (95% confidence interval of 0.73-0.94, P < 0.0001).

Conclusion : A baseline SpO₂ ≤78% is an excellent predictor of MV requirement with a positive predictive value of 100%. Moreover, the ROX index measured within the first 6 h of hospital admission is a good indicator of early NIV failure.

Conclusion (proposition de traduction) : Une SpO₂ initiale ≤ 78 % (en air ambiant) est un excellent critère prédictif des besoins en ventilation mécanique avec une valeur prédictive positive de 100 %. De plus, l'indice ROX (≤ 1,4) mesuré dans les 6 premières heures d'hospitalisation est un bon indicateur d'échec précoce de la ventilation non invasive.

A comparative study of dexmedetomidine and propofol to prevent recovery agitation in adults undergoing procedural sedation with ketamine: A randomized double-blind clinical trial.
Azizkhani R, Kouhestani S, Heydari F, Majidinejad S. | Am J Emerg Med. 2021 Dec;50:167-172
DOI: https://doi.org/10.1016/j.ajem.2021.07.059
Keywords: Dexmedetomidine; Ketamine; Procedural sedation; Propofol; Recovery agitation.

Research article

Introduction : The present study was designed to evaluate the effect of dexmedetomidine and propofol on ketamine-induced recovery agitation in adults when used as co-administration with ketamine.

Méthode : In this prospective, randomized, and double-blind clinical trial, 93 patients aged 18 years or older who were candidates for painful procedures in the emergency department (ED) were enrolled and assigned into three equal groups to receive either ketadex (dexmedetomidine 0.7 μg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg) or ketamine alone (1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between groups.

Résultats : There were no significant differences in demographic characteristics, procedures, pain scores, pre-sedation agitation, and duration of procedure between the three groups. The incidence of recovery agitation was 26% in the Ketadex group, 29% in the Ketofol group, and 58% in the Ketamine group. The difference in incidence of recovery agitation between Ketadex group and Ketamine group was 32% (95% confidence interval (CI), 9 to 56]) and between Ketofol group and Ketamine group was 29% (95% CI, 6 to 53). The severe agitation was significantly higher in Ketamine group, with a difference between Ketamine and Ketadex group of 19% (95% CI, 6 to 33), and a difference between Ketamine and Ketofol group of 16% (95% CI, 1 to 31).

Conclusion : In this study, a combination of ketamine-dexmedetomidine and ketamine-propofol reduced the incidence and severity of ketamine-induced recovery agitation in adults undergoing procedural sedation in the ED.

Conclusion (proposition de traduction) : Dans cette étude, la combinaison de kétamine-dexmédétomidine et de kétamine-propofol a réduit l'incidence et la gravité de l'agitation lors de la phase de récupération induite par la kétamine chez les adultes bénéficiant d'une sédation procédurale aux urgences.

Adverse events after prehospital nitroglycerin administration in a nationwide registry analysis.
Popp LM, Lowell LM, Ashburn NP, Stopyra JP. | Am J Emerg Med. 2021 Dec;50:196-201
DOI: https://doi.org/10.1016/j.ajem.2021.08.006
Keywords: Adverse reaction; Chest pain; Emergency medical services (EMS); Hypotension.

Research article

Introduction : Nitroglycerin (NTG) is a vasodilator used in the prehospital setting with chest pain patients. Potential adverse effects include hypotension, bradycardia or tachycardia, and mental status change. However, it is unclear which factors, if any, are associated with patients having an adverse event after receiving NTG. The objective of this study was to determine demographic and clinical factors associated with adverse events after prehospital NTG administration.

Méthode : The ESO Data Collaborative (Austin, TX), containing records from 1322 EMS agencies, was queried for 911 encounters where NTG was administered to patients ≥18 years old by EMS. Adverse event outcomes were defined as a new systolic blood pressure (SBP) < 90, heart rate (HR) < 50 or > 120, mean arterial pressure (MAP) < 65, or change in mental status following NTG administration. Descriptive statistics and logistic regression models adjusting for age, sex, race, ethnicity, intravenous (IV) access, and initial vital signs were used to assess for adverse event-related factors.

Résultats : Among 80,760 encounters, the mean age was 61 (IQR 50-72), with 52% males, 71% white race, and 7% Hispanic ethnicity. Adverse events occurred in 7% of encounters. Adverse events were found to be less common among Black patients (OR = 0.74, 95%CI:0.69-0.80). IV access obtained prior to NTG administration was associated with fewer adverse events (OR = 0.92, 95%CI:0.85-0.99). Increasing age (OR = 1.02, 95%CI:1.01-1.02) and HR (OR = 1.03, 95%CI:1.02-1.03) were associated with increased odds of adverse events while SBP (OR = 0.99, 95%CI:0.98-0.99) was inversely associated.

Conclusion : Adverse events following prehospital NTG administration were rare, especially in patients with an SBP > 110 and a HR < 100, and less frequent in those with existing IV access. Demographics were not found to be clinically significant.

Conclusion (proposition de traduction) : Les événements indésirables suite à l'administration préhospitalière de nitroglycérine étaient rares, en particulier chez les patients avec une PAS > 110 mmHg et une FC < 100 bpm, et moins fréquents chez ceux qui avaient déjà un accès veineux. Les données démographiques ne se sont pas avérées cliniquement significatives.

Passive antipyretic therapy is not as effective as invasive hypothermia for maintaining normothermia after cardiac arrest.
Alnabelsi TS, Faulkner SP, Cook M, Freeman K, Shelton J, Paranzino M, Nerusu S, Smyth SS, Gupta VA. | Am J Emerg Med. 2021 Dec;50:202-206
DOI: https://doi.org/10.1016/j.ajem.2021.06.069
Keywords: Antipyretics; Cardiac arrest; Hypothermia; Target temperature management.

Research article

Introduction : Targeted temperature management is a class I indication in comatose patients after a cardiac arrest. While the literature has primarily focused on innovative methods to achieve target temperatures, pharmacologic therapy has received little attention. We sought to examine whether pharmacologic therapy using antipyretics is effective in maintaining normothermia in post cardiac arrest patients.

Méthode : Patients ≥18 years who were resuscitated after an in-hospital or out-of-hospital cardiac arrest and admitted at our institution from January 2012 to September 2015 were retrospectively included. Patients were divided into groups based on the method of temperature control that was utilized. The primary outcome was temperature control <38 °C during the first 48 h after the cardiac arrest.

Résultats : 671 patients were identified in Group 1 (no hypothermia), 647 in Group 2 (antipyretics), 44 in Group 3 (invasive hypothermia), and 51 in Group 4 (invasive hypothermia and antipyretics). Mean patient age was 59 (SD ±15.7) years with 40.6% being female. Using Group 1 as the control arm, 57.7% of patients maintained target temperature with antipyretics alone (p < 0.001), compared to 69.3% in the control group and 82.1% in the combined hypothermia groups 3&4 (p = 0.01). Patients receiving both invasive hypothermia and antipyretics (Group 4), had the greatest mean temperature decrease of 5.2 °C.

Conclusion : Among patients undergoing targeted temperature management, relying solely on as needed use of antipyretics is not sufficient to maintain temperatures <38 °C. However, antipyretics could be used as an initial strategy if given regularly and/or in conjunction with more aggressive cooling techniques.

Conclusion (proposition de traduction) : Chez les patients soumis à une gestion ciblée de la température, compter uniquement sur l'utilisation au besoin d'antipyrétiques n'est pas suffisant pour maintenir une température inférieure à 38° C. Cependant, les antipyrétiques peuvent être utilisés comme stratégie initiale s'ils sont administrés régulièrement et/ou en conjonction avec des techniques de refroidissement plus agressives.

Hypertonic versus isotonic crystalloid infusion for cerebral perfusion pressure in a porcine experimental cardiac arrest model.
Kim KH, Hong KJ, Shin SD, Song KJ, Ro YS, Jeong J, Kim TH, Park JH, Lim H, Kang HJ. | Am J Emerg Med. 2021 Dec;50:224-231
DOI: https://doi.org/10.1016/j.ajem.2021.08.014
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Cerebral perfusion pressure; Hypertonic crystalloid; Isotonic crystalloid.

Research article

Introduction : The effect of intravenous (IV) fluid administration type on cerebral perfusion pressure (CePP) during cardiopulmonary resuscitation (CPR) is controversial. The purpose of this study was to evaluate the association between IV fluid type and CePP in a porcine cardiac arrest model.

Méthode : We randomly assigned 12 pigs to the hypertonic crystalloid, isotonic crystalloid and no-fluid groups. After 4 min of untreated ventricular fibrillation (VF), chest compression was conducted for 2 cycles (CC only). Chest compression with IV fluid infusion (CC + IV) was followed for 2 cycles. Advanced life support, including defibrillation and epinephrine, was added for 8 cycles (ALS phase). Mean arterial pressure (MAP), intracranial pressure (ICP) and CePP were measured. A paired t-test was used to measure the mean difference in CePP.

Résultats : Twelve pigs underwent the experiment. The hypertonic crystalloid group showed higher CePP values than those demonstrated by the isotonic crystalloid group from ALS cycles 2 to 8. The MAP values in the hypertonic group were higher than those in the isotonic group starting at ALS cycle 2. The ICP values in the hypertonic group were lower than those in the isotonic group starting at ALS cycle 4. From ALS cycles 2 to 8, the reduction in the mean difference in the isotonic group was larger than that in the other groups.

Conclusion : In a VF cardiac arrest porcine study, the hypertonic crystalloid group showed higher CePP values by maintaining higher MAP values and lower ICP values than those of the isotonic crystalloid group.

Conclusion (proposition de traduction) : Dans cette étude porcine sur la fibrillation ventriculaire et l'arrêt cardiaque, le groupe cristalloïde hypertonique a montré des valeurs de pression de perfusion cérébrale plus élevées en maintenant des valeurs de PAM plus élevées et des valeurs de pression intracrânienne plus faibles que celles du groupe cristalloïde isotonique.

Factors associated with poor prognosis in patients with atrial fibrillation: An emergency department perspective the EMERG-AF study.
Varona M, Coll-Vinent B, Martín A, Carbajosa J, Sánchez J, Tamargo J, Cancio M, Sánchez S, Del Arco C, Ríos J, Fernández-Simón A, Ormaetxe JM, Suero C; EMERG-AF investigators (Appendix 1). | Am J Emerg Med. 2021 Dec;50:270-277
DOI: https://doi.org/10.1016/j.ajem.2021.07.055
Keywords: Atrial fibrillation; Clinical factors; Emergency department; Prognosis.

Research article

Introduction : We sought to identify the factors associated with a worse prognosis in Emergency Department (ED) patients with atrial fibrillation (AF), crucial information to guide management decisions.

Méthode : This is a secondary analysis of a prospective, multicenter, observational cohort of consecutive AF patients attended in 62 EDs in Spain. Clinical variables were collected on enrollment. Follow-up was performed at 30 days and one year. The primary composite outcome was all-cause mortality, major bleeding and/or stroke at one year. Secondary outcomes were each of these components considered separately, plus one-year cardiovascular mortality and the composite outcome at 30 days.

Résultats : We analyzed 1107 patients. The primary outcome occurred in 209 patients (18.9%), one-year all-cause mortality in 151 (13.6%), major bleeding in 47 (4.2%), and stroke in 31 (2.8%). Disability (HR 2.064, 95% CI 1.478-2.882), previous known AF (HR 1.829, 95% CI 1.096-3.051), long duration of the AF episode (HR 1.849, 95% CI 1.052-3.252) and renal failure (HR 2.073, 95% CI 1.433-2.999) were independently associated with the primary outcome, whereas anticoagulation at discharge was inversely associated (HR 0.576, 95% CI 0.415-0.801). Disability was associated with mortality, cardiovascular mortality, and the composite at 30 days, and renal failure with mortality and major bleeding.

Conclusion : Comorbidities like renal failure, long AF duration and disability were related to adverse outcomes and should be decisive to guide management decisions in ED patients with AF. Anticoagulation had a positive impact on prognosis and should be the mainstay of therapy in AF patients attended in ED.

Conclusion (proposition de traduction) : Les comorbidités telles que l'insuffisance rénale, la durée prolongée de la FA et l'invalidité étaient liées à des résultats indésirables et devraient être décisives pour guider les décisions de prise en charge chez les patients atteints de FA. L'anticoagulation a eu un impact positif sur le pronostic et devrait être le pilier du traitement chez les patients atteints de FA traités aux urgences.

Initial fluid resuscitation (30 mL/kg) in patients with septic shock: More or less?.
Wang HL, Shao J, Liu WL, Wu F, Chen HB, Zheng RQ, Chen QH. | Am J Emerg Med. 2021 Dec;50:309-315
DOI: https://doi.org/10.1016/j.ajem.2021.08.016
Keywords: Initial fluid resuscitation; Mortality; Septic shock.

Research article

Introduction : The 2018 Surviving Sepsis Campaign (SSC) recommends rapid administration of 30 mL/kg crystalloid fluids for hypotension or lactate ≥4 mmol/L in patients with septic shock; however, there is limited evidence to support this recommendation. The purpose of this study was to examine the relationship between initial fluid resuscitation doses and prognosis in patients with septic shock.

Méthode : This was a multicenter prospective observational study of adult patients with septic shock who were admitted to four intensive care units (ICUs) in a total of three Jiangsu Province teaching hospitals over a 3-year span from May 8, 2018, to June 15, 2021. Each enrolled patients with septic shock was categorized into the low-volume (below 20 mL/kg fluid), medium-volume (20-30 mL/kg fluid) or high-volume (above 30 mL/kg fluid) fluid group according to the initial infusion dose given for fluid resuscitation. Various demographic attributes and other variables were collected from medical records. Logistic regression and Kaplan-Meier curve analysis were used to determine the relationship between initial fluid resuscitation doses and patient outcomes.

Résultats : A total of 302 patients who presented to the ICU were diagnosed with septic shock. The 28-day mortality was highest in the high-volume group (48.3%) and lowest in the medium-volume group (26.3%, P < 0.05). Patients who completed 30 mL/kg initial fluid resuscitation in the first 1-2 h had the lowest 28-day mortality rate (22.8%, P < 0.05). Logistic regression showed that a medium initial fluid volume dose was an independent protective factor, with the odds ratio (OR) indicating significantly decreased mortality (OR, 0.507; 95% confidence interval, 0.310-0.828; P = 0.007; P < 0.05). A Kaplan-Meier curve stratified by initial fluid resuscitation dose was constructed for the probability of 28-day mortality. The medium-volume fluid group showed a significantly lower 28-day mortality rate than the high-volume group or the low-volume group (log-rank test, P = 0.0016).

Conclusion : In septic shock patients, an initial fluid resuscitation rate of 20-30 mL/kg within the first hour may be associated with reduced 28-day mortality; however, this result needs to be confirmed by further high-quality randomized controlled clinical trials.

Conclusion (proposition de traduction) : Chez les patients en choc septique, un taux initial de remplissage de 20 à 30 ml/kg dans la première heure peut être associé à une réduction de la mortalité à 28 jours ; cependant, ce résultat doit être confirmé par d'autres essais cliniques contrôlés randomisés de haute qualité.

Predictors of seizure recurrence in emergency department pediatric patients with first-onset afebrile seizure: A retrospective observational study.
Woo S, Nah S, Kim M, Moon J, Han S. | Am J Emerg Med. 2021 Dec;50:316-321
DOI: https://doi.org/10.1016/j.ajem.2021.08.031
Keywords: Acidosis; Age of onset; Epilepsy; Hyperglycemia; Recurrence; Seizure.

Research article

Introduction : The primary goals of emergency department (ED) clinicians when dealing with a pediatric patient experiencing a seizure are to control the seizure and prevent seizure-related complications. After stabilizing the patient, the clinician should determine whether the patient is likely to have recurrent seizures that may need treatment such as antiepileptic drugs (AEDs). The early identification of pediatric seizure patients at high risk for recurrence can be of great help in consulting with their parents. This study aimed to identify predictors of seizure recurrence in pediatric patients who visited the ED for first-onset afebrile seizure.

Méthode : This retrospective study was conducted with pediatric patients aged 1 month to 18 years who visited our ED for afebrile seizure from January 2016 to March 2020. Children with a known seizure disorder, known underlying genetic or metabolic disorder, or acute trauma history, and those lost to follow-up were excluded. Multivariable logistic regression analysis was performed to identify factors associated with seizure recurrence.

Résultats : A total of 253 pediatric patients were included in the study. Seizure recurrence was observed in 117 patients (46.3%). From the multivariable logistic regression analysis, older age at onset (11-15 years, odds ratio [OR] 5.781, p = 0.001; 16-18 years, OR 6.223, p = 0.002), a longer seizure duration (1-5 min, OR 3.043, p = 0.002; 6-10 min, OR 5.629, p = 0.002; >10 min, OR 8.882, p = 0.002), blood pH under 7.2 (OR 8.308, p = 0.015), and a glucose level over 144 mg/dL (OR 6.408, p = 0.030) were significantly associated with seizure recurrence. The area under the receiver operating characteristic curve for the multivariable logistic regression analysis was 0.774.

Conclusion : Age at onset ≥11 years, a longer seizure duration, acidosis, and hyperglycemia were predictors of seizure recurrence in children who had experienced first-onset afebrile seizure.

Conclusion (proposition de traduction) : L'âge de la premièrere crise ≥ 11 ans, une durée des crises plus longue, une acidose et une hyperglycémie étaient des facteurs prédictifs de récidive des crises chez les enfants qui avaient subi une première crise apyrétique.

Physical activity and quality of cardiopulmonary resuscitation: A secondary analysis of the MANI-CPR trial.
Ippolito M, Cortegiani A, Ferraro OE, Borrelli P, Contri E, Burkart R, Baldi E; MANI-CPR Investigators. | Am J Emerg Med. 2021 Dec;50:330-334
DOI: https://doi.org/10.1016/j.ajem.2021.08.039
Keywords: Une RCP de qualité correcte peut ne pas nécessiter un niveau d'activité physique de base élevé pour être effectuée par un secouriste non professionnel.

Research article

Introduction : The association between the level of physical activity and quality of cardio-pulmonary resuscitation (CPR) performed by laypeople is unclear. The aim of this study was to evaluate the associations between physical activity level and laypeople performance during an eight-minute scenario of CPR.

Méthode : This study was a secondary analysis of the MANI-CPR Trial. The entire cohort of participants was grouped based on the level of physical activity assessed using the International Physical Activity Questionnaire (IPAQ) into a "low-moderate" level group and a "high" level group. Descriptive statistics were used for unadjusted analysis and multivariate logistic and linear regression models were also performed.

Résultats : A total of 492 participants who reached the score of "Advanced CPR performer" at the 1-min final test monitored by Laerdal Resusci Anne QCPR were included in this analysis; 224 with a low-moderate level and 268 with a high level of physical activity. A statistically significant difference was found for the outcome of percentage of compressions with adequate depth (low-moderate group: 87.8% [41·4%-99·3%], high group: 97% [63·2%-100%]; P = 0·003). No associations remained significant after controlling for biometric characteristics of the participants, compression protocols and sex.

Conclusion (proposition de traduction) : Adequate quality CPR may not need high baseline level of physical activity to be performed by a lay rescuer.

Commentaire : CPR; OHCA; Physical activity.

The high impulse, palm lift technique for chest compression: Prospective, experimental, pilot study.
Wołoszyn P, Baumberg I, Baker D. | Am J Emerg Med. 2021 Dec;50:345-351
DOI: https://doi.org/10.1016/j.ajem.2021.08.030
Keywords: BLS; Cardiac arrest; Chest compression technique; EtCO2 measurement; High impulse palm lifting.

Research article

Introduction : The classic technique of high quality chest compression (HQCC) during cardiopulmonary resuscitation (CPR) is based on the International Liaison Committee on Resuscitation (ILCOR) guidelines which specify that the rescuer's hands should maintain constant contact with the chest surface but should not lean upon it, in order to provide full chest recoil. Since end-tidal CO2 (EtCO2) values have been shown to be a reliable indicator of CPR quality, we examined a method where classic HQCC was modified by a high impulse and palm lifting (HIPL) technique which merged rapid forceful compression with disconnection of the rescuer's palm from the patient's sternum during the recoil phase. The object of the study was to detect any differences in HIPL EtCO2 values in comparison with those from classic HQCC.

Méthode : We report a prospective pilot study in which we compared EtCO2 readings achieved during 2 min of classic HQCC technique with readings after implementing 2 min of the HIPL technique during out-of-hospital CPR, provided by medical emergency response teams for cases of cardiac arrest.

Résultats : EtCO2 values obtained from16 cases who received HQCC followed by HIPL compressions showed a significant difference (p = 0.037) between the two techniques. Mean ± SD EtCO2 values after 2 min of each technique were: HQCC: 18 ± 9 mmHg; HIPL: 27 ± 11 mmHg; followed by a further 2 min of HQCC: 19 ± 11 mmHg. Linear regression showed that the differences in EtCO2 were associated with non - significant changes in ventilation rate (p = 0.493) and chest compression rate (p = 0.889).

Conclusion : The results obtained suggest that modifying HQCC with the HIPL technique led to a significant increase in EtCO2 values in comparison with classic HQCC, indicating an improvement in circulation during CPR. We think that these encouraging early results warrant a larger multi - centre study of HIPL.

Conclusion (proposition de traduction) : Les résultats obtenus suggèrent que la modification de la compression thoracique de haute qualité avec la technique "en relevant le talon de la main et à haute fréquence" a entraîné une augmentation significative des valeurs d'EtCO₂ par rapport à la compression thoracique classique de haute qualité, indiquant une amélioration de la circulation pendant la RCP. Nous pensons que ces premiers résultats encourageants justifient une étude multicentrique plus large sur la technique qui consiste à relever le talon de la main et un massage cardiaque à haute fréquence.

Commentaire :  Description du protocole d'étude avec chaque étape présentée sur l'axe temporel de la RCP. De plus, les tendances des niveaux des valeurs d'EtCO₂ (cas n° 15) et les données des impressions d'écran du moniteur montrent comment les formes d'onde des compressions/décompressions thoraciques ont changé en fonction de chacune des techniques appliquées (cas n° 7). Pour une meilleure visualisation des différences entre la fin de la phase de décompression dans les deux techniques, la configuration de la paume est indiquée dans chaque cas. Au cours d'une séquence d'étude de 6 minutes, la ventilation a été assurée au moyen d'un Ballon Autoremplisseur à Valve Unidirectionnelle par la même personne en maintenant constant le taux de ventilation chez chaque patient ainsi qu'un débit constant d'O₂ de 15 l/min. Le moment de l'administration du médicament, la vérification du rythme et les défibrillations n'ont pas été modifiés dans le protocole de recherche et sont restés conformes aux recommandations de l'ILCOR.

Evaluation of prehospital hydroxocobalamin use in the setting of smoke inhalation.
Cumpston KL, Rodriguez V, Nguyen T, MacLasco A, Zin C, Rose SR, Ferguson J, Wills BK. | Am J Emerg Med. 2021 Dec;50:365-368
DOI: https://doi.org/10.1016/j.ajem.2021.08.056
Keywords: Cyanide; Emergency medical services; Hydroxocobalamin; Prehospital; Smoke inhalation.

Research article

Introduction : The indications for prehospital hydroxocobalamin are not well defined. The aim of this study was to evaluate prehospital signs and symptoms in patients who received hydroxocobalamin to improve future use.

Méthode : In this retrospective study, all patients who received prehospital Hydroxocobalamin at a tertiary care burn center from December 2012 to March 2018 were reviewed. Each case was evaluated for evidence of suspected cyanide toxicity: hypotension, syncope, CNS depression/altered mentation, seizures, respiratory or cardiac arrest. A determination was made whether or not hydroxocobalamin was indicated.

Résultats : In this study, EMS providers administered hydroxocobalamin to 42 patients between December 2012 and March 2018. The majority (71%) of suspected cyanide exposures were from house fires. The most common prehospital findings were coma or depressed CNS (36%), followed by hypotension (16%) and cardiac arrest (12%). Sixty percent of patients treated with hydroxocobalamin had none of the six clinical indicators for potential cyanide toxicity. Carboxyhemoglobin and serum lactate were significantly different in patients that had a clinical indication for hydroxocobalamin compared to those who did not.

Conclusion : Prehospital hydroxocobalamin was used empirically however, indications are unclear. Using defined clinical indications may provide greater clarity for providers and reduce unnecessary use of hydroxocobalamin.

Conclusion (proposition de traduction) : L'hydroxocobalamine préhospitalière a été administrée de façon empirique, mais les indications ne sont pas claires. L'utilisation d'indications cliniques définies peut apporter une plus grande clarté aux prestataires et réduire l'utilisation inutile d'hydroxocobalamine.

Decision tree analysis to predict the risk of intracranial haemorrhage after mild traumatic brain injury in patients taking DOACs.
Turcato G, Zaboli A, Pfeifer N, Maccagnani A, Tenci A, Giudiceandrea A, Zannoni M, Ricci G, Bonora A, Brigo F. | Am J Emerg Med. 2021 Dec;50:388-393
DOI: https://doi.org/10.1016/j.ajem.2021.08.048
Keywords: DOACs; Decision tree; Direct oral anticoagulants; Intracranial haemorrhage; Mild traumatic brain injury; Oral anticoagulant terapy.

Research article

Introduction : Although the preliminary evidence seems to confirm a lower incidence of post-traumatic bleeding in patients treated with direct oral anticoagulants (DOACs) compared to those on vitamin K antagonists (VKAs), the recommended management of mild traumatic brain injury (MTBI) in patients on DOACs is the same as those on the older VKAs, risking excessive use of CT in the emergency department (ED).
Aim: To determine which easily identifiable clinical risk factors at the first medical evaluation in the ED may indicate an increased risk of post-traumatic intracranial haemorrhage (ICH) in patients on DOACs with MTBI.

Méthode : Patients on DOACs who were evaluated in the ED for an MTBI from 2016 to 2020 at four centres in Northern Italy were considered. A decision tree analysis using the chi-square automatic interaction detection (CHAID) method was conducted to assess the risk of post-traumatic ICH after an MTBI. Known pre- and post-traumatic clinical risk factors that are easily identifiable at the first medical evaluation in the ED were used as input predictor variables.

Résultats : Among the 1146 patients on DOACs in this study, post-traumatic ICH was present in 6.5% (75/1146). Decision tree analysis using the CHAID method found post-traumatic TLOC, post-traumatic amnesia, major trauma dynamic, previous neurosurgery and evidence of trauma above the clavicles to be the strongest predictors associated with the presence of post-traumatic ICH in patients on DOACs. The absence of a concussion seems to indicate subgroups at very low risk of requiring neurosurgery.

Conclusion : The machine-based CHAID model identified distinct prognostic groups of patients with distinct outcomes based on clinical factors. Decision trees can be useful as guides for patient selection and risk stratification.

Conclusion (proposition de traduction) : Le modèle CHAID mécanisé a identifié des groupes pronostiques distincts de patients avec des résultats distincts en fonction de facteurs cliniques. Les arbres de décision peuvent être utiles comme guides pour la sélection des patients et la stratification des risques.

The additive value of copeptin for early diagnosis and prognosis of acute coronary syndromes.
Ahmed TAN, Johny JS, Abdel-Malek MY, Fouad DA. | Am J Emerg Med. 2021 Dec;50:413-421
DOI: https://doi.org/10.1016/j.ajem.2021.08.069
Keywords: Acute coronary syndrome; Cardiac troponin I; Copeptin.

Research article

Introduction : One promising biomarker that has received substantial interest for the evaluation of suspected acute coronary syndromes (ACS) is copeptin. Therefore, our goal was to assess the additive value of copeptin for early diagnosis and prognosis of Non-ST segment acute coronary syndromes (NSTE-ACS).

Méthode : The study included ninety patients with suspected ACS. Patients with typical ischemic chest pain within six hours of symptom onset and without ST-segment elevation on electrocardiograph (ECG) were included. In addition to cardiac troponin I (cTnI), copeptin was assayed from venous blood samples obtained on admission, followed by serial troponin measurements six and twelve hours later. One year follow-up was performed for any major adverse cardiac events (MACEs) including cardiac death, re-infarction, re- hospitalization for ischemic events, heart failure, stroke and target lesion revascularization (TLR).

Résultats : Of seventy nine patients included in the final analysis, Forty (50.6%) were diagnosed as unstable angina (UA), while thirty nine (49.4%) had a non-ST elevation myocardial infarction (NSTEMI). Copeptin level on admission was significantly higher among NSTEMI patients than those with UA. With regard to the correlation analyses, copeptin was positively correlated with each of, Global Registry of Acute Coronary Events (GRACE), Thrombolysis In Myocardial Infarction (TIMI) and synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) scores. The sensitivity and negative predictive value (NPV) of the combination of admission copeptin and cTn-I were 100% and 100%, respectively, versus 57% and 70%, respectively, with admission of cTn-I alone. The area under curve (AUC) of the combination of copeptin and cTn-I was (0.975, p < 0.001) and was significantly higher than the AUC of cTn-I alone (0.888, p < 0.001). Admission copeptin was an independent predictor for MACEs by multiple regression analysis (OR: 0.01, 95% CI: 0.0-0.8, P = 0.04). High values of copeptin had the highest rate of MACEs and coronary revascularization during one year of follow up.

Conclusion : The combination of copeptin and conventional troponin I aids in early rule out of NSTEMI virtually independent of chest pain onset (CPO) with high NPV in patients presenting within three hours from chest pain onset with excellent prognostic value for risk stratification and prediction of MACEs.

Conclusion (proposition de traduction) : La combinaison de la copeptine et de la troponine I conventionnelle aide à écarter précocement l'infarctus du myocarde sans élévation du segment ST, pratiquement indépendamment de l'apparition de la douleur thoracique (CPO) avec une valeur prédictive négative élevée chez les patients se présentant dans les trois heures suivant l'apparition de la douleur thoracique avec une excellente valeur pronostique du risque stratification et prédiction des événements cardiaques indésirables majeurs.

Association of the duration of on-scene advanced life support with good neurological recovery in out-of-hospital cardiac arrest.
Jang DH, Jo YH, Park SM, Lee KJ, Kim YJ, Lee DK. | Am J Emerg Med. 2021 Dec;50:486-491
DOI: https://doi.org/10.1016/j.ajem.2021.09.006
Keywords: Cardiopulmonary resuscitation; Emergency medical services; Scene time interval.

Research article

Introduction : As advanced life support (ALS) provided by emergency medical services (EMS) on scene becomes more common, the scene time interval (STI) for which EMS providers stay on scene tends to lengthen. We investigated the relationship between the STI and neurological outcome of patients at hospital discharge when ALS was provided by EMS on scene.

Méthode : We conducted a retrospective analysis of prospectively collected out-of-hospital cardiac arrest (OHCA) data between August 2015 and December 2018. A restricted cubic spline curve was used to investigate the relationship between the STI and neurologic outcome, and patients were divided into two groups based on the cut-off value obtained through receiver operating characteristic (ROC) analysis. Comparisons of outcomes between the two groups were performed before and after propensity score matching.

Résultats : 4548 patients were included in the analysis. In ROC analysis, the optimal cut-off value for STI was 19 min. For the group with an STI <19 min, survival admission, survival discharge, and good neurologic outcome at hospital discharge were all higher than for the group with STI ≥19 min before and after propensity score matching. The multivariable model also showed that the STI ≥19 min was significantly associated with poor neurologic outcome at hospital discharge compared with the STI <19 min (adjusted odds ratio, 2.00; 95% CI, 1.40-2.88).

Conclusion : A duration of on-scene ALS more than 19 min was associated with a poor neurologic outcome of patients at hospital discharge in OHCA.

Conclusion (proposition de traduction) : Une durée de réanimation spécialisée sur place supérieure à 19 minutes était associée à un mauvais résultat neurologique des patients à la sortie de l'hôpital en arrêt cardiaque en dehors de l'hôpital.

Long-term consequences of electrical injury without initial signs of severity: The AFTER-ELEC study.
Chauveau N, Renard A, Gasperini G, Cazes N. | Am J Emerg Med. 2021 Dec;50:518-525
DOI: https://doi.org/10.1016/j.ajem.2021.09.022
Keywords: Electrical injury; Long-term consequences; Low-voltage injuries; Neuropsychological symptoms.

Research article

Introduction : There is no specificity of emergency or long-term management of benign electrical injuries (EI). The main objective of our work was to describe the occurrence of long-term complications of EI considered as benign.

Méthode : Single-center retrospective study of a cohort of adult patients who consulted for EI without initials signs of severity in an emergency department between 2012 and 2019. All included patients were secondarily contacted by telephone at least one year after their EI to complete a questionnaire.

Résultats : 76 adult patients visited the emergency department and 48 of them could be contacted by phone. 82% of the recalled patients had at least one complication following their EI. The main long-term complications were neurological (65%), psychological (58%) and cardiological (31%). Patients recalled eight years after EI had higher rates of neuropsychological complications than those recalled one year after EI. Only the time spent in the emergency department was statistically longer in patients who developed long-term complications compared to those who did not.

Discussion : The occurrence of long-term neuropsychological complications predominates. The knowledge and management of these long-term consequences must be particularly well known by emergency physicians because they are often the first medical contact of the patient. Our results also seem to show a crescendo in time of the occurrence of long-term complications.

Conclusion : all health professionals involved in the care of victims of a EI must be made widely aware of the occurrence of these long-term complications, particularly neuropsychological ones, in order to improve the long-term patient care.

Conclusion (proposition de traduction) : Tous les professionnels de santé impliqués dans la prise en charge des victimes d'un accident électrique doivent être largement sensibilisés à la survenue de ces complications à long terme, notamment neuropsychologiques, afin d'améliorer la prise en charge à long terme de ces patients.

Effect of head and shoulder positioning on the cross-sectional area of the subclavian vein in obese subjects.
Kim H, Chang JE, Won D, Lee JM, Kim TK, Min SW, Kim C, Hwang JY. | Am J Emerg Med. 2021 Dec;50:561-565
DOI: https://doi.org/10.1016/j.ajem.2021.08.013
Keywords: Cross-sectional area; Obese; Subclavian vein; Ultrasound.

Research article

Introduction : Head and shoulder positioning may affect cross-sectional area (CSA) and location of the subclavian vein (SCV). We investigated the CSA of the SCV and the depth of the SCV, depending on the head and shoulder positions.

Méthode : In 24 healthy obese volunteers, the short axis ultrasound images of the SCV and adjacent structures were obtained in three different head positions (neutral, 30° turned to the contralateral side, and 30° turned to the ipsilateral side) and two different shoulder positions (neutral and lowered). Images of the right and left SCVs were obtained in the supine and Trendelenburg positions. Subsequently, the CSA and depth of the SCV were measured.

Résultats : Significant differences were found in the CSA of the SCV in different head positions (30° turned to contralateral side vs. neutral: -0.06 cm², 95% confidence interval [CI], -0.10 to -0.02; Pcorrected = 0.002, 30° turned to contralateral side vs. 30° turned to ipsilateral side: -0.16 cm², 95% CI, -0.22 to -0.11; Pcorrected < 0.001, Neutral vs. 30° turned to ipsilateral side: -0.10 cm², 95% CI, -0.14 to -0.07; Pcorrected < 0.001). The CSA of the SCV was significantly different, depending on shoulder positions (neutral vs. lowered: 0.44 cm², 95% CI, 0.33 to 0.54; Pcorrected < 0.001), and body position (supine vs. Trendelenburg: -0.15 cm², 95% CI, -0.19 to -0.12; Pcorrected < 0.001). However, the depth of the SCV did not differ with respect to head, shoulder, and body positions.

Conclusion : Ipsilateral 30° head rotation, neutral shoulder position, and Trendelenburg position significantly enhanced the CSA of the SCV in obese participants.

Conclusion (proposition de traduction) : La rotation homolatérale de la tête à 30°, la position neutre de l'épaule et la position de Trendelenburg ont significativement amélioré la section transversale de la veine sous-clavière chez les participants obèses.

Leg-heel chest compression as an alternative for medical professionals in times of COVID-19.
Ott M, Krohn A, Bilfield LH, Dengler F, Jaki C, Echterdiek F, Schilling T, Heymer J. | Am J Emerg Med. 2021 Dec;50:575-581
DOI: https://doi.org/10.1016/j.ajem.2021.09.007  | Télécharger l'article au format  
Keywords: Aerosol; COVID-19; Cardiopulmonary resuscitation; Chest compression.

Research article

Introduction : To evaluate leg-heel chest compression without previous training as an alternative for medical professionals and its effects on distance to potential aerosol spread during chest compression.

Méthode : 20 medical professionals performed standard manual chest compression followed by leg-heel chest compression after a brief instruction on a manikin. We compared percentage of correct chest compression position, percentage of full chest recoil, percentage of correct compression depth, average compression depth, percentage of correct compression rate and average compression rate between both methods. In a second approach, potential aerosol spread during chest compression was visualized.

Résultats : Our data indicate no credible difference between manual and leg-heel compression. The distance to potential aerosol spread could have been increased by leg-heel method.

Conclusion : Under special circumstances like COVID-19-pandemic, leg-heel chest compression may be an effective alternative without previous training compared to manual chest compression while markedly increasing the distance to the patient.

Conclusion (proposition de traduction) : Dans des circonstances particulières comme la pandémie de COVID-19, la compression thoracique jambe-talon peut être une alternative efficace sans formation préalable par rapport à la compression thoracique manuelle tout en augmentant considérablement la distance au patient.

Commentaire : 

Emergency cricothyrotomy in morbid obesity: comparing the bougie-guided and traditional techniques in a live animal model.
Driver BE, Klein LR, Perlmutter MC, Reardon RF. | Am J Emerg Med. 2021 Dec;50:582-586
DOI: https://doi.org/10.1016/j.ajem.2021.09.015
Keywords: Airway; Cricothyrotomy; Emergency intubation; Surgical airway.

Research article

Introduction : Cricothyrotomy is a rare, time sensitive procedure that is more challenging to perform when anatomical landmarks are not easily palpated before the initial incision. There is a paucity of literature describing the optimal technique for cricothyrotomy in patients with impalpable airway structures, such as in morbid obesity. In this study, we used a live sheep model of morbid obesity to compare the effectiveness of two common cricothyrotomy techniques.

Méthode : We randomly assigned emergency medicine residents to perform one of two cricothyrotomy techniques on a live anesthetized sheep. To simulate the anterior soft tissue neck thickness of an adult with morbid obesity we injected 120 mL of a mixture of autologous blood and saline into the anterior neck of the sheep. The traditional technique (as described in the New England Journal Video titled "Cricothyroidotomy") used a Shiley tracheostomy tube and no bougie, and the bougie-guided technique used a bougie and a standard endotracheal tube. The primary outcome was the total procedure time; the secondary outcome was first attempt success.

Résultats : 23 residents were included, 11 assigned to the bougie-guided technique and 12 to the traditional technique. After injection of blood and saline, the median depth from skin to cricothyroid membrane was 3.0 cm (IQR 2.5-3.4 cm). The median time for the bougie technique was 118 s (IQR 77-200 s) compared to 183 s (IQR 134-270 s) for the traditional technique (median difference 62 s, 95% CI 10-144 s). Success on the first attempt occurred in 7/11 (64%) in the bougie group and 6/12 (50%) in the traditional technique group.

Conclusion : In this study, which simulated morbid obesity on a living animal model complete with active hemorrhage and time pressure caused by extubation before the procedure, the bougie-guided technique was faster than the traditional technique using a tracheostomy tube without a bougie.

Conclusion (proposition de traduction) : Dans cette étude, qui simulait l'obésité morbide sur un modèle animal vivant complet avec hémorragie active et pression temporelle causée par l'extubation avant l'intervention, la technique guidée par bougie était plus rapide que la technique traditionnelle utilisant une canule de trachéotomie sans bougie.

Commentaire :  Tube de trachéotomie sur bougie

Effects of cardiopulmonary resuscitation on direct versus video laryngoscopy using a mannequin model.
Kei J, Mebust DP. | Am J Emerg Med. 2021 Dec;50:587-591
DOI: https://doi.org/10.1016/j.ajem.2021.09.031
Keywords: Airway; Cardiopulmonary resuscitation; Chest compressions; Direct laryngoscopy; Intubation; Video laryngoscopy.

Research article

Introduction : During the last decade, guidelines for cardiopulmonary resuscitation has shifted, placing chest compressions and defibrillation first and airway management second. Physicians are being forced to intubate simultaneously with uninterrupted, high quality chest compressions. Using a mannequin model, this study examines the differences between direct and video laryngoscopy, comparing their performance with and without simultaneous chest compressions.

Méthode : Fifty emergency medicine physicians were randomly assigned to intubate a mannequin six times, using direct laryngoscopy (DL) and with two video laryngoscopy (VL) systems, a C-MAC traditional Macintosh blade and a GlideScope hyperangulated blade, with and without simultaneous chest compressions. A total of 300 intubations were completed and variables including intubation times, accuracy, difficulty, success rates and glottic views were recorded.

Résultats : The C-MAC VL system resulted in quicker intubations compared to DL (p = 0.007) and the GlideScope VL system (p = 0.039) during active chest compressions. Compared to DL, intubations were rated easier for both the C-MAC (p < 0.0001) and the GlideScope (p < 0.0001). Intubation failure rates were also higher when DL was used compared to either the C-MAC or GlideScope (p = 0.029). VL devices provided a superior overall Cormack-Lehane grade view compared to DL (p < 0.0001). The presence of chest compressions significantly impaired Cormack-Lehane views during direct laryngoscopy (p = 0.007). Chest compressions made the intubation more difficult under DL (p = 0.002) and when using the C-MAC (p = 0.031). Chest compressions also made ETT placement less accurate when using DL (p = 0.004).

Conclusion : Using a mannequin model, the C-MAC conventional VL blade resulted in decrease intubation times compared with DL or the GlideScope hyperangulated VL blade system. Overall, VL out performed DL in terms of providing a superior glottic view, minimizing failed attempts, and improving physician's overall perception of intubation difficulty. Chest compressions resulted in worse Cormack-Lehane views and higher rates of inaccurate endotracheal tube placement with DL, compared to VL.

Conclusion (proposition de traduction) : En utilisant un modèle de mannequin, la lame de laryngoscopie vidéo conventionnelle C-MAC a entraîné une diminution des temps d'intubation par rapport à la laryngoscopie directe ou au système de lames de laryngoscopie vidéo hyperangulée GlideScope. Dans l'ensemble, la laryngoscopie vidéo a surpassé la laryngoscopie directe en termes de fourniture d'une vue glottique supérieure, de minimisation des tentatives infructueuses et d'amélioration de la perception globale des difficultés d'intubation par le médecin. Les compressions thoraciques ont entraîné de moins bonnes vues de Cormack-Lehane et des taux plus élevés de placement inexact du tube endotrachéal avec la laryngoscopie directe, par rapport à la laryngoscopie vidéo.

Prevalence of pulmonary embolism in patients with acute exacerbations of COPD: A systematic review and meta-analysis.
Sato R, Hasegawa D, Nishida K, Takahashi K, Schleicher M, Chaisson N. | Am J Emerg Med. 2021 Dec;50:606-617
DOI: https://doi.org/10.1016/j.ajem.2021.09.041
Keywords: AECOPD; Chronic obstructive pulmonary disease; Pulmonary embolism; Venous thromboembolism.

Research article

Introduction : Identification of pulmonary embolism (PE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) carries significant therapeutic implications. We aimed to investigate the prevalence of PE in patients with AECOPD.

Méthode : We searched MEDLINE, the Cochrane Central Register of Controlled Trials, and Embase. We registered the protocol at the PROSPERO (CRD42021230481). Two authors independently evaluated whether titles and abstracts met the eligibility criteria, which were as follows: (1), prospective study or cross-sectional study in case the protocol for workup of PE was specified in advance, (2) patients with AECOPD aged ≥ 18 years, and (3) investigated the prevalence of PE or venous thromboembolism (VTE). Two authors independently extracted the selected patient and study characteristics and outcomes. We presented the results of all analyses with the use of random-effects models. The primary outcome was the prevalence of PE.

Résultats : We included 16 studies (N = 4093 patients) in this meta-analysis. The prevalence of PE in patients with AECOPD was 12% [95% confidence interval (CI), 9 to 16%]. Substantial heterogeneity was observed (I² = 94.8%). The pooled mortality was higher in patients with PE than those without (odds ratio 5.30, 95%CI: 2.48-11.30, p-value < 0.001).

Conclusion : In this meta-analysis, the prevalence of PE in patients with AECOPD was 12% and the mortality of patients with PE was higher than those without. This suggests an acute necessity to develop validated diagnostic strategies for identifying PE in patients with AECOPD.

Conclusion (proposition de traduction) : Dans cette méta-analyse, la prévalence de l'embolie pulmonaire chez les patients présentant une exacerbation aiguë de bronchopneumopathie chronique obstructive était de 12 % et la mortalité des patients atteints d'embolie pulmonaire était plus élevée que celle des autres. Cela suggère une nécessité aiguë de développer des stratégies de diagnostic validées pour identifier l'embolie pulmonaire chez les patients présentant une exacerbation aiguë de bronchopneumopathie chronique obstructive.

Clinical prediction rule of termination of resuscitation for out-of-hospital cardiac arrest patient with pre-hospital defibrillation given.
Sun KF, Poon KM, Lui CT, Tsui KL. | Am J Emerg Med. 2021 Dec;50:733-738
DOI: https://doi.org/10.1016/j.ajem.2021.09.058
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Pre-hospital defibrillation; Termination of resuscitation.

Research article

Introduction : To derive a clinical prediction rule of termination of resuscitation (TOR) for out-of-hospital cardiac arrest (OHCA) with pre-hospital defibrillation given.

Méthode : This was a retrospective multicenter cohort study performed in three emergency departments (EDs) of three regional hospitals from 1/1/2012 to 31/12/2018. Patients of OHCA aged ≥18 years old were included. Those with post-mortem changes, return of spontaneous circulation and receiving no resuscitation in EDs were excluded. A TOR rule was derived by logistic regression analysis based on demographics and end-tidal carbon dioxide level of included subjects with pre-hospital defibrillation given.

Résultats : There were 447 included patients had received pre-hospital defibrillation, in which 148 had return of spontaneous circulation (ROSC), with 22 survived to discharge (STD). Independent predictors for death on or before ED arrival (no ROSC) included EMS call to ED time >20 min and ETCO2 level <20 mmHg from first three sets. A 2-criteria rule predicting death on or before ED arrival by fulfilling both of the independent predictors had a specificity of 0.95 (95% CI 0.90-0.98) and positive predictive value (PPV) of 0.95 (95% CI 0.90-0.98), if 2nd set of ETCO2 was used. The positive likelihood ratio was 10.04 (95% CI 4.83-20.89).

Conclusion : The 2-criteria TOR rule for OHCA patients with pre-hospital defibrillation had a high specificity and PPV for predicting death on or before ED arrival.

Conclusion (proposition de traduction) : La règle d'arrêt de la réanimation à 2 critères pour les patients en arrêt cardiaque en dehors de l'hôpital avec défibrillation préhospitalière avait une spécificité élevée et une valeur prédictive positive pour prédire le décès à l'arrivée ou avant l'arrivée aux urgences.

Tranexamic acid for subarachnoid hemorrhage: A systematic review and meta-analysis.
Feng Y, Chen H. | Am J Emerg Med. 2021 Dec;50:748-752
DOI: https://doi.org/10.1016/j.ajem.2021.09.047
Keywords: Meta-analysis; Rebleeding; Subarachnoid hemorrhage; Tranexamic acid.

Research article

Introduction : The efficacy of tranexamic acid for subarachnoid hemorrhage remains controversial. Thus, we conduct this meta-analysis to explore the efficacy of tranexamic acid for subarachnoid hemorrhage.

Méthode : PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of tranexamic acid on subarachnoid hemorrhage were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random-effect model.

Résultats : Five RCTs and 2359 patients were included in the meta-analysis. Overall, compared with control intervention for subarachnoid hemorrhage, tranexamic acid was associated with significantly reduced risk of rebleeding (Odd ratio [OR] =0.62; 95% confidence interval [CI] =0.41 to 0.93; P = 0.02), but had no influence on mortality (OR = 0.94; 95% CI = 0.75 to 1.18; P = 0.61), poor outcome (OR = 0.95; 95% CI = 0.61 to 1.48; P = 0.82), hydrocephalus (OR = 1.17; 95% CI = 0.94 to 1.46; P = 0.17) or delayed cerebral ischemia (OR = 1.26; 95% CI = 0.78 to 2.04; P = 0.34).

Conclusion : Tranexamic acid may be effective to reduce the risk of rebleeding in patients with subarachnoid hemorrhage.

Conclusion (proposition de traduction) : L'acide tranexamique peut être efficace pour réduire le risque de récidive chez les patients présentant une hémorragie sous-arachnoïdienne.

The emergency department evaluation and management of massive hemoptysis.
Atchinson PRA, Hatton CJ, Roginski MA, Backer ED, Long B, Lentz SA. | Am J Emerg Med. 2021 Dec;50:148-155
DOI: https://doi.org/10.1016/j.ajem.2021.07.041
Keywords: Airway management; Massive hemoptysis; Respiratory failure; Severe hemoptysis.

Review article

Introduction : Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment.

Méthode : The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician.

Discussion : Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology.

Conclusion : Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.

Conclusion (proposition de traduction) : L'hémoptysie massive est une affection potentiellement mortelle que les cliniciens d'urgence doivent être prêts à gérer. Les urgentistes doivent axer leur prise en charge sur la réanimation immédiate, la préservation des voies respiratoires comprenant souvent l'intubation et l'isolement du poumon non saignant, et la coordination de la prise en charge définitive avec les consultants disponibles, notamment en radiologie interventionnelle, en pneumologie interventionnelle et en chirurgie thoracique.

Efficacy of intravenous vitamin C intervention for septic patients: A systematic review and meta-analysis based on randomized controlled trials.
Li T, Zeng J, Li DH, Yang GY, Wang K, Deng HF, Jiang H. | Am J Emerg Med. 2021 Dec;50:242-250
DOI: https://doi.org/10.1016/j.ajem.2021.08.012
Keywords: Meta-analysis; Sepsis; Septic shock; Systematic Review; Vitamin C.

Review article

Introduction : The role of vitamin C in sepsis is still controversial, we aimed to systematically review the efficacy of intravenous vitamin C supplementation in the treatment of sepsis.

Méthode : MEDLINE, EmBase, Web of Science, WanFang Data and CNKI were comprehensively searched to collect randomized controlled trails (RCTs) of vitamin C supplementation for patients with sepsis or sepsis shock from January 2000 to March 2021. Two researchers independently screened the literature, extracted the data and accessed the risk of bias in the included studies; meta-analysis was then performed by using Revman 5.4 software.

Résultats : A total of 10 RCTs involving 1400 participants were included. The results of meta-analysis showed that intravenous vitamin C supplementation can improve SOFA (ΔSOFA) within 72 h [RR = 1.32,95% CI(0.80,1.85), P < 0.0001] of septic patients. There were no difference on short term mortality (28-30d)[RR = 0.83,95% CI(0.65,1.05), P = 0.11], long term mortality (90d) [RR = 1.16,95% CI(0.82,1.66), P = 0.40], hospital LOS[RR = 0.15,95% CI(-0.73,1.03), P = 0.55], ventilator-free days[RR = 0.09,95% CI(-0.24,0.42), P = 0.60], ICU-LOS[RR = 0.22,95% CI(-0.13,0.57), P = 0.22], between two groups. The results of Subgroup analysis showed that intravenous vitamin C alone can reduce the risk of short term mortality (28-30d) [RR = 0.61,95% CI(0.47,0.79), P = 0.0002]of sepsis patients.

Conclusion : Based on current RCTs, our work indicated that mono-intravenous vitamin C therapy may reduce short-term mortality of sepsis patients, and it may protect organ functions. Due to the limitation of the quantity and quality of included studies, the above conclusions need to be verified by more large scale and high quality randomized control trials.

Conclusion (proposition de traduction) : Sur la base des essais contrôlés randomisés actuels, nos travaux ont indiqué que le traitement seulement par intraveineux de vitamine C peut réduire la mortalité à court terme des patients atteints de septicémie et peut protéger la fonction des organes. En raison de la limitation de la quantité et de la qualité des études incluses, les conclusions ci-dessus doivent être vérifiées par des essais contrôlés randomisés à plus grande échelle et de haute qualité.

Modified Valsalva maneuver for treatment of supraventricular tachycardias: A Meta-analysis.
Lan Q, Han B, Wu F, Peng Y, Zhang Z. | Am J Emerg Med. 2021 Dec;50:507-512
DOI: https://doi.org/10.1016/j.ajem.2021.08.067
Keywords: Meta-analysis; Modified Valsalva maneuver; Supraventricular tachycardia.

Review article

Introduction : alsalva maneuver (VM) is a simple and easy method for acute termination of supraventricular tachycardia (SVT), while a postural modification to the VM has been suggested to be superior to the standard VM (SVM). The objective of this meta-analysis is to explore the efficacy and safety of the modified VM (MVM) to terminate SVT compared with the SVM.

Méthode : Extensive literature was conducted using the database such as PubMed, Embase, Web of Science, Cochrane library and included randomized controlled trials (RCTs) assessing the efficacy and safety of the MVM and SVM for SVT. Meta-analysis was performed using mean difference (MD), relative risk (RR) and 95% confidence interval (CI). Statistical analysis was performed using Review Manager 5.4.1 software. The quality of the published studies was evaluated using the Oxford quality scoring system (Jadad scale).

Résultats : Six RCTs involving 1208 patients were reviewed, including 603 patients in the MVM group and 605 patients in the SVM group. The results of the meta-analysis showed that MVM was found to significantly increase the success rate of the sinus rhythm after single VM (RR = 2.83; 95% CI = 2.19 to 3.66; P < 0.00001), sinus rhythm after multiple VM (RR = 3.83; 95% CI = 2.26 to 6.50; P < 0.00001), and single and multiple VM (RR = 2.85, 95% CI = 2.35 to 3.45; P < 0.00001). MVM also decreased the emergency anti-arrhythmic treatments (RR = 0.70; 95% CI = 0.62 to 0.79; P < 0.00001), and use of adenosine and verapamil (RR = 0.69; 95% CI = 0.61 to 0.78; P < 0.00001). There was no significant difference in adverse events (RR = 1.48; 95% CI = 0.91 to 2.42; P = 0.11) and time in emergency department (ED) (RR = 0.03; 95% CI = -0.17 to 0.23, P = 0.79) between MVM and SVM.

Conclusion : Compared with MVM, the conversion rate of SVT to sinus rhythm was more effective than SVM. MVM also reduced the use of anti-arrhythmic measures and drugs, and had no increased time in ED and adverse events.

Conclusion (proposition de traduction) : Par rapport à la manœuvre de Valsalva modifiée, le taux de conversion d'une tachycardie supraventriculaire en rythme sinusal était plus efficace que la manœuvre de Valsalva standard. La manœuvre de Valsalva modifiée a également réduit l'utilisation de mesures et de médicaments anti-arythmiques, et n'a pas augmenté le temps passé au service d'urgence ni les événements indésirables.

Efficacy and safety of tranexamic acid in aneurysmal subarachnoid hemorrhage: A meta-analysis of randomized controlled trials.
Liu T, Wu L, Xue R, Ding H. | Am J Emerg Med. 2021 Dec;50:646-653
DOI: https://doi.org/10.1016/j.ajem.2021.09.051
Keywords: Adverse events; Meta; Mortality; Outcome; Subarachnoid hemorrhage; Tranexamic acid.

Review article

Introduction : Tranexamic acid, as a traditional hemostatic agent, is commonly used to treat or prevent excessive blood loss. However, the role of tranexamic acid in promoting good clinical outcomes and reducing mortality and risk of adverse events during the treatment of aneurysmal subarachnoid hemorrhage remains unclear.

Méthode : In strict accordance with the inclusion and exclusion criteria, Cochrane Library, Embase, Web of Science, and PubMed databases were assessed for randomized controlled trials (published between 1980 and 2021). Data were analyzed using STATA 16.0 and RevMan 5.3. In addition, the fixed-effects model (M-H method) and effect size (risk difference; RD) were used as a pooled measure to combine data. We also performed a post hoc sensitivity analysis and subgroup analysis to evaluate each outcome with low heterogeneity.

Résultats : A meta-analysis revealed that although tranexamic acid was related to less rebleeding (RD = -0.06; 95% CI [-0.09, -0.03]; P = 0.0006), there is evidence that it has no an effect on good clinical outcomes or mortality (RD = -0.01; 95% CI [-0.05, 0.02]; P = 0.51; RD = 0.00; 95% CI [-0.03, 0.04]; P = 0.91). Tranexamic acid was associated with increased hydrocephalus (RD = 0.04; 95% CI [0.01, 0.08]; P = 0.02) and seizure (RD = 0.04; 95% CI [0.00, 0.08]; P = 0.05). The incidence of thromboembolic complications or delayed cerebral ischemia was not different in the two groups (RD = -0.01; 95% CI [-0.04, 0.03]; P = 0.62; RD = 0.00; 95% CI [-0.03, 0.03]; P = 0.96), and significant drug-related overall adverse events were identified (RD = 0.02; 95% CI [0.00, 0.04]; P = 0.03).

Conclusion : These findings indicate that the routine use of tranexamic acid is not suggested for patients with aneurysmal subarachnoid hemorrhage.

Conclusion (proposition de traduction) : Ces résultats indiquent que l'utilisation systématique de l'acide tranexamique n'est pas suggérée pour les patients présentant une hémorragie sous-arachnoïdienne anévrismale.

Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis.
Makkar JK, Singh NP, Bhatia N, Samra T, Singh PM. | Am J Emerg Med. 2021 Dec;50:654-660
DOI: https://doi.org/10.1016/j.ajem.2021.09.038
Keywords: Analgesia; Emergency department; Fascia iliaca; Geriatric; Hip fracture.

Review article

Introduction : Fascia iliaca block (FICB) has been used to reduce pain and its impact on geriatric patients with hip fractures.
Objective: We conducted this meta-analysis to investigate the analgesic efficacy of this block in comparison to standard of care (SOC) when performed by non-anesthesiologist in the emergency department.

Méthode : Search on PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane database for randomized and quasi-randomized trials were performed. The primary outcome was to compare pain relief at rest at 2-4 h. The pain relief at various time intervals, reduction in opioid use, the incidence of nausea/ vomiting, delirium and length of hospital stay were the secondary outcomes studied. Trial Sequential Analysis (TSA) was performed for the primary outcome.

Résultats : Eleven trials comprising 895 patients were included in the meta-analysis. Patients receiving FICB had significant better pain relief at rest at 2-4 h with mean difference of 1.59 (95% CI, 0.59-2.59, p = 0.002) with I² = 96%. However, the certainty of the evidence was low and TSA showed that the sample size could not reach the requisite information size. A significant difference in pain relief at rest and on movement started within 30 min and lasted till 4 h of the block. Use of FICB was associated with a significant reduction in post-procedure parenteral opioid consumption, nausea and vomiting and length of hospital stay.

Conclusion : FICB is associated with significant pain relief both at rest and on movement lasting up to 4 h as well as a reduction in opioid requirement and associated nausea and vomiting in geriatric patients with hip fracture. However, the quality of evidence is low and additional trials are necessary.

Conclusion (proposition de traduction) : Le bloc ilio-fascial est associé à un soulagement significatif de la douleur au repos et lors de mouvements pouvant durer jusqu'à 4 h, ainsi qu'à une réduction des besoins en opioïdes et des nausées et vomissements associés chez les patients gériatriques présentant une fracture de la hanche. Cependant, la qualité des preuves est faible et des essais supplémentaires sont nécessaires.

Near-infrared spectroscopy for intracranial hemorrhage detection in traumatic brain injury patients: A systematic review.
Viderman D, Ayapbergenov A, Abilman N, Abdildin YG. | Am J Emerg Med. 2021 Dec;50:758-764
DOI: https://doi.org/10.1016/j.ajem.2021.09.070
Keywords: Intracranial hematoma; Intracranial hemorrhage; NIRS; Near-infrared spectroscopy; Traumatic brain injury.

Review article

Introduction : To synthesize evidence of the use of near-infrared spectroscopy (NIRS) to detect intracranial hemorrhage in traumatic brain injury (TBI) patients.

Méthode : The literature search was conducted in PubMed and Google Scholar (from inception to July 2021).

Résultats : 216 original articles were found, 197 of which were omitted, and the final review contained 19 original articles covering 2291 patients.

Conclusion : For patients with TBI, a NIRS test may be useful as a screening tool for intracranial hemorrhage, especially at the prehospital level. Negative results may help rule out intracranial hemorrhage and may remove the need for more head computed tomography (CT) scanning. Prehospital testing may guide the decision of whether the patient should be transferred to a craniotomy-equipped specialized hospital. NIRS can also be useful in situations when CT is not available. For future research, a significant objective is to show whether the effects of NIRS can improve outcomes and lead to meaningful improvements in clinical practice and decision making.

Conclusion (proposition de traduction) : Pour les patients présentant une lésion cérébrale traumatique, la saturation en oxygène des tissus cérébraux (par spectroscopie dans le proche infrarouge [NIRS]) peut être utile comme outil de dépistage de l'hémorragie intracrânienne, en particulier en préhospitalier. Des résultats négatifs peuvent aider à exclure une hémorragie intracrânienne et peuvent éliminer la nécessité d'une tomodensitométrie (TDM) crânienne supplémentaire. Les mesures préhospitalières peuvent guider la décision de transférer ou non le patient dans un hôpital spécialisé équipé pour la craniotomie. La saturation en oxygène des tissus cérébraux peut également être utilisée dans les situations où la tomodensitométrie n'est pas disponible. Pour les recherches futures, un objectif important serait de montrer si les effets de la saturation en oxygène des tissus cérébraux peuvent améliorer les résultats et conduire à des améliorations significatives dans la pratique clinique et la prise de décision.

Vitamin D supplementation for the treatment of migraine: A meta-analysis of randomized controlled studies.
Hu C, Fan Y, Wu S, Zou Y, Qu X. | Am J Emerg Med. 2021 Dec;50:784-788
DOI: https://doi.org/10.1016/j.ajem.2021.07.062
Keywords: Headache attacks per month; Migraine; Randomized controlled trials; Vitamin D supplementation.

Review article

Introduction : It is not well established to use vitamin D supplementation for migraine, and this meta-analysis aims to explore the efficacy of vitamin D for migraine patients.

Méthode : PubMed, EMbase, Web of science, EBSCO and Cochrane library databases were systematically searched up to May 2021, and we included randomized controlled trials (RCTs) exploring the effect of vitamin D for migraine patients.

Résultats : Six RCTs and 301 patients were included in the meta-analysis. Compared with control group in migraine patients, vitamin D supplementation could remarkably decrease headache attacks per month (MD = -2.74; 95% CI = -3.82 to -1.67; P < 0.00001), headache days per month (MD = -1.56; 95% CI = -2.44 to -0.68; P = 0.0005) and MIDAS score (MD = -5.72; 95% CI = -10.90 to -0.54; P = 0.03), but demonstrated no obvious influence on attack duration (MD = -2.20; 95% CI = -7.38 to 2.97; P = 0.40) or headache severity (MD = -0.56; 95% CI = -1.18 to 0.06; P = 0.08).

Conclusion : Vitamin D supplementation provided additional benefits to treat migraine.

Conclusion (proposition de traduction) : La supplémentation en vitamine D a fourni des avantages supplémentaires pour traiter la migraine.

Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients.
Wentz AE, Wang RC, Marshall BDL, Shireman TI, Liu T, Merchant RC. | J Emerg Med. 2021 Dec;61(6):637-648
DOI: https://doi.org/10.1016/j.jemermed.2021.09.002
Keywords: Acute pain; emergency department; opioid analgesia; urolithiasis.

Research article

Introduction : Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain.
Objectives: Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis.

Méthode : We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge.

Résultats : Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90.

Conclusion : Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.

Conclusion (proposition de traduction) : La prescription d'analgésiques opioïdes a doublé le risque de douleur persistante chez les patients des services d'urgence suspectés de lithiase urinaire. Limiter la prescription d'analgésiques morphiniques à la sortie du service des urgences pour ces patients pourrait prévenir la douleur persistante en plus de limiter l'accès à ces médicaments.

Alcoholic Ketoacidosis: Etiologies, Evaluation, and Management.
Long B, Lentz S, Gottlieb M. | J Emerg Med. 2021 Dec;61(6):658-665
DOI: https://doi.org/10.1016/j.jemermed.2021.09.007
Keywords: acidosis; alcohol; alcoholic ketoacidosis; malnutrition.

Research article

Introduction : Alcoholic ketoacidosis (AKA) is defined by metabolic acidosis and ketosis in a patient with alcohol use. This is a common presentation in the emergency department (ED) and requires targeted therapies.

Méthode : This narrative review evaluates the pathogenesis, diagnosis, and management of AKA for emergency clinicians.

Résultats : AKA is frequently evaluated and managed in the ED. The underlying pathophysiology is related to poor glycogen stores and elevated nicotinamide adenine dinucleotide and hydrogen. This results in metabolic acidosis with elevated beta-hydroxybutyrate levels. Patients with AKA most commonly present with a history of alcohol use (acute or chronic), poor oral intake, gastrointestinal symptoms, and ketoacidosis on laboratory assessment. Patients are generally dehydrated, and serum glucose can be low, normal, or mildly elevated. An anion gap metabolic acidosis with ketosis and electrolyte abnormalities are usually present on laboratory evaluation. Management includes fluid resuscitation, glucose and vitamin supplementation, electrolyte repletion, and evaluation for other conditions.

Conclusion : Emergency clinician knowledge of the evaluation and management of AKA is essential in caring for these patients.

Conclusion (proposition de traduction) : Les connaissances des urgentistes sur l'évaluation et la prise en charge de l'acidocétose alcoolique sont essentielles pour la prise en charge de ces patients.

Commentaire :  Prise en charge de l'acidocétose alcoolique

Posterior Reversible Encephalopathy Syndrome: A Narrative Review for Emergency Clinicians.
Mergen S, Long B, Matlock A. | J Emerg Med. 2021 Dec;61(6):666-673
DOI: https://doi.org/10.1016/j.jemermed.2021.09.005
Keywords: eclampsia; encephalopathy; hypertension; immunosuppression; posterior reversible encephalopathy syndrome; reversible posterior leukoencephalopathy; seizures.

Research article

Introduction : Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic disorder characterized by seizures, headache, altered mental status, and visual disturbances, and is often associated with acute hypertension.
Objective: This narrative review provides a focused description of the presentation, diagnostic evaluation, and management of PRES.

Discussion : PRES is associated with a variety of factors, including acute rise in blood pressure, renal disease, preeclampsia/eclampsia, and immunosuppressive therapy. The pathophysiology is theorized to involve dysfunction of cerebral autoregulation leading to vascular leak or endothelial dysfunction resulting in vasogenic edema. In the emergency department (ED), clinical findings suggestive of PRES should prompt diagnostic testing focused on confirming the diagnosis and excluding other conditions that may present similarly. Laboratory studies are primarily useful for excluding alternative diagnoses. Computed tomography (CT) and, in particular, magnetic resonance imaging (MRI) are the recommended neuroimaging modalities for diagnosis. CT and MRI may demonstrate cerebral vasogenic edema, most often in the distribution of the posterior circulation. Treatment involves management of seizures, control of blood pressure if elevated, and treatment of any underlying trigger.

Conclusion : PRES is a neurological disorder that is typically reversible if recognized on presentation and promptly and appropriately managed. This narrative review characterizes this condition for emergency clinicians.

Conclusion (proposition de traduction) : La leucoencéphalopathie postérieure réversible est un trouble neurologique qui est généralement réversible s'il est reconnu dès la présentation et pris en charge rapidement et de manière appropriée. Cette revue narrative caractérise cette condition pour les cliniciens d'urgence.

Commentaire : La leucoencéphalopathie postérieure réversible (PRES) est un trouble clinicoradiologique caractérisé par des convulsions, des céphalées, une altération de l'état mental et des troubles visuels, et est souvent associé à une hypertension aiguë.
Voir l'article : Mohebbi Amolia A, Mégarbanea B, Chabriat H. La leucoencéphalopathie postérieure réversible. Réanimation (2007) 16, 490-497  .

Evaluation and Management of Thrombotic Thrombocytopenic Purpura in the Emergency Department.
Long B, Bridwell RE, Manchanda S, Gottlieb M. | J Emerg Med. 2021 Dec;61(6):674-682
DOI: https://doi.org/10.1016/j.jemermed.2021.07.045
Keywords: TTP; hematology; microangiopathic hemolytic anemia; thrombotic microangiopathy; thrombotic thrombocytopenic purpura.

Research article

Introduction : Thrombotic thrombocytopenic purpura (TTP) is a dangerous condition that can be misdiagnosed in the emergency department.
Objective : The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of TTP, with a focus on emergency clinicians.

Discussion : TTP is a disorder with microangiopathic hemolytic anemia, severe thrombocytopenia, and multiorgan ischemic injury. It may be acquired or hereditary, and is caused by a reduced amount or function of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), which is an enzyme involved in cleaving von Willebrand factor. The classic presentation of TTP includes fever, neurologic abnormalities, thrombocytopenia with purpura, microangiopathic hemolytic anemia, and acute renal injury. However, < 7% of cases have all of these findings present. Testing should include a complete blood count, complete metabolic panel, blood smear, coagulation panel, fibrinogen, D-dimer, lactate dehydrogenase, ADAMTS13 level, troponin, human immunodeficiency virus assessment, urinalysis, pregnancy test as appropriate, and electrocardiogram. Management includes hematology consultation if available, plasma exchange and corticosteroids, and treatment of end-organ complications. All patients require admission for treatment and close monitoring.

Conclusion : TTP is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.

Conclusion (proposition de traduction) : Le purpura thrombocytopénique thrombotique (PTT) est une circonstance médicale potentiellement dangereuse nécessitant un diagnostic et une prise en charge rapides. Il est essentiel que les urgentistes sachent comment diagnostiquer et traiter cette entité.

Commentaire : Le Purpura Thrombotique Thrombocytopénique (PTT) ou maladie de Moschcowitz fait partie des microangiopathies thrombotiques (MAT) caractérisées par l’association d’une anémie hémolytique mécanique (c’est-à-dire associée à des schizocytes ou fragments de globule rouge), d’une thrombopénie périphérique et de défaillances d’organe de sévérité variable. C'est une urgence diagnostique et thérapeutique.
Le purpura thrombotique thrombocytopénique, forme grave de MAT caractérisée par une thrombopénie profonde et une souffrance d’un ou de plusieurs organes (cerveau et cœur en particulier), en rapport avec la formation de thrombi dans les vaisseaux de la microcirculation. Le PTT est une maladie rare, qui résulte d'un déficit sévère en ADAMTS13 (A Disintegrin And Metalloproteinase with ThromboSpondin-1 motifs, 13rd member), enzyme intervenant dans la régulation de la taille des multimères plasmatiques de facteur Willebrand.
Le traitement, en urgence, comporte des échanges plasmatiques, associés à un nanocorps inhibant l’interaction entre les plaquettes et le facteur Willebrand (le caplacizumab), et un traitement immunosuppresseur par corticoïdes et immunomodulation anti-lymphocytes B (rituximab).
Fiche «  Microangiopathies thrombotiques   » sur Orphanet Urgences.
Voir l'article : Retornaz F, Soubeyrand J. Le purpura thrombotique thrombocytopénique : physiopathologie et traitement. Réanimation 2002;11:333-40  .

Ultrasound Measurement of the Intervertebral Space in the Lateral Recumbent Versus Sitting Positions.
Shi D, Perice L, Grimaldi C, Perera T, Nelson M. | J Emerg Med. 2021 Dec;61(6):705-710
DOI: https://doi.org/10.1016/j.jemermed.2021.07.015
Keywords: interspinous space; lumbar puncture; point-of-care ultrasound; position.

Research article

Introduction : Diagnostic lumbar puncture (LP) is an invasive procedure routinely performed within the emergency department (ED). LP is traditionally performed with the patient in either the lateral recumbent or sitting position. We investigated if the intervertebral space is larger in one of these positions. If one position is larger than the other, this would imply that one position offers a higher chance of a successful lumbar puncture than the other position.
Objective : We sought to determine if there is a significant size difference of the L4/L5 intervertebral space in the lateral recumbent compared with the sitting position.

Méthode : Point-of-care ultrasound (POCUS) was performed to measure the size of each volunteer's L4/L5 intervertebral space in both the seated and lateral recumbent positions. All volunteers >18 years of age were eligible for the study. Thirty volunteers had measurements taken. Three measurements were taken by each investigator in both positions for each volunteer.

Résultats : The median L4/L5 intervertebral space distance was 1.7511 cm in the lateral recumbent position and 1.9511 cm in the seated position with a Wilcoxon signed rank p value <.0001. The interspinous space in the seated position was found to be significantly larger than in the lateral recumbent position.

Conclusion : The size of the interspinous space in the seated position on ultrasound was found to be larger than the lateral recumbent position, suggesting that LP may be more successful in the seated position.

Conclusion (proposition de traduction) : La taille de l'espace interépineux en position assise à l'échographie s'est avérée plus grande qu'en position couchée latérale, ce qui suggère que la ponction lombaire peut être plus efficace en position assise.

Manual Palpation vs. Femoral Arterial Doppler Ultrasound for Comparison of Pulse Check Time During Cardiopulmonary Resuscitation in the Emergency Department: A Pilot Study.
Schwartz BE, Gandhi P, Najafali D, Gregory MM, Jacob N, Helberg T, Thomas C, Lowie BJ, Huis In 't Veld MA, Cruz-Cano R. | J Emerg Med. 2021 Dec;61(6):720-730
DOI: https://doi.org/10.1016/j.jemermed.2021.03.016
Keywords: cardiopulmonary resuscitation; femoral arterial Doppler ultrasound; manual palpation; pulse check.

Research article

Introduction : Manual palpation (MP) is frequently employed for pulse checks, but studies have shown that trained medical personnel have difficulty accurately identifying pulselessness or return of spontaneous circulation (ROSC) using MP. Any delays in identifying pulselessness can lead to significant delays in starting or resuming high-quality chest compressions.
Objectives: This study explored whether femoral arterial Doppler ultrasound (FADU) decreases pulse check duration during cardiopulmonary resuscitation (CPR) compared with MP among patients in the emergency department (ED) receiving CPR directed by emergency medicine physicians who had received minimal additional didactic ultrasound training.

Méthode : We performed a prospective observational cohort study from October 2018 to May 2019 at an urban community ED. Using convenience sampling, we enrolled patients arriving at our ED or who decompensated during their ED stay and received CPR. For continuous data, median (interquartile range [IQR]) were calculated, and medians were compared using Kruskal-Wallis test.

Résultats : Fifty-two eligible patients were enrolled and 135 pulse checks via MP and 35 via FADU were recorded. MP observations had a median (IQR) of 11.00 (7.36-15.48) s, whereas FADU had a median (IQR) of 8.98 (5.45-13.85) s. There was a difference between the two medians of 2.02 s (p = 0.05).

Conclusion : In this study, the use of FADU was superior to MP in achieving shorter pulse check times. Further research is needed to confirm the accuracy of FADU for identifying ROSC as well as to determine whether FADU can improve clinical outcomes.

Conclusion (proposition de traduction) : Dans cette étude, l'utilisation de l'échographie Doppler artérielle fémorale était supérieure à la palpation manuelle pour obtenir des temps de contrôle du pouls plus courts. Des recherches supplémentaires sont nécessaires pour confirmer la précision de l'échographie Doppler artérielle fémorale pour identifier le retour de la circulation spontanée ainsi que pour déterminer si l'échographie Doppler artérielle fémorale peut améliorer les résultats cliniques.

Intranasal Fentanyl and Midazolam Use in Children 3 Years of Age and Younger in the Emergency Department.
Chang JG, Regen RB, Peravali R, Harlan SS, Smeltzer MP, Kink RJ. | J Emerg Med. 2021 Dec;61(6):731-739
DOI: https://doi.org/10.1016/j.jemermed.2021.09.006
Keywords: analgesia; anxiolysis; fentanyl; midazolam; pediatric.

Research article

Introduction : Although the efficacy and safety profiles of both intranasal fentanyl and midazolam are well studied in pediatric patients, few studies examine their use in younger children.
Objectives: To examine and report our experiences in a pediatric emergency department (ED) with intranasal fentanyl and midazolam in children aged 3 years and younger.

Méthode : This retrospective study investigated intranasal fentanyl and midazolam administration, alone and in combination, in children 3 years and younger treated in a pediatric ED.

Résultats : Of 6198 patients included, 1762 received intranasal fentanyl alone, 1115 received intranasal midazolam alone, and 3321 received combination therapy. The median (interquartile range [IQR]) patient age was 2.2 (1.5-3) years. Initial median (IQR) fentanyl dose was 2.7 (2-3) µg/kg, with 13.3% receiving a repeat dose. Initial median (IQR) midazolam dose was 0.3 (0.2-0.3) mg/kg, with 3.3% receiving a second dose. Children receiving both fentanyl and midazolam had median (IQR) initial doses of 2.8 (2.1-3) µg/kg and 0.3 (0.2-0.3) mg/kg, respectively. Of these, 3.2% received repeat doses of both medications. Laceration repairs (33.8%) and incision and drainage (22.2%) accounted for the majority of indications. Only 2.9% (n = 178) received additional opioids. No serious adverse events requiring a reversal agent or respiratory support were reported.

Conclusion : Intranasal fentanyl and midazolam, alone and in combination, can provide analgesia and anxiolysis to children aged 3 years and younger in the ED setting. Further prospective studies are needed to better evaluate their safety and efficacy in this younger population.

Conclusion (proposition de traduction) : Le fentanyl intranasal et le midazolam, seuls ou en association, peuvent fournir une analgésie et une anxiolyse aux enfants âgés de 3 ans et moins dans le cadre d'un service d'urgence. D'autres études prospectives sont nécessaires pour mieux évaluer leur innocuité et leur efficacité dans cette population plus jeune.

Chest wall injuries due to cardiopulmonary resuscitation and the effect on in-hospital outcomes in survivors of out-of-hospital cardiac arrest.
Prins JTH, Van Lieshout EMM, Van Wijck SFM, Scholte NTB, Den Uil CA, Vermeulen J, Verhofstad MHJ, Wijffels MME. | J Trauma Acute Care Surg. 2021 Dec 1;91(6):966-975
DOI: https://doi.org/10.1097/ta.0000000000003379
Keywords: Level of evidence:

CWIS 2021

Introduction : This study aimed to assess the prevalence of chest wall injuries due to cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA) and to compare in-hospital outcomes in patients with versus without chest wall injuries.

Méthode : A retrospective cohort study of all intensive care unit (ICU)-admitted patients who underwent cardiopulmonary resuscitation for OHCA between January 1, 2007, and December 2019 was performed. The primary outcome was the occurrence of chest wall injuries, as diagnosed on chest computed tomography. Chest wall injury characteristics such as rib fracture location, type, and dislocation were collected. Secondary outcomes were in-hospital outcomes and subgroup analysis of patients with good neurological recovery to identify those who could possibly benefit from the surgical stabilization of rib fractures.

Résultats : Three hundred forty-four patients were included, of which 291 (85%) sustained chest wall injury. Patients with chest wall injury had a median of 8 fractured ribs (P25-P75, 4-10 ribs), which were most often undisplaced (on chest computed tomography) (n = 1,574 [72.1%]), simple (n = 1,948 [89.2%]), and anterior (n = 1,785 [77.6%]) rib fractures of ribs 2 to 7. Eight patients (2.3%) had a flail segment, and 136 patients (39.5%) had an anterior flail segment. Patients with chest wall injury had fewer ventilator-free days (0 days [P25-P75, 0-16 days] vs. 13 days [P25-P75, 2-22 days]; p = 0.006) and a higher mortality rate (n = 102 [54.0%] vs. n = 8 [22.2%]; p < 0.001) than those without chest wall injury. For the subgroup of patients with good neurological recovery, the presence of six or more rib fractures or a single displaced rib fracture was associated with longer hospital and ICU length of stay, respectively.

Conclusion : Cardiopulmonary resuscitation-related chest wall injuries in survivors of OHCA and especially rib fractures are common. Patients with chest wall injury had fewer ventilator-free days and a higher mortality rate. Patients with good neurological recovery might represent a subgroup of patients who could benefit from surgical stabilization of rib fractures.

Conclusion (proposition de traduction) : Les lésions de la paroi thoracique liées à la réanimation cardiopulmonaire chez les survivants d'un arrêt cardiaque en dehors de l'hôpital et en particulier les fractures des côtes sont courantes. Les patients présentant une lésion de la paroi thoracique avaient moins de jours sans ventilateur et un taux de mortalité plus élevé. Les patients avec une bonne récupération neurologique pourraient représenter un sous-groupe de patients qui pourraient bénéficier d'une stabilisation chirurgicale des fractures de côtes.

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation.
Desch S, Freund A, Akin I and al; TOMAHAWK Investigators. | N Engl J Med. 2021 Dec 30;385(27):2544-2553
DOI: https://doi.org/10.1056/nejmoa2101909
Keywords: Aucun

Original article

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

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

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

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

Conclusion (proposition de traduction) : Chez les patients ayant subi un arrêt cardiaque extrahospitalier réanimé sans sus-décalage du segment ST, une stratégie d'angiographie immédiate n'apportait aucun avantage par rapport à une stratégie différée ou sélective en ce qui concerne le risque de décès à 30 jours, quelle qu'en soit la cause.

Myocarditis after Covid-19 Vaccination in a Large Health Care Organization.
Witberg G, Barda N, Hoss S, Richter I, Wiessman M, Aviv Y, Grinberg T, Auster O, Dagan N, Balicer RD, Kornowski R. | N Engl J Med. 2021 Dec 2;385(23):2132-2139
DOI: https://doi.org/10.1056/nejmoa2110737  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Reports have suggested an association between the development of myocarditis and the receipt of messenger RNA (mRNA) vaccines against coronavirus disease 2019 (Covid-19), but the frequency and severity of myocarditis after vaccination have not been extensively explored.

Méthode : We searched the database of Clalit Health Services, the largest health care organization (HCO) in Israel, for diagnoses of myocarditis in patients who had received at least one dose of the BNT162b2 mRNA vaccine (Pfizer-BioNTech). The diagnosis of myocarditis was adjudicated by cardiologists using the case definition used by the Centers for Disease Control and Prevention. We abstracted the presentation, clinical course, and outcome from the patient's electronic health record. We performed a Kaplan-Meier analysis of the incidence of myocarditis up to 42 days after the first vaccine dose.

Résultats : Among more than 2.5 million vaccinated HCO members who were 16 years of age or older, 54 cases met the criteria for myocarditis. The estimated incidence per 100,000 persons who had received at least one dose of vaccine was 2.13 cases (95% confidence interval [CI], 1.56 to 2.70). The highest incidence of myocarditis (10.69 cases per 100,000 persons; 95% CI, 6.93 to 14.46) was reported in male patients between the ages of 16 and 29 years. A total of 76% of cases of myocarditis were described as mild and 22% as intermediate; 1 case was associated with cardiogenic shock. After a median follow-up of 83 days after the onset of myocarditis, 1 patient had been readmitted to the hospital, and 1 had died of an unknown cause after discharge. Of 14 patients who had left ventricular dysfunction on echocardiography during admission, 10 still had such dysfunction at the time of hospital discharge. Of these patients, 5 underwent subsequent testing that revealed normal heart function.

Conclusion : Among patients in a large Israeli health care system who had received at least one dose of the BNT162b2 mRNA vaccine, the estimated incidence of myocarditis was 2.13 cases per 100,000 persons; the highest incidence was among male patients between the ages of 16 and 29 years. Most cases of myocarditis were mild or moderate in severity.

Conclusion (proposition de traduction) : Parmi les patients d'un vaste système de santé israélien qui avaient reçu au moins une dose du vaccin à ARNm BNT162b2, l'incidence estimée de la myocardite était de 2,13 cas pour 100 000 personnes ; l'incidence la plus élevée concernait les patients de sexe masculin âgés de 16 à 29 ans. La plupart des cas de myocardite étaient de gravité légère ou modérée.

Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article.
Ávila-Reyes D, Acevedo-Cardona AO, Gómez-González JF, Echeverry-Piedrahita DR, Aguirre-Flórez M, Giraldo-Diaconeasa A. | Ultrasound J. 2021 Dec 2;13(1):46
DOI: https://doi.org/10.1186/s13089-021-00248-0  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Critical Care; Echocardiography; POCUS-point-of-care ultrasound; Ultrasound.

Review

Editorial : The POCUS-CA (Point-of-care ultrasound in cardiac arrest) is a diagnostic tool in the Intensive Care Unit and Emergency Department setting. The literature indicates that in the patient in a cardiorespiratory arrest it can provide information of the etiology of the arrest in patients with non-defibrillable rhythms, assess the quality of compressions during cardiopulmonary resuscitation (CPR), and define prognosis of survival according to specific findings and, thus, assist the clinician in decision-making during resuscitation. This narrative review of the literature aims to expose the usefulness of ultrasound in the setting of cardiorespiratory arrest as a tool that allows making a rapid diagnosis and making decisions about reversible causes of this entity. More studies are needed to support the evidence to make ultrasound part of the resuscitation algorithms. Teamwork during cardiopulmonary resuscitation and the inclusion of ultrasound in a multidisciplinary approach is important to achieve a favorable clinical outcome.

Conclusion : Ultrasound has become a safe and accurate diagnostic tool for critically ill patients in the intrahospital setting, prioritizing the emergency department and the ICU. Greater accessibility and portability have made ultrasound at the point of care an available tool for the intensivist. The point-of-care ultrasound in cardiac arrest in the hands of a trained clinician, allows the evaluation of the quality of the compressions, the rapid diagnosis of reversible causes of arrest with non-defibrillable rhythms, the monitoring of interventions in terms of response to treatment, and provides prognostic information regarding the possibility of ROSC and survival. Given the importance that ultrasound has taken in this setting and its usefulness as a predictive tool, the importance of strengthening the available evidence through high-quality studies such as controlled clinical trials that allow integrating point-of-care ultrasound in cardiac arrest into universal CPR algorithms is highlighted. In this sense, medical specialists must be intervened in ultrasound training to minimize the time necessary to obtain and interpret images in stressful situations; the implementation of checklists could be carried out to allow rapid image acquisition and control of interruptions.

Conclusion (proposition de traduction) : L'échographie est devenue un outil de diagnostic sûr et précis pour les patients gravement malades en milieu intrahospitalier, donnant la priorité au service des urgences et à l'USI. Une plus grande accessibilité et portabilité ont fait de l'échographie au point d'intervention un outil disponible pour l'intensiviste. L'échographie au point d'intervention pendant un arrêt cardiorespiratoire entre les mains d'un clinicien formé, permet l'évaluation de la qualité des compressions, le diagnostic rapide des causes réversibles d'arrêt cardiaque lors des rythmes non défibrillables, le suivi des interventions en termes de réponse au traitement et fournit des informations pronostiques concernant la possibilité de RACS et la survie. Compte tenu de l'importance que l'échographie a prise dans ce contexte et de son utilité en tant qu'outil prédictif, l'importance de renforcer les preuves disponibles grâce à des études de haute qualité telles que des essais cliniques contrôlés qui permettraient d'intégrer l'échographie au point d'intervention dans les algorithme universel de réanimation de l'arrêt cardiorespiratoire est mis en évidence. En ce sens, les médecins spécialistes doivent intervenir dans la formation en échographie pour minimiser le temps nécessaire à l'obtention et à l'interprétation des images dans des situations stressantes ; la mise en place de listes de contrôle pourrait être effectuée pour permettre une acquisition rapide des images et un contrôle des interruptions.

Commentaire : 

What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?.
Stolz L, Situ-LaCasse E, Acuña J, Thompson M, Hawbaker N, Valenzuela J, Stolz U, Adhikari S. | World J Emerg Med. 2021;12(3):169-173
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2021.03.001  | Télécharger l'article au format  
Keywords: Apical; Emergency department; Parasternal; Pericardial effusion; Pericardiocentesis; Point-of-care ultrasound; Subxiphoid.

Original Article

Introduction : Traditionally performed using a subxiphoid approach, the increasing use of point-of-care ultrasound in the emergency department has made other approaches (parasternal and apical) for pericardiocentesis viable. The aim of this study is to identify the ideal approach for emergency-physician-performed ultrasound-guided pericardiocentesis as determined by ultrasound image quality, distance from surface to pericardial fluid, and likely obstructions or complications.

Méthode : A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial effusions. The images were reviewed for technical quality, distance of effusion from skin surface, and predicted complications.

Résultats : A total of 166 pericardial effusions were identified during the study period. The mean skin-to-pericardial fluid distance was 5.6 cm (95% confidence interval [95% CI] 5.2-6.0 cm) for the subxiphoid views, which was significantly greater than that for the parasternal (2.7 cm [95% CI 2.5-2.8 cm], P<0.001) and apical (2.5 cm [95% CI 2.3-2.7 cm], P<0.001) views. The subxiphoid view had the highest predicted complication rate at 79.7% (95% CI 71.5%-86.4%), which was significantly greater than the apical (31.9%; 95% CI 21.4%-44.0%, P<0.001) and parasternal (20.2%; 95% CI 12.8%-29.5%, P<0.001) views.

Conclusion : Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach. The distance from skin to fluid collection is the least in both of these views.

Conclusion (proposition de traduction) : Nos résultats suggèrent que les taux de complications avec la péricardiocentèse seront plus faibles via l'approche parasternale ou apicale par rapport à l'approche sous-xiphoïdienne. La distance entre la peau et le recueil de liquide est la plus faible dans ces deux accès.

Intensivists' response to hyperoxemia in mechanical ventilation patients: The status quo and related factors.
Ke ZW, Jiang Y, Bao YP, Yang YQ, Zong XM, Liu M, Guan XY, Lu ZQ. | World J Emerg Med. 2021;12(3):202-206
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2021.03.007  | Télécharger l'article au format  
Keywords: Arterial blood gas; Fraction of inspired oxygen; Hyperoxemia; Intensive care unit; Mechanical ventilation.

Original article

Introduction : Due to the still sparse literature in China, the investigation of hyperoxemia management is required. Thus, we aim to conduct a retrospective study to provide more information about hyperoxemia management in intensive care unit (ICU) patients.

Méthode : We retrospectively screened the medical records of adult patients (age ≥18 years) who required mechanical ventilation (MV) ≥24 hours from January 1, 2018, to December 31, 2018. All arterial blood gas (ABG) tested during MV was retrieved, and MV settings were recorded. The median arterial partial pressure of oxygen (PaO₂) >120 mmHg (1 mmHg=0.133 kPa) was defined as mild to moderate hyperoxemia, and PaO₂ >300 mmHg as extreme hyperoxemia. Intensivists' response to hyperoxemia was assessed based on the reduction of fraction of inspired oxygen (FiO₂) within one hour after hyperoxemia was recorded. Multivariable logistic regression analysis was performed to determine the independent factors associated with the intensivists' response to hyperoxemia.

Résultats : A total of 592 patients were finally analyzed. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 21 (15-26). The PaO₂, arterial oxygen saturation (SaO₂), FiO₂, and positive end expiratory pressure (PEEP) were 96.4 (74.0-126.0) mmHg, 97.8% (95.2%-99.1%), 0.4 (0.4-0.5), and 5 (3-6) cmH₂O, respectively. Totally 174 (29.39%) patients had PaO₂ >120 mmHg, and 19 (3.21%) patients had extreme hyperoxemia at PaO₂ >300 mmHg. In cases of mild to moderate hyperoxemia with FiO₂ ≤0.4, only 13 (2.20%) patients had a decrease in FiO₂ within one hour. The multivariable logistic regression analysis showed that a positive response was independently associated with FiO₂ (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.06-1.12, P<0.001), PaO2 (OR 1.01, 95% CI 1.00-1.01, P=0.002), and working shifts (OR 5.09, 95% CI 1.87-13.80, P=0.001).

Conclusion : Hyperoxemia occurs frequently and is neglected in most cases, particularly when mild to moderate hyperoxemia, hyperoxemia with lower FiO₂, hyperoxemia during night and middle-night shifts, or FiO₂ less likely to be decreased. Patients may be at a risk of oxygen toxicity because of the liberal oxygen strategy. Therefore, further research is needed to improve oxygen management for patients with MV in the ICUs.

Conclusion (proposition de traduction) : L'hyperoxémie survient fréquemment et est négligée dans la plupart des cas, particulièrement lorsque l'hyperoxémie est légère à modérée, l'hyperoxémie avec une FiO₂ plus faible, l'hyperoxémie pendant les quarts et de milieu de nuit ou la FiO₂ est moins susceptible d'être diminuée. Les patients peuvent être exposés à un risque de toxicité de l'oxygène en raison de la stratégie libérale d'oxygène. Par conséquent, des recherches supplémentaires sont nécessaires pour améliorer la gestion de l'oxygène pour les patients sous ventilation mécanique dans les unités de soins intensifs.

Efficacy and safety of low-dose corticosteroids for acute respiratory distress syndrome: A systematic review and meta-analysis.
Cui YQ, Ding XF, Liang HY, Wang D, Zhang XJ, Li LF, Kan QC, Wang LX, Sun TW. | World J Emerg Med. 2021;12(3):207-213
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2021.03.008  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; Corticosteroid; Low-dose; Meta-analysis; Mortality; Systematic review.

Original article

Introduction : There are conflicting results regarding whether corticosteroids have better efficacy than placebo in acute respiratory distress syndrome (ARDS) patients. Therefore, we aim to further evaluate the efficacy and safety of corticosteroids in adult ARDS patients.

Méthode : The databases, including Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, were searched from their inception to May 2, 2020. Randomized controlled trials (RCTs) and observational cohort studies were selected to assess the use of corticosteroids in adult ARDS patients. The quality of the results was judged by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The inverse-variance method with random or fixed effects modeling was used to compute pooled odds ratio (OR), standardized mean difference (SMD), and their 95% confidence interval (CI).

Résultats : Eight eligible RCTs and six cohort studies were included. The use of corticosteroids was associated with reduced mortality (OR 0.57, 95% CI 0.43-0.76, I2=35.1%, P=0.148) in ARDS patients, and the result was confirmed in the included cohort studies (OR 0.51, 95% CI 0.27-0.95, I2=66.7%, P=0.010). The subgroup analysis stratified by the initiation time and duration of corticosteroid use showed that early ARDS and prolonged corticosteroid use had significant survival benefits in the RCTs. The low-dose corticosteroid use was also associated with significantly more ventilator-free days and a reduced rate of new infections in ARDS patients.

Conclusion : The low-dose corticosteroid therapy may be safe and reduce mortality, especially in patients with prolonged treatment and early ARDS.

Conclusion (proposition de traduction) : La corticothérapie à faible dose peut être sûre et réduire la mortalité, en particulier chez les patients avec un traitement prolongé et un SDRA précoce.