Bibliographie de Médecine d'Urgence

Mois de janvier 2022

Academic Emergency Medicine

Levetiracetam compared with phenytoin or fosphenytoin in benzodiazepine-refractory pediatric status epilepticus.
Long B, Gottlieb M. | Acad Emerg Med. 2022 Jan;29(1):125-127
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Keywords: fosphenytoin; levetiracetam; pediatric status epilepticus; phenytoin; seizure.


Introduction : Status epilepticus, defined by continuous seizure activity for at least 5 min or recurrent seizures without a return to baseline, is a neurologic emergency. The annual incidence in children approximates 20 per 100,000 population. Unfortunately, a significant portion of children presenting with status epilepticus can experience long-term neurologic, cognitive, or behavior abnormalities; therefore, rapid treatment is essential. While benzodiazepines are considered first-line treatment, they fail to stop seizure activity in approximately one-third of patients. Common second-line agents include phenytoin, its prodrug fosphenytoin, and levetiracetam.

Conclusion : Based on the available evidence, the review summarized here found that levetiracetam compared to phenytoin or fosphenytoin was associated with similar time to seizure cessation and a similar safety profile. Because of similarity in efficacy and safety profiles, we have assigned a color recommendation of yellow (similar efficacy and safety profiles). One reasonable conclusion from the data is that levetiracetam is not superior to phenytoin/fosphenytoin in the acute setting. Whether they are truly equivalent would require equiva-lence (noninferiority) trials, which have yet to be done. However, no clinically important safety or efficacy differences were found in the trials data reviewed. For patients with benzodiazepine-refractory status epilepticus, existing data suggest that levetiracetam and phe-nytoin are both reasonable agents.

Conclusion (proposition de traduction) : Sur la base des preuves disponibles, la revue résumée ici a révélé que le lévétiracétam, comparé à la phénytoïne ou à la fosphénytoïne, était associé à un délai similaire avant l'arrêt des crises et à un profil d'innocuité similaire. En raison de la similitude des profils d'efficacité et d'innocuité, nous avons attribué une recommandation de couleur jaune (profils d'efficacité et d'innocuité similaires).
Une conclusion raisonnable à partir des données est que le lévétiracétam n'est pas supérieur à la phénytoïne/fosphénytoïne dans le cadre aigu. Pour savoir s'ils sont vraiment équivalents, il faudrait des essais d'équivalence (non-infériorité), qui n'ont pas encore été réalisés. Cependant, aucune différence d'innocuité ou d'efficacité cliniquement importante n'a été trouvée dans les données des essais examinés. Pour les patients en état de mal épileptique réfractaire aux benzodiazépines, les données existantes suggèrent que le lévétiracétam et la phénytoïne sont tous deux des agents raisonnables.

Prehospital airway management for out-of-hospital cardiac arrest: A nationwide multicenter study from the KoCARC registry.
Chang H, Jeong D, Park JE, Kim T, Lee GT, Yoon H, Hwang SY, Cha WC, Shin TG, Sim MS, Jo IJ, Lee SH, Shin SD, Choi JH. | Acad Emerg Med. 2022 Jan 22
Keywords: advanced airway management; neurologically favorable survival; out-of-hospital cardiac arrest.


Introduction : This study investigated whether prehospital advanced airway management (AAM) is associated with improved survival of out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask (BVM) ventilation.

Méthode : We investigated the neurologically favorable survival of adult patients with OHCA who underwent BVM or AAM using the Korean Cardiac Arrest Research Consortium (KoCARC), a multicenter OHCA registry of Korea. The differences in clinical characteristics were adjusted by matching or weighting the clinical propensity for use of AAM or by least absolute shrinkage and selection operator (LASSO). The primary outcome was 30-day survival with neurologically favorable status defined by cerebral performance category 1 or 2.

Résultats : Of the 9,616 patients enrolled (median age = 71 years; 65% male), there were 6,243 AAM and 3,354 BVM patients. In unadjusted analysis, the 30-day neurologically favorable survival was lower in the AAM group compared with the BVM group (5.5% vs. 10.0%; hazard ratio [HR] = 1.21, 95% confidence interval [CI] = 1.16 to 1.27; all p < 0.001). In propensity score matching-adjusted analysis, these differences were not found (9.6% vs. 10.0%; HR = 0.98, 95% CI = 0.93 to 1.03, p > 0.05). Inverse probability of treatment weighting- and LASSO-adjusted analyses replicated these results.

Conclusion : In this nationwide real-world data analysis of OHCA, the 30-day neurologically favorable survival did not differ between prehospital AAM and BVM after adjustment for clinical characteristics.

Conclusion (proposition de traduction) : Dans cette analyse des données du monde réel à l'échelle nationale sur l'arrêt cardiaque en dehors de l'hôpital, la survie sans séquelle neurologique sévère à 30 jours ne différait pas en préhospitalier, entre la gestion avancée des voies aérienne et la ventilation au masque avec ballon après ajustement pour les caractéristiques cliniques.

Acute Medicine & Surgery

Phenytoin versus other antiepileptic drugs as treatments for status epilepticus in adults: a systematic review and meta-analysis.
Hoshiyama E, Kumasawa J, Uchida M, Hifumi T, Moriya T, Ajimi Y, Miyake Y, Kondo Y, Yokobori S; Japan Resuscitation Council (JRC) Neuroresuscitation Task Force and the Guidelines Editorial Committee. | Acute Med Surg. 2022 Jan 7;9(1):e717
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Keywords: Neurological outcome; phenytoin; seizure cessation; status epilepticus.

Mini Review Article

Introduction : Status epilepticus (SE) is a life-threatening neurological emergency. There is insufficient evidence regarding which antiepileptic therapy is most effective in patients with benzodiazepine-refractory convulsive SE. Therefore, this study aimed to evaluate intravenous phenytoin (PHT) and other intravenous antiepileptic medications for SE.

Méthode : We searched PubMed, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for published randomized controlled trials (RCTs) in humans up to August 2019. We compared outcomes between intravenous PHT and other intravenous medications. The important primary composite outcomes were the successful clinical cessation of seizures, mortality, and neurological outcomes at discharge. The reliability of the level of evidence for each outcome was compared using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Résultats : A total of 1,103 studies were identified from the databases, and 10 RCTs were included in the analysis. The ratio of successful clinical seizure cessation was significantly lower (risk ratio [RR] 0.89; 95% confidence interval [CI], 0.82-0.97) for patients treated with intravenous PHT than with other medications. When we compared mortality and neurological outcomes at discharge, we observed no significant differences between patients treated with PHT and those treated with other medications. The RRs were 1.07 (95% CI, 0.55-2.08) and 0.91 (95% CI, 0.72-1.15) for mortality and neurological outcomes at discharge, respectively.

Conclusion : Our findings showed that intravenous PHT was significantly inferior to other medications in terms of the cessation of seizures. No significant differences were observed in mortality or neurological outcomes between PHT and other medications.

Conclusion (proposition de traduction) : Nos résultats ont montré que la phénytoïne intraveineuse était significativement inférieure aux autres médicaments en termes d'arrêt des crises. Aucune différence significative n'a été observée dans la mortalité ou les résultats neurologiques entre la phénytoïne et d'autres médicaments.


2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.
Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. | Anesthesiology. 2022 Jan 1;136(1):31-81
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Keywords: Aucun

Practice Parameter

Editorial : The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Commentaire : Difficult airway algorithm:
Adult patients

Pediatric patients

Annals of Emergency Medicine

Fixed Versus Variable Dosing of Prothrombin Complex Concentrate for Bleeding Complications of Vitamin K Antagonists-The PROPER3 Randomized Clinical Trial.
Abdoellakhan RA, Khorsand N, Ter Avest E, Lameijer H, Faber LM, Ypma PF, Nieuwenhuizen L, Veeger NJGM, Meijer K. | Ann Emerg Med. 2022 Jan;79(1):20-30
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Keywords: Aucun

General Medicine

Introduction : To determine if a fixed dose of 1000 IU of 4-factor prothrombin complex concentrate (4F-PCC) is as effective as traditional variable dosing based on body weight and international normalized ratio (INR) for reversal of vitamin K antagonist (VKA) anticoagulation.

Méthode : In this open-label, multicenter, randomized clinical trial, patients with nonintracranial bleeds requiring VKA reversal with 4F-PCC were allocated to either a 1,000-IU fixed dose of 4F-PCC or the variable dose. The primary outcome was the proportion of patients with effective hemostasis according to the International Society of Thrombosis and Haemostasis definition. The design was noninferiority with a lower 95% confidence interval of no more than -6%. When estimating sample size, we assumed that fixed dosing would be 4% superior.

Résultats : From October 2015 until January 2020, 199 of 310 intended patients were included before study termination due to decreasing enrollment rates. Of the 199 patients, 159 were allowed in the per-protocol analysis. Effective hemostasis was achieved in 87.3% (n=69 of 79) in fixed compared to 89.9% (n=71 of 79) in the variable dosing cohort (risk difference 2.5%, 95% confidence interval -13.3 to 7.9%, P=.27). Median door-to-needle times were 109 minutes (range 16 to 796) in fixed and 142 (17 to 1076) for the variable dose (P=.027). INR less than 2.0 at 60 minutes after 4F-PCC infusion was reached in 91.2% versus 91.7% (P=1.0).

Conclusion : The large majority of patients had good clinical outcome after 4F-PCC use; however, noninferiority of the fixed dose could not be demonstrated because the design assumed the fixed dose would be 4% superior. Door-to-needle time was shortened with the fixed dose, and INR reduction was similar in both dosing regimens.

Conclusion (proposition de traduction) : La grande majorité des patients ont eu de bons résultats cliniques après l'utilisation de 4F-PCC (ndlr : concentré de complexe prothrombinique, aussi appelé PPSB) ; cependant, la non-infériorité de la dose fixe n'a pas pu être démontrée car la conception (de l'étude) supposait que la dose fixe serait supérieure de 4 %. Le temps de mise en oeuvre du traitement à l'admission a été plus court avec la dose fixe, et la réduction de l'INR était similaire dans les deux schémas posologiques.

Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study.
Grewal K, Atzema CL, Sutradhar R, Everett K, Horner D, Thompson C, Theodoropoulos J, Borgundvaag B, McLeod SL, de Wit K. | Ann Emerg Med. 2022 Jan;79(1):35-47
Keywords: Aucune

General Medicine

Introduction : Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups.

Méthode : This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism.

Résultats : There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85).

Conclusion : The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

Conclusion (proposition de traduction) : L'incidence de la phlébite à 90 jours chez les patients sortis de l'urgence avec une fracture de la cheville nécessitant une immobilisation était de 1,3 %. Ces patients présentaient un risque accru de 5,7 à 6,3 fois par rapport aux témoins appariés. Certains patients immobilisés pour des fractures de la cheville présentent un risque plus élevé de thromboembolie veineuse, et cela devrait être reconnu par les médecins urgentistes.

Commentaire : Les facteurs associés à une phlébite étaient :
• l'âge avancé :
• la présence antérieure d'une phlébite ou les antécédents de phlébite superficielle :
• une admission récente à l'hôpital :
• une chirurgie récente pour fracture autre que la cheville :
• une chirurgie ultérieure pour fracture de la cheville.

What is the Diagnostic Accuracy of Chest Radiography, Ultrasound, and Computed Tomography for COVID-19?.
Gottlieb M, Jay A, Mogni B. | Ann Emerg Med. 2022 Jan;79(1):64-65
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Keywords: Aucun

Infectious Disease

Méthode : The authors searched PubMed, Embase, the CDC Library on COVID-19 research articles database, and preprints indexed in bioRxiv and medRxiv through September 30, 2020. The authors also searched and the World Health Organization International Clinical Trials Registry Platform.
Study selection: Two authors independently screened articles for inclusion, with discrepancies resolved by consensus with a third reviewer. With the exception of case-control studies, the authors included all study designs that reported on the test accuracy of chest radiography, lung ultrasound, or chest CT. Study participants included individuals suspected of having COVID-19 regardless of age. The reference standard was a positive reverse transcriptase–polymerase chain reaction (RT-PCR) COVID-19 result (from any manufacturer and using any sample type), positive WHO criteria for COVID-19, positive China CDC criteria for COVID-19, positive serology for SARS-CoV-2 antibodies with concurrent symptoms, or positive findings using study-specific criteria. There were no language restrictions.

Résultats : Two review authors independently extracted data and assessed methodological quality, with discrepancies resolved by consensus with a third reviewer. The risk of bias and applicability concerns were assessed using the QUADAS-2 domain list.1 Data were analyzed using a bivariate model to account for within- and between-study variance as well as the correlation between sensitivity and specificity across studies. Heterogeneity was investigated through visual inspection of forest plots and summary receiver operating characteristics plots. The authors did not assess for publication bias.

Conclusion : Chest radiography is a reasonable initial test for COVID-19 due to its moderate sensitivity and specificity. Chest computed tomography (CT) and lung ultrasound have greater sensitivity and can be considered when the initial chest radiograph is nondiagnostic.

Conclusion (proposition de traduction) : La radiographie thoracique est un examen initial raisonnable pour la COVID-19 en raison de sa sensibilité et de sa spécificité modérées. La tomodensitométrie (TDM) thoracique et l'échographie pulmonaire ont une plus grande sensibilité et peuvent être envisagées lorsque la radiographie thoracique initiale n'est pas contributive.

Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis.
Powell EC, Roskind CG, Schnadower D, Olsen CS, Casper TC, Tarr PI, O'Connell KJ, Levine AC, Poonai N, Schuh S, Rogers AJ, Bhatt SR, Gouin S, Mahajan P, Vance C, Hurley K, Farion KJ, Sapien RE, Freedman SB; Pediatric Emergency Research Canada and Pediatric Emergency Care Applies Research Networks. | Ann Emerg Med. 2022 Jan;79(1):66-74
Keywords: Aucun


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

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

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

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

Conclusion (proposition de traduction) : Chez les enfants en âge préscolaire présentant une gastro-entérite et qui ont besoin de soins aux urgences, l’administration d’ondansétron par voie orale a été associée à une réduction de l’indice d’administration intraveineuse de solutés aux urgences ; elle n’a pas été associée à l'administration de solutés intraveineux dans les 72 heures, à une hospitalisation ou vomissements et à une diarrhée dans les 24 heures suivant le retour à domicile.

Archives of Academic Emergency Medicine

Remote Analysis and Transmission System of Electrocardiogram in Prehospital Setting; a Diagnostic Accuracy Study.
Almukhambetova E, Almukhambetov M, Musayev A, Yeshmanova A, Indershiyev V, Kalhodzhaeva Z. | Arch Acad Emerg Med. 2022 Jan 1;10(1):e5
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Keywords: Cardiovascular system; cardiovascular diseases; diagnosis; health services administration; quality of health care.

Original/Research Article

Introduction : One of the trends in the development of medical technologies is considered to be telemedicine. This study aimed to evaluate the accuracy of a remote electrocardiogram (ECG) analysis and transmission system in prehospital setting.

Méthode : In this cross-sectional study, the data of 19,265 ECGs was gathered from emergency medical service (EMS) database of Almaty city, Kazakhstan, from 2015 to 2019. All ECGs were recorded in the prehospital setting by a paramedic, using "Poly-Spectrum" ECG recording device. Subsequently, all ECGs were sent to the cardiologist for interpretation and the findings were compared between software and cardiologist.

Résultats : 19,265 ECGs were registered. The average time from taking ECGs to receiving an expert's conclusion was 9.2 ± 2.5 minutes. The medical teams were called in 17.9% of cases after paramedic ECG recording; however, in the rest of the cases there was no need to call those teams. Using the device reduced the number of visits of specialist teams. The overall sensitivity, specificity, and accuracy of ECG analysis device in diagnosis of ECG abnormalities were 83.8% (95%CI: 82.6 - 84.9), 95.5% (95%CI: 95.1 - 95.8), and 93.3% (95%CI: 92.9 - 93.7), respectively.

Conclusion : The findings of this study showed the 93.3% accuracy of automatic ECG analysis device in interpretation of ECG abnormalities in prehospital setting compared with the cardiologist interpretations. Using the device causes a decrease in the number of cardiologist visits needed as well as reduction in cost and elapsed time.

Conclusion (proposition de traduction) : Les résultats de cette étude ont montré une précision de 93,3 % du dispositif d'analyse ECG automatique dans l'interprétation des anomalies de l'ECG en milieu préhospitalier par rapport aux interprétations d'un cardiologue. L'utilisation de l'appareil entraîne une diminution du nombre de visites de cardiologue nécessaires ainsi qu'une réduction des coûts et du temps écoulé.

Nifekalant versus Amiodarone for Out-Of-Hospital Cardiac Arrest with Refractory Shockable Rhythms; a Post Hoc Analysis.
Funakoshi H, Aso S, Homma Y, Onodera R, Tahara Y. | Arch Acad Emerg Med. 2022 Jan 1;10(1):e6
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Keywords: Anti-arrhythmia agents; Cardiopulmonary resuscitation; Nifekalant; Ventricular fibrillation; Ventricular flutter.

Original/Research Article

Introduction : It is still unclear that which anti-arrhythmics are adequate for treating refractory dysrhythmia. This study aimed to compare amiodarone and nifekalant in management of out-of-hospital cardiac arrest cases with refractory shockable rhythm.

Méthode : This was a post hoc analysis of cases registered in a nationwide, multicentre, prospective registry that includes 288 critical care medical centres in Japan. From June 2014 to December 2017, we included all out-of-hospital cardiac arrest patients aged ≥18 years who presented with refractory arrhythmia (sustained ventricular fibrillation or ventricular tachycardia following delivery of at least two defibrillator shocks) and treated with nifekalant or amiodarone after arrival to hospital. Overlap weight was performed to address potential confounding factors.

Résultats : 1,317 out-of-hospital cardiac arrest patients with refractory arrhythmia were enrolled and categorized into amiodarone (n = 1,275) and nifekalant (n = 42) groups. After overlap weight was performed, there were no significant intergroup differences in increased the rate of admission after return of spontaneous circulation [-5.9% (95%CI: -7.1 to 22.4); p = 0.57], 30-day favourable neurological outcome [0.1% (95%CI: -14 to 13.9); p = 0.99], and 30-day survival [-3.9% (95% CI: -19.8 to 12.0); p = 0.63].

Conclusion : This nationwide study showed that nifekalant was not associated with improved outcomes regarding admission after return of spontaneous circulation, 30-day survival, and 30-day favourable neurological outcome compared with amiodarone.

Conclusion (proposition de traduction) : Cette étude nationale a montré que le nifekalant n'était pas associé à de meilleurs résultats concernant l'admission après le retour de la circulation spontanée, la survie à 30 jours et les résultats neurologiques favorables à 30 jours par rapport à l'amiodarone.

Risk Stratification of Pulmonary Thromboembolism using Brain Natriuretic Peptide and Troponin I; a Brief Report.
Ebrahimi M, Arab MM, Zamani Moghadam H, Jalal Yazdi M, Rayat Doost E, Foroughian M. | Arch Acad Emerg Med. 2022 Jan 8;10(1):e8
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Keywords: Brain; Computed Tomography Angiography; Natriuretic Peptide; Pulmonary Embolism; Troponin.

Original/Research Article

Introduction : Pulmonary thromboembolism (PTE) is one of the most prevalent medical disorders, with a notable annual fatality rate. This study aimed to evaluated the accuracy of serum pro-BNP and troponin I levels in PTE diagnosis.

Méthode : This cross-sectional study was implemented on 267 patients with suspected PTE (sudden chest pain or sudden dyspnea) in Imam Reza Hospital in Mashhad, Iran. All patients underwent pulmonary computed tomography (CT) angiography (as the gold standard test) and their serum levels of troponin I and pro-BNP were measured. The screening performance characteristics of pro-BNP in detection of PTE cases were measured and reported using receiver operating characteristic (ROC) curve analysis.

Résultats : Two-hundred-sixty-seven patients with a mean age of 67.7 ±11.5 years were evaluated (60.1% male). PTE was confirmed via CT angiography in 121 patients. The area under the ROC curve of troponin I and pro-BNP in detection of PTE was 0.501 ng/mL and 0.972 pg/mL, respectively. The sensitivity and specificity of proBNP at the best cut-off point (100 pg/ml) were 85.4% and 80.2%, respectively. The sensitivity and specificity of troponin I at the best cut-off point (0.005 ng/ml) were 65.5% and 42%, respectively.

Conclusion : Due to the comparatively good sensitivity and specificity of proBNP in diagnosis of pulmonary thromboembolism, it can be employed as a diagnostic determinant in patients with suspected pulmonary thromboembolism along with other laboratory tests.

Conclusion (proposition de traduction) : En raison de la sensibilité et de la spécificité relativement bonnes du proBNP dans le diagnostic de l'embolie pulmonaire, il peut être utilisé comme déterminant diagnostique chez les patients suspects d'embolie pulmonaire avec d'autres tests de laboratoire.

Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study.
Sazgar M, Montazer SH, Hosseininejad SM, Jahanian F, Rezaimehr B, Behbohaninia M, Aminiahidashti H. | Arch Acad Emerg Med. 2022 Jan 11;10(1):e9
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Keywords: Acute Pain; Early Diagnosis; Emergency Service; Hospital; Scrotum; Spermatic Cord Torsion.

Original/Research Article

Introduction : Testicular torsion is an important and critical issue in patients with acute scrotum referring to emergency department (ED). Early detection is very important to save the testicles. This study aimed to determine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion.

Méthode : This prospective cross-sectional study was done using the information of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluation of the clinical predictors of testicular torsions, which were confirmed by surgery.

Résultats : 81 patients with the mean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testicular torsion. Patients with torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sudden onset pain (p = 0.003), left side pain (p < 0.0001), and lower white blood cell (WBC) count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001) was the sole independent predictor of testicular torsion. The highest area under the receiver operating characteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 - 98.7)], pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively.

Conclusion : It seems that clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard.

Conclusion (proposition de traduction) : Il semble que les variables cliniques ne soient pas suffisamment précises pour être considérées comme le seul prédicteur de la torsion testiculaire et qu'elles doivent être utilisées avec prudence et en combinaison avec d'autres outils de dépistage disponibles comme l'échographie Doppler à cet égard.

BMC Emergency Medicine

Comparison of 3-factor versus 4-factor prothrombin complex concentrate for emergent warfarin reversal: a systematic review and meta-analysis.
Margraf DJ, Brown SJ, Blue HL, Bezdicek TL, Wolfson J, Chapman SA. | BMC Emerg Med. 2022 Jan 24;22(1):14
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Keywords: Blood coagulation factors; Meta-analysis; Prothrombin complex concentrate; Systematic review; Warfarin.

Research article

Introduction : Patients requiring emergent warfarin reversal (EWR) have been prescribed three-factor prothrombin complex concentrate (PCC3) and four-factor prothrombin complex concentrate (PCC4) to reverse the anticoagulant effects of warfarin. There is no existing systematic review and meta-analysis of studies directly comparing PCC3 and PCC4.

Méthode : The primary objective of this systematic review and meta-analysis was to determine the effectiveness of achieving study defined target INR goal after PCC3 or PCC4 administration. Secondary objectives were to determine the difference in safety endpoints, thromboembolic events (TE), and survival during the patients' hospital stay. Random-effects meta-analysis models were used to estimate the odds ratios (OR), and heterogeneity associated with the outcomes. The Newcastle-Ottawa Scale was used to assess study quality, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Résultats : Ten full-text manuscripts and five abstracts provided data for the primary and secondary outcomes. Patients requiring EWR had more than three times the odds of reversal to goal INR when they were given PCC4 compared to PCC3 (OR = 3.61, 95% CI: 1.97-6.60, p < 0.001). There was no meaningful clinical association or statistically significant result between PCC4 and PCC3 groups in TE (OR = 1.56, 95% CI: 0.83-2.91, p = 0.17), or survival during hospital stay (OR = 1.34, 95% CI: 0.81-2.23, p = 0.25).

Conclusion : PCC4 is more effective than PCC3 in meeting specific predefined INR goals and has similar safety profiles in patients requiring emergent reversal of the anticoagulant effects of warfarin.

Conclusion (proposition de traduction) : Le concentré de complexe prothrombique à quatre facteurs est plus efficace que le concentré de complexe prothrombique à trois facteurs pour atteindre les objectifs spécifiques prédéfinis d'INR et présente des profils d'innocuité similaires chez les patients nécessitant une réversion émergente des effets anticoagulants de la warfarine.

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study.
Trimmel H, Egger A, Doppler R, Pimiskern M, Voelckel WG. | BMC Emerg Med. 2022 Jan 15;22(1):8
DOI:  | Télécharger l'article au format  
Keywords: Emergency medical service; Inhaled analgesia; Methoxyflurane; Paramedics; Prehospital pain management.

Research article

Introduction : Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria.

Méthode : Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients.

Résultats : Median numeric pain rating was 8.0 (7.0-8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed.

Conclusion : In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

Conclusion (proposition de traduction) : En préhospitalier, le méthoxyflurane inhalé comme unique analgésique est efficace pour le transport des patients traumatisés (62 %) avec des douleurs modérées à sévères. Les patients plus âgés bénéficient particulièrement du méthoxyflurane inhalé. Les effets secondaires sont bénins et les paramètres vitaux ne sont pas affectés. Ainsi, le méthoxyflurane inhalé pourrait être un dispositif précieux pour les secouristes EMS non-médecins également dans la région de l'Europe centrale.

Commentaire : Le méthoxyflurane (Penthrox®) est un anesthésique halogéné, antalgique non opioïde indiqué dans le soulagement d'urgence des douleurs modérées à sévères associées à un traumatisme chez des patients adultes conscients.
Il est destiné à être autoadministré avec l'inhalateur sous la supervision d'une personne formée à son administration. Les professionnels de santé administrant Penthrox doivent fournir et expliquer la notice d'information du produit au patient.
La dose antalgique efficace la plus faible doit être administrée et ne doit pas dépasser 6 mL en une administration unique.

Canadian Journal of Emergency Medicine

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing.
O'Rielly CM, Andruchow JE, McRae AD. | CJEM. 2022 Jan;24(1):68-74
DOI:  | Télécharger l'article au format  
Keywords: Chest pain; HEAR score; Risk stratification.

Original Research

Introduction : The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE).

Méthode : This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds.

Résultats : Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity.

Conclusion : A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.

Conclusion (proposition de traduction) : Un score HEAR ≤ 1 peut identifier plus de 17 % de tous les patients comme étant à index très faible de risque de survenu d'infarctus aigu du myocarde et d'événements cardiaques indésirables majeurs sur 30 jours et peu susceptibles de nécessité un dosage de la troponine. La mise en œuvre à grande échelle de cette stratégie pourrait entraîner d'importantes économies de ressources.

Timing of endoscopy for acute upper gastrointestinal bleeding: journal club review.
Guy A, Eppler K, Moe J. | CJEM. 2022 Jan;24(1):20-22
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Need to Know: CJEM Journal Club

Editorial : Acute upper gastrointestinal bleeding (UGIB) has a mor- tality of 10%. Endoscopy within 24 h is recommended by international consensus guidelines to facilitate treatment of actively bleeding or high-risk lesions. However, data are conflicting on whether earlier endoscopic intervention in high-risk patients with UGIB improves outcomes.

Conclusion : This study demonstrated no difference in all-cause mortal- ity at 30 days with a strategy of urgent compared to early endoscopy for high-risk, stable patients with UGIB. While it may be safe to perform endoscopy in a non-urgent manner in this population, patients demonstrating clinical deterioration or with signs of further bleeding should continue to receive emergent endoscopy.

Conclusion (proposition de traduction) : Cette étude n'a démontré aucune différence dans la mortalité toutes causes confondues à 30 jours avec une stratégie d'urgence par rapport à une endoscopie précoce pour les patients stables à haut risque présentant une hémorragie gastro-intestinale haute. Bien qu'il puisse être sécuritaire d'effectuer une endoscopie de manière non urgente dans cette population, les patients présentant une détérioration clinique ou présentant des signes de saignement ultérieur doivent continuer à bénéficier d'une endoscopie d'urgence.

Commentaire : Lau J, et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. New England Journal of Medicine. 2020 Apr 02;382(14):1299–1308  .

Clinical failure in abscess treatment: the role of ultrasound and incision and drainage.
Goulding M, Haran J, Sanseverino A, Zeoli T, Gaspari R. | CJEM. 2022 Jan;24(1):39-43
DOI:  | Télécharger l'article au format  
Keywords: Abscess; Adult; Emergency service hospital; Skin; Treatment failure; Ultrasonography.

Brief Original Research

Introduction : Skin and soft tissue abscesses are commonly treated in emergency departments (ED). The use of bedside ultrasound may improve patient outcomes. The primary objective of this study was to examine the relationship between ultrasound use and risk of treatment failure in ED patients treated for abscesses.

Méthode : In this multi-center observational study, we reviewed medical records of adult patients evaluated for abscesses. Demographics, infection characteristics, treatments rendered, use of ultrasound (for diagnosis and/or treatment) and follow-up data were collected from electronic medical record review. Treatment failure, the primary outcome, was defined as any surgical intervention after the initial ED visit. Multivariable logistic regression tested whether incision and drainage utilizing ultrasound was associated with reduced treatment failure.

Résultats : We identified 609 patients diagnosed with abscesses over a 22-month period. Of them 75% were treated with incision and drainage, 55% had an ultrasound and 15% failed treatment. Multi-variable analysis demonstrated an 8% probability of failure with ultrasound plus incision and drainage, 14% with blind incision and drainage and 25% without incision and drainage. Individuals with incision and drainage performed were 50% less likely to fail treatment (RR 0.53, 95%CI 0.35-0.81) and 70% less likely to fail treatment (RR 0.30, 95%CI 0.18-0.51) with ultrasound and incision and drainage.

Conclusion : The use of ultrasound in diagnosing and or/treating patients with abscesses in the ED is associated with decreased treatment failure risk when utilized with incision and drainage. Consideration of ultrasound use in other studies which assess treatment methods in relation to patient outcomes may be warranted.

Conclusion (proposition de traduction) : L'utilisation de l'échographie pour diagnostiquer et/ou traiter aux urgences les patients souffrant d'abcès est associée à une diminution du risque d'échec du traitement lorsqu'elle est utilisée avec l'incision et le drainage. La prise en compte de l'utilisation de l'échographie dans d'autres études qui évaluent les méthodes de traitement par rapport aux résultats pour les patients peut être justifiée.


Prolonged Prehospital Time Is a Risk Factor for Pneumonia in Trauma (the PRE-TRIP Study): A Retrospective Analysis of the United States National Trauma Data Bank.
Morrow LE, Jagan N, Walters RW, Plambeck RW, Oshiro M, Malesker MA. | Chest. 2022 Jan;161(1):85-96
DOI:  | Télécharger l'article au format  
Keywords: emergency medical services; pneumonia; wounds and injuries.

Original Research

Introduction : Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown.
Research question: Is prolonged prehospital time an independent risk factor for pneumonia?

Méthode : We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016.

Résultats : Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (P < .001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (P < .001, 4.3% mortality without pneumonia vs 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns.

Conclusion : Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important, because prolonged prehospital time may need to be considered in subsequent decision-making.

Conclusion (proposition de traduction) : L'augmentation du temps de prise en charge préhospitalier est un facteur de risque indépendant de développer une pneumopathie et d'augmenter la mortalité chez les patients ayant subi un traumatisme causé par un accident de la voie publique. Bien que le temps préhospitalier ne soit pas toujours modifiable, le reconnaître comme un facteur de risque de pneumopathie est important, car un temps de prise en charge préhospitalier prolongé peut devoir être pris en compte dans la prise de décision ultérieure.

Antibiotic Timing and Progression to Septic Shock Among Patients in the ED With Suspected Infection.
Bisarya R, Song X, Salle J, Liu M, Patel A, Simpson SQ. | Chest. 2022 Jan;161(1):112-120
DOI:  | Télécharger l'article au format  
Keywords: SIRS; antibiotics; qSOFA; septic shock; suspected infection.

Original Research

Introduction : Recent medical society opinions have questioned the use of early antimicrobials in patients with sepsis, but without septic shock.
Research question: Is time from ED presentation to administration of antibiotics associated with progression to septic shock among patients with suspected infection?

Méthode : This was a retrospective cohort study from March 2007 through March 2020. All adults with suspected infection and first antimicrobial administered within 24 h of triage were included. Patients with shock on presentation were excluded. We performed univariate and multivariate logistic regression analyses predicting progression to septic shock.

Résultats : Seventy-four thousand one hundred fourteen patient encounters were included in the study. Five thousand five hundred ten patients (7.4%) progressed to septic shock. Of the patients who progressed to septic shock, 88% had received antimicrobials within the first 5 h from triage. In the multivariate logistic model, time (in hours) to first antimicrobial administration showed an OR of 1.03 (95% CI, 1.02-1.04; P < .001) for progression to septic shock and 1.02 (95% CI, 0.99-1.04; P = .121) for in-hospital mortality. When adjusted for severity of illness, each hour delayed until initial antimicrobial administration was associated with a 4.0% increase in progression to septic shock for every 1 h up to 24 h from triage. Patients with positive quick Sequential Organ Failure Assessment (qSOFA) results were given antibiotics at an earlier time point than patients with positive systemic inflammatory response syndrome (SIRS) score (0.82 h vs 1.2 h; P < .05). However, median time to septic shock was significantly shorter (P < .05) for patients with positive qSOFA results at triage (11.2 h) compared with patients with positive SIRS score at triage (26 h).

Conclusion : Delays in first antimicrobial administration in patients with suspected infection are associated with rapid increases in likelihood of progression to septic shock. Additionally, qSOFA score has higher specificity than SIRS score for predicting septic shock, but is associated with a worse outcome, even when patients receive early antibiotics.

Conclusion (proposition de traduction) : Les retards dans la première administration d'antibiotique chez les patients suspects d'infection sont associés à des augmentations rapides de la probabilité de progression vers un choc septique. De plus, le score qSOFA a une spécificité plus élevée que le score SIRS pour prédire le choc septique, mais est associé à un résultat pire, même lorsque les patients bénéficient une antibiothérapie précoce.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Chaque heure passée sans antibiotique accroit de 4% le risque de survenue d’un choc septique chez les patients admis dans un service d’urgences pour une suspicion d’infection  . Rédigé par le Dr Olivier Leroy, le 24 février 2022.


Colchicine in Cardiovascular Disease: In-Depth Review.
Deftereos SG, Beerkens FJ, Shah B, Giannopoulos G, Vrachatis DA, Giotaki SG, Siasos G, Nicolas J, Arnott C, Patel S, Parsons M, Tardif JC, Kovacic JC, Dangas GD. | Circulation. 2022 Jan 4;145(1):61-78
Keywords: Aucun

State of the Art

Editorial : Inflammation plays a prominent role in the development of atherosclerosis and other cardiovascular diseases, and anti-inflammatory agents may improve cardiovascular outcomes. For years, colchicine has been used as a safe and well-tolerated agent in diseases such as gout and familial Mediterranean fever. The widely available therapeutic has several anti-inflammatory effects, however, that have proven effective in a broad spectrum of cardiovascular diseases as well. It is considered standard-of-care therapy for pericarditis, and several clinical trials have evaluated its role in postoperative and postablation atrial fibrillation, postpericardiotomy syndrome, coronary artery disease, percutaneous coronary interventions, and cerebrovascular disease. We aim to summarize colchicine's pharmacodynamics and the mechanism behind its anti-inflammatory effect, outline thus far accumulated evidence on treatment with colchicine in cardiovascular disease, and present ongoing randomized clinical trials. We also emphasize real-world clinical implications that should be considered on the basis of the merits and limitations of completed trials. Altogether, colchicine's simplicity, low cost, and effectiveness may provide an important addition to other standard cardiovascular therapies. Ongoing studies will address complementary questions pertaining to the use of low-dose colchicine for the treatment of cardiovascular disease.

Conclusion : There is broad evidence about colchicine’s benefits in acute and recurrent pericarditis, and emerging indica- tions for its use in postprocedural AF, CAD, and stroke on the basis of its targeting of cardiovascular inflamma- tion. Indeed, colchicine may potentially become an impor- tant addition to other standard cardiovascular therapies. Guidelines already recommend colchicine for cardiovas- cular diseases such as pericarditis, and ESC has recently included CAD as a potential indication as well. However, questions remain about its use in patients with severe chronic kidney disease and its potential effect on noncar- diovascular mortality. Large ongoing trials (Table 6) should further clarify how best to use this old therapeutic agent in cardiac disease in the most safe and effective manner. Given colchicine’s promise, they are eagerly awaited.

Conclusion (proposition de traduction) : Il existe de nombreuses preuves sur les avantages de la colchicine dans la péricardite aiguë et récidivante, et sur les nouvelles indications de son utilisation dans la fibrillation atriale post-opératoire, les maladies coronariennes et les accidents vasculaires cérébraux sur la base de son ciblage sur l'inflammation cardiovasculaire. En effet, la colchicine peut potentiellement devenir un complément important aux autres traitements cardiovasculaires standard. Les lignes directrices recommandent déjà la colchicine pour les maladies cardiovasculaires telles que la péricardite, et la Société Européenne de Cardiologie a récemment également inclus la coronaropathie comme indication potentielle. Cependant, des questions subsistent quant à son utilisation chez les patients présentant une insuffisance rénale chronique sévère et son effet possible sur la mortalité non cardiovasculaire. De grands essais en cours devraient clarifier davantage la meilleure façon d'utiliser cet ancien agent thérapeutique dans les maladies cardiaques de la manière la plus sûre et la plus efficace. Vu la promesse de la colchicine, ils sont très attendus.

Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation: Patient-Level Network Meta-Analyses of Randomized Clinical Trials With Interaction Testing by Age and Sex.
Carnicelli AP, Hong H, Connolly SJ and al.; COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) Investigators. | Circulation. 2022 Jan 25;145(4):242-255
Keywords: anticoagulants; atrial fibrillation; meta-analysis; stroke; warfarin.

Original Research Articles

Introduction : Direct oral anticoagulants (DOACs) are preferred over warfarin for stroke prevention in atrial fibrillation. Meta-analyses using individual patient data offer substantial advantages over study-level data.

Méthode : We used individual patient data from the COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) database, which includes all patients randomized in the 4 pivotal trials of DOACs versus warfarin in atrial fibrillation (RE-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation], ARISTOTLE [Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation], and ENGAGE AF-TIMI 48 [Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48]), to perform network meta-analyses using a stratified Cox model with random effects comparing standard-dose DOAC, lower-dose DOAC, and warfarin. Hazard ratios (HRs [95% CIs]) were calculated for efficacy and safety outcomes. Covariate-by-treatment interaction was estimated for categorical covariates and for age as a continuous covariate, stratified by sex.

Résultats : A total of 71 683 patients were included (29 362 on standard-dose DOAC, 13 049 on lower-dose DOAC, and 29 272 on warfarin). Compared with warfarin, standard-dose DOACs were associated with a significantly lower hazard of stroke or systemic embolism (883/29 312 [3.01%] versus 1080/29 229 [3.69%]; HR, 0.81 [95% CI, 0.74-0.89]), death (2276/29 312 [7.76%] versus 2460/29 229 [8.42%]; HR, 0.92 [95% CI, 0.87-0.97]), and intracranial bleeding (184/29 270 [0.63%] versus 409/29 187 [1.40%]; HR, 0.45 [95% CI, 0.37-0.56]), but no statistically different hazard of major bleeding (1479/29 270 [5.05%] versus 1733/29 187 [5.94%]; HR, 0.86 [95% CI, 0.74-1.01]), whereas lower-dose DOACs were associated with no statistically different hazard of stroke or systemic embolism (531/13 049 [3.96%] versus 1080/29 229 [3.69%]; HR, 1.06 [95% CI, 0.95-1.19]) but a lower hazard of intracranial bleeding (55/12 985 [0.42%] versus 409/29 187 [1.40%]; HR, 0.28 [95% CI, 0.21-0.37]), death (1082/13 049 [8.29%] versus 2460/29 229 [8.42%]; HR, 0.90 [95% CI, 0.83-0.97]), and major bleeding (564/12 985 [4.34%] versus 1733/29 187 [5.94%]; HR, 0.63 [95% CI, 0.45-0.88]). Treatment effects for standard- and lower-dose DOACs versus warfarin were consistent across age and sex for stroke or systemic embolism and death, whereas standard-dose DOACs were favored in patients with no history of vitamin K antagonist use (P=0.01) and lower creatinine clearance (P=0.09). For major bleeding, standard-dose DOACs were favored in patients with lower body weight (P=0.02). In the continuous covariate analysis, younger patients derived greater benefits from standard-dose (interaction P=0.02) and lower-dose DOACs (interaction P=0.01) versus warfarin.

Conclusion : Compared with warfarin, DOACs have more favorable efficacy and safety profiles among patients with atrial fibrillation.

Conclusion (proposition de traduction) : Par rapport à la warfarine, les AOD ont des profils d'efficacité et d'innocuité plus favorables chez les patients présentant une fibrillation atriale.

Cochrane Database of Systematic Reviews

Cuffed versus uncuffed endotracheal tubes for neonates.
Dariya V, Moresco L, Bruschettini M, Brion LP. | Cochrane Database Syst Rev. 2022 Jan 24;1(1):CD013736
Keywords: Aucun


Introduction : Endotracheal intubation is a commonly performed procedure in neonates, the risks of which are well-described. Some endotracheal tubes (ETT) are equipped with a cuff that can be inflated after insertion of the ETT in the airway to limit leak or aspiration. Cuffed ETTs have been shown in larger children and adults to reduce gas leak around the ETT, ETT exchange, accidental extubation, and exposure of healthcare workers to anesthetic gas during surgery. With improved understanding of neonatal airway anatomy and the widespread use of cuffed ETTs by anesthesiologists, the use of cuffed tubes is increasing in neonates.
Objectives: To assess the benefits and harms of cuffed ETTs (inflated or non-inflated) compared to uncuffed ETTs for respiratory support in neonates.

Méthode : We searched CENTRAL, PubMed, and CINAHL on 20 August 2021; we also searched trial registers and checked reference lists to identify additional studies.
Selection criteria: We included randomized controlled trials (RCTs), quasi-RCTs, and cluster-randomized trials comparing cuffed (inflated and non-inflated) versus uncuffed ETTs in newborns. We sought to compare 1. inflated, cuffed versus uncuffed ETT; 2. non-inflated, cuffed versus uncuffed ETT; and 3. inflated, cuffed versus non-inflated, cuffed ETT.
Data collection and analysis: We used the standard methods of Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence.

Résultats : We identified one eligible RCT for inclusion that compared the use of cuffed (inflated if ETT leak greater than 20% with cuff pressure 20 cm H2O or less) versus uncuffed ETT. The author provided a spreadsheet with individual data. Among 76 infants in the original manuscript, 69 met the inclusion and exclusion criteria for this Cochrane Review. We found possible bias due to lack of blinding and other bias. We are very uncertain about frequency of postextubation stridor, because the confidence intervals (CI) of the risk ratio (RR) were very wide (RR 1.36, 95% CI 0.35 to 5.25; risk difference (RD) 0.03, -0.11 to 0.18; 1 study, 69 participants; very low-certainty evidence). No neonate was diagnosed with postextubation subglottic stenosis; however, endoscopy was not available to confirm the clinical diagnosis. We are very uncertain about reintubation for stridor or subglottic stenosis because the CIs of the RR were very wide (RR 0.27, 95% CI 0.01 to 6.49; RD -0.03, 95% CI -0.11 to 0.05; 1 study, 69 participants; very low-certainty evidence). No neonate had surgical intervention (e.g. endoscopic balloon dilation, cricoid split, tracheostomy) for stridor or subglottic stenosis (1 study, 69 participants). Neonates randomized to cuffed ETT may be less likely to have a reintubation for any reason (RR 0.06, 95% CI 0.01 to 0.45; RD -0.39, 95% CI -0.57 to -0.21; number needed to treat for an additional beneficial outcome 3, 95% CI 2 to 5; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about accidental extubation because the CIs of the RR were wide (RR 0.82, 95% CI 0.12 to 5.46; RD -0.01, 95% CI -0.12 to 0.10; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about all-cause mortality during initial hospitalization because the CIs of the RR were extremely wide (RR 2.46, 95% CI 0.10 to 58.39; RD 0.03, 95% CI -0.05 to 0.10; 1 study, 69 participants; very low-certainty evidence). There is one ongoing trial. We classified two studies as awaiting classification because outcome data were not reported separately for newborns and older infants.

Conclusion : Evidence for comparing cuffed versus uncuffed ETTs in neonates is limited by a small number of babies in a single RCT with possible bias. There is very low certainty evidence for all outcomes of this review. CIs of the estimate for postextubation stridor were wide. No neonate had clinical evidence for subglottic stenosis; however, endoscopy results were not available to assess the anatomy. Additional RCTs are necessary to evaluate the benefits and harms of cuffed ETTs (inflated and non-inflated) in the neonatal population. These studies must include neonates and be conducted both for short-term use (in the setting of the operating room) and chronic use (in the setting of chronic lung disease) of cuffed ETTs.

Conclusion (proposition de traduction) : Les données permettant de comparer les tubes endotrachéaux à ballonnet et sans ballonnet chez les nouveau-nés sont limitées par un petit nombre de bébés dans un seul essai contrôlé randomisé avec un biais possible. Il y a très peu d’indices de certitude pour tous les résultats de cette revue. Les intervalles de confiance de l’estimation du stridor après l'extubation étaient larges. Aucun nouveau-né ne présentait de signes cliniques de sténose sous-glottique ; toutefois, les résultats de l’endoscopie n’étaient pas disponibles pour évaluer l’anatomie. D’autres essais contrôlés randomisés sont nécessaires pour évaluer les avantages et les inconvénients des tubes endotrachéaux à ballonnet (gonflés et non gonflés) dans la population néonatale. Ces études doivent inclure des nouveau-nés et porter sur l’utilisation à court terme (en salle d’opération) et sur l’utilisation chronique (en cas de maladie pulmonaire chronique) des tubes endotrachéaux à ballonnet.

Oral antiplatelet therapy for acute ischaemic stroke.
Minhas JS, Chithiramohan T, Wang X, Barnes SC, Clough RH, Kadicheeni M, Beishon LC, Robinson T. | Cochrane Database Syst Rev. 2022 Jan 14;1(1):CD000029
Keywords: Aucun


Introduction : In people with acute ischaemic stroke, platelets become activated and can cause blood clots to form and block an artery in the brain, resulting in damage to part of the brain. Such damage gives rise to the symptoms of stroke. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and also reduce the risk of early recurrent ischaemic stroke, thereby reducing the risk of early death and improving long-term outcomes in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage.
Objectives: To assess the efficacy and safety of immediate oral antiplatelet therapy (i.e. started as soon as possible and no later than two weeks after stroke onset) in people with acute presumed ischaemic stroke.

Méthode : We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and two trials registers, and performed forward reference/cited reference searching in August 2020.
Selection criteria: Randomised controlled trials (RCTs) comparing oral antiplatelet therapy (started within 14 days of the stroke) with control in people with definite or presumed ischaemic stroke.
Data collection and analysis: Two review authors independently applied the inclusion criteria and assessed trial quality. For the included trials, they extracted and cross-checked the data. They assessed risk of bias of each study using the Risk of Bias 1 (RoB1) tool and overall certainty of the evidence for each outcome using the GRADE approach.

Résultats : We included 11 studies involving 42,226 participants. Three new trials have been added since the last update (743 participants). As per the previous version of this review, two trials testing aspirin 160 mg to 300 mg once daily, started within 48 hours of onset, contributed 96% of the data. The risk of bias was low. The maximum follow-up was six months. With treatment, there was a decrease in death or dependency at the end of follow-up (odds ratio (OR) 0.95, 95% confidence interval (CI) 0.91 to 0.99; 7 RCTs, 42,034 participants; moderate-certainty evidence). For every 1000 people treated with aspirin, 13 people would avoid death or dependency (number needed to treat for an additional beneficial outcome 79).

Conclusion : Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in people who cannot swallow) and started within 48 hours of onset of presumed ischaemic stroke, significantly decreased death and dependency, and reduced the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications; long-term outcomes were improved.

Conclusion (proposition de traduction) : Un traitement anti-agrégant plaquettaire par de l'aspirine 160 mg à 300 mg par jour, administré par voie orale (ou par sonde nasogastrique ou par voie rectale chez les personnes incapables d'avaler) et débuté dans les 48 heures suivant l'apparition d'un AVC ischémique présumé, a significativement diminué la mortalité et la dépendance, et réduit le risque de AVC ischémique récidivant précoce sans risque majeur de complications hémorragiques précoces ; les résultats à long terme ont été améliorés.

Critical Care

Vitamin C improves microvascular reactivity and peripheral tissue perfusion in septic shock patients.
Lavillegrand JR, Raia L, Urbina T, Hariri G, Gabarre P, Bonny V, Bigé N, Baudel JL, Bruneel A, Dupre T, Guidet B, Maury E, Ait-Oufella H. | Crit Care. 2022 Jan 21;26(1):25
DOI:  | Télécharger l'article au format  
Keywords: Microvascular function; Mottling; Sepsis; Tissue perfusion; Vitamin C.


Introduction : Vitamin C has potential protective effects through antioxidant and anti-inflammatory properties. However, the effect of vitamin C supplementation on microvascular function and peripheral tissue perfusion in human sepsis remains unknown. We aimed to determine vitamin C effect on microvascular endothelial dysfunction and peripheral tissue perfusion in septic shock patients.

Méthode : Patients with septic shock were prospectively included after initial resuscitation. Bedside peripheral tissue perfusion and skin microvascular reactivity in response to acetylcholine iontophoresis in the forearm area were measured before and 1 h after intravenous vitamin C supplementation (40 mg/kg). Norepinephrine dose was not modified during the studied period.

Résultats : We included 30 patients with septic shock. SOFA score was 11 [8-14], SAPS II was 66 [54-79], and in-hospital mortality was 33%. Half of these patients had vitamin C deficiency at inclusion. Vitamin C supplementation strongly improved microvascular reactivity (AUC 2263 [430-4246] vs 5362 [1744-10585] UI, p = 0.0004). In addition, vitamin C supplementation improved mottling score (p = 0.06), finger-tip (p = 0.0003) and knee capillary refill time (3.7 [2.6-5.5] vs 2.9 [1.9-4.7] s, p < 0.0001), as well as and central-to-periphery temperature gradient (6.1 [4.9-7.4] vs 4.6 [3.4-7.0] °C, p < 0.0001). The beneficial effects of vitamin C were observed both in patients with or without vitamin C deficiency.

Conclusion : In septic shock patients being resuscitated, vitamin C supplementation improved peripheral tissue perfusion and microvascular reactivity whatever plasma levels of vitamin C.

Conclusion (proposition de traduction) : Chez les patients en choc septique en réanimation, la supplémentation en vitamine C a amélioré la perfusion tissulaire périphérique et la réactivité microvasculaire quel que soit le taux plasmatique de vitamine C.

Commentaire : Voir l'article : Fujii T, Salanti G, Belletti A and al. Effect of adjunctive vitamin C, glucocorticoids, and vitamin B1 on longer-term mortality in adults with sepsis or septic shock: a systematic review and a component network meta-analysis. Intensive Care Med. 2022 Jan;48(1):16-24  .

Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study.
Im Y, Kang D, Ko RE, Lee YJ, Lim SY, Park S, Na SJ, Chung CR, Park MH, Oh DK, Lim CM, Suh GY; Korean Sepsis Alliance (KSA) investigators. | Crit Care. 2022 Jan 13;26(1):19
DOI:  | Télécharger l'article au format  
Keywords: Hour-1 bundle; Mortality; Sepsis; Septic shock; Time-to-antibiotics.


Introduction : Timely administration of antibiotics is one of the most important interventions in reducing mortality in sepsis. However, administering antibiotics within a strict time threshold in all patients suspected with sepsis will require huge amount of effort and resources and may increase the risk of unintentional exposure to broad-spectrum antibiotics in patients without infection with its consequences. Thus, controversy still exists on whether clinicians should target different time-to-antibiotics thresholds for patients with sepsis versus septic shock.

Méthode : This study analyzed prospectively collected data from an ongoing multicenter cohort of patients with sepsis identified in the emergency department. Adjusted odds ratios (ORs) were compared for in-hospital mortality of patients who had received antibiotics within 1 h to that of those who did not. Spline regression models were used to assess the association of time-to-antibiotics as continuous variables and increasing risk of in-hospital mortality. The differences in the association between time-to-antibiotics and in-hospital mortality were assessed according to the presence of septic shock.

Résultats : Overall, 3035 patients were included in the analysis. Among them, 601 (19.8%) presented with septic shock, and 774 (25.5%) died. The adjusted OR for in-hospital mortality of patients whose time-to-antibiotics was within 1 h was 0.78 (95% confidence interval [CI] 0.61-0.99; p = 0.046). The adjusted OR for in-hospital mortality was 0.66 (95% CI 0.44-0.99; p = 0.049) and statistically significant in patients with septic shock, whereas it was 0.85 (95% CI 0.64-1.15; p = 0.300) in patients with sepsis but without shock. Among patients who received antibiotics within 3 h, those with septic shock showed 35% (p = 0.042) increased risk of mortality for every 1-h delay in antibiotics, but no such trend was observed in patients without shock.

Conclusion : Timely administration of antibiotics improved outcomes in patients with septic shock; however, the association between early antibiotic administration and outcome was not as clear in patients with sepsis without shock.

Conclusion (proposition de traduction) : L'administration rapide d'antibiotiques a amélioré les résultats chez les patients en choc septique ; cependant, l'association entre l'administration précoce d'antibiotiques et le résultat n'était pas aussi claire chez les patients présentant un septisis sans état de choc.

Critical Care Medicine

Trends in Endotracheal Intubation During In-Hospital Cardiac Arrests: 2001-2018.
Schwab K, Buhr RG, Grossetreuer AV, Balaji L, Lee ES, Moskowitz AL; American Heart Association’s Get With the Guidelines-Resuscitation Investigators. | Crit Care Med. 2022 Jan 1;50(1):72-80
Keywords: Aucun

Clinical Investigation

Introduction : Airway management during in-hospital cardiac arrest represents a fundamental component of resuscitative efforts, yet little is known about temporal trends in intubation during in-hospital cardiac arrest. Our objective was to investigate changes in in-hospital cardiac arrest airway management over time and in response to national guideline updates.
Design: Observational cohort study of a prospectively collected database.
Setting: Multicenter study of hospitals participating in the "Get With The Guidelines-Resuscitation" registry from January 1, 2001, to December 31, 2018.

Méthode : Adult patients who experienced an in-hospital cardiac arrest and did not have an invasive airway in place prior to the arrest.
Interventions: The primary outcome was the rate of intra-arrest intubation from 2001 to 2018. We constructed multivariable regression models with generalized estimating equations to determine the annual adjusted odds of intubation. We also assessed the timing of intubation relative to the onset of pulselessness and other arrest measures. We used an interrupted time-series analysis to assess the association between the 2010 Advanced Cardiac Life Support guideline update and intubation rates.

Résultats : One thousand sixty-six eight hundred patients from 797 hospitals were included. From 2001 to 2018, the percentage of patients intubated during an arrest decreased from 69% to 55% for all rhythms, 73% to 60% for nonshockable rhythms, and 58% to 36% for shockable rhythms (p < 0.001 for trend for all 3 groups). The median time from onset of pulselessness to intubation increased from 5 minutes in 2001 (interquartile range, 2-8 min) to 6 minutes in 2018 (interquartile range, 4-10 min) (p < 0.001 for trend). Following the 2010 guideline update, there was a downward step change and a steeper decrease over time in the rate of intubation as compared to the preintervention period (p < 0.001).

Conclusion : Endotracheal intubation rates during in-hospital cardiac arrest have decreased significantly over time, with a more substantial decline following the updated 2010 guideline that prioritized chest compressions over airway management.

Conclusion (proposition de traduction) : Les taux d'intubation endotrachéale lors d'un arrêt cardiaque à l'hôpital ont considérablement diminué au fil du temps, avec une baisse plus importante à la suite de la mise à jour des directives de 2010 qui accordait la priorité aux compressions thoraciques par rapport à la gestion des voies respiratoires.

Current Opinion in Critical Care

Noninvasive respiratory support for acute respiratory failure due to COVID-19.
Menga LS, Berardi C, Ruggiero E, Grieco DL, Antonelli M. | Curr Opin Crit Care. 2022 Feb 1;28(1):25-50
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Noninvasive respiratory support has been widely applied during the COVID-19 pandemic. We provide a narrative review on the benefits and possible harms of noninvasive respiratory support for COVID-19 respiratory failure.

Résultats : Maintenance of spontaneous breathing by means of noninvasive respiratory support in hypoxemic patients with vigorous spontaneous effort carries the risk of patient self-induced lung injury: the benefit of averting intubation in successful patients should be balanced with the harms of a worse outcome in patients who are intubated after failing a trial of noninvasive support.The risk of noninvasive treatment failure is greater in patients with the most severe oxygenation impairment (PaO2/FiO2 < 200 mmHg).High-flow nasal oxygen (HFNO) is the most widely applied intervention in COVID-19 patients with hypoxemic respiratory failure. Also, noninvasive ventilation (NIV) and continuous positive airway pressure delivered with different interfaces have been used with variable success rates. A single randomized trial showed lower need for intubation in patients receiving helmet NIV with specific settings, compared to HFNO alone.Prone positioning is recommended for moderate-to-severe acute respiratory distress syndrome patients on invasive ventilation. Awake prone position has been frequently applied in COVID-19 patients: one randomized trial showed improved oxygenation and lower intubation rate in patients receiving 6-h sessions of awake prone positioning, as compared to conventional management.

Conclusion : Noninvasive respiratory support and awake prone position are tools possibly capable of averting endotracheal intubation in COVID-19 patients; carefully monitoring during any treatment is warranted to avoid delays in endotracheal intubation, especially in patients with PaO2/FiO2 < 200 mmHg.

Conclusion (proposition de traduction) : La ventilation non invasive et la décubitus ventral vigile sont des outils susceptibles d'éviter l'intubation endotrachéale chez les patients COVID-19 ; une surveillance attentive pendant tout traitement est justifiée pour éviter des retards dans l'intubation endotrachéale, en particulier chez les patients avec PaO2/FiO2 < 200 mmHg.

Hong Kong Journal of Emergency Medicine

Hyperglycemia as a positive predictor of mortality in major trauma.
Chang CP , Hsiao CT, Wang CH, Chen KH, Chen IC, Lin CN, Hsiao KY. | Hong Kong J Emerg Med. 2022 January;29(1):46–50
DOI:  | Télécharger l'article au format  
Keywords: Hyperglycemia; major trauma; mortality

Original Article

Introduction : Hyperglycemia in the acute phase after trauma is a stress response and a metabolic reflection in humans with injury, which could adversely affect outcome in trauma patients. In this study, we attempted to identify if hyperglycemia a reliable predictor for mortality in major trauma patients.
Objectives: In order to identify if hyperglycemia a reliable predictor for mortality in major trauma, we designed and proformed a prospective observational study in a tertiary hospital.

Méthode : We performed a prospective observational study to review the records of 601 patients with major trauma (injury severity scores >15) who visited our hospital’s emergency department from August 2012 to July 2015. Logistic regression was performed to assess the effect of hyperglycemia on mortality.

Résultats : Major trauma patients in the hyperglycemia group had low systolic/diastolic blood pressure at triage, low initial Glasgow Coma Scale score, high incidence of hypotension episodes, coagulopathy, acidosis, and anemia. Hyperglycemia was significantly correlated with mortality in major trauma patients in this study (odds ratio: 1.97, 95% confidence interval: 1.04–3.74).

Conclusion : In major trauma patients with injury severity scores >15, hyperglycemia has a positive correlation with mortality, which could be a predictor of mortality in clinical practice

Conclusion (proposition de traduction) : Chez les patients victimes de traumatismes majeurs dont le score de gravité des blessures est supérieur à 15, l'hyperglycémie présente une corrélation positive avec la mortalité, ce qui pourrait être un facteur prédictif de la mortalité dans la pratique clinique.

Intensive Care Medicine

Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial.
Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO; EvK Clinical Trial Collaborators. | Intensive Care Med. 2022 Jan;48(1):78-91
Keywords: Airway management; Anesthetic induction medication; Emergency endotracheal intubation; Etomidate; Ketamine.


Introduction : Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation.

Méthode : A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival.

Résultats : Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval - 13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence interval - 9.3, 3.9, p = 0.294).

Conclusion : While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.

Conclusion (proposition de traduction) : Bien que le critère principal de survie au 7e jour ait été plus élevé chez les patients randomisés dans le groupe kétamine, il n’y avait pas de différence significative de survie au 28e jour.

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

Voir également l'analyse de l'article sur :
JournalFeed  . Janvier 2022 par le Clay Smith.

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications.
Abrams D, MacLaren G, Lorusso R, Price S, Yannopoulos D, Vercaemst L, Bělohlávek J, Taccone FS, Aissaoui N, Shekar K, Garan AR, Uriel N, Tonna JE, Jung JS, Takeda K, Chen YS, Slutsky AS, Combes A, Brodie D. | Intensive Care Med. 2022 Jan;48(1):1-15
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Narrative Review

Editorial : Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

Conclusion : L'ECPR offre la promesse d'améliorer significativement les faibles taux de survie avec récupération fonctionnelle et neurologique chez les patients victimes d'un arrêt cardiaque. À l'heure actuelle, il existe suffisamment de données pour soutenir l'initiation de l'ECPR chez certains individus présentant des étiologies réversibles d'arrêt cardiaque chez qui le temps de faible débit est minimisé - et même dans certaines circonstances avec un temps de faible débit plus prolongé - avec un plus grand bénéfice potentiel dans un arrêt cardiaque à l'hôpital qu'à l'extérieur de l'hôpital. Ces conditions supposent que le système de santé dans lequel l'ECPR est proposé est conçu pour fournir l'intervention de manière efficace et efficiente. Deux essais contrôlés randomisés récents ont démontré que l'ECPR est mieux mise en œuvre dans un système organisé à volume élevé, avec une formation et une coordination approfondies entre les départements, y compris les services d'urgence pour les arrêts cardiaques en dehors de l'hôpital. Les recherches futures devraient approfondir notre compréhension actuelle du rôle de l'ECPR dans l'arrêt cardiaque et affiner notre approche de cette entreprise complexe.

Conclusion (proposition de traduction) : Cardiac arrest; Extracorporeal cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; IHCA; OHCA.

Effect of adjunctive vitamin C, glucocorticoids, and vitamin B1 on longer-term mortality in adults with sepsis or septic shock: a systematic review and a component network meta-analysis.
Fujii T, Salanti G, Belletti A, Bellomo R, Carr A, Furukawa TA, Luethi N, Luo Y, Putzu A, Sartini C, Tsujimoto Y, Udy AA, Yanase F, Young PJ. | Intensive Care Med. 2022 Jan;48(1):16-24
DOI:  | Télécharger l'article au format  
Keywords: Hydrocortisone; Network meta-analysis; Sepsis; Systematic review; Thiamine; Vitamin C.

Systematic Review

Editorial : We aimed to compare the effects of vitamin C, glucocorticoids, vitamin B1, combinations of these drugs, and placebo or usual care on longer-term mortality in adults with sepsis or septic shock. MEDLINE, Embase, CENTRAL, and WHO-ICTRP were searched. The final search was carried out on September 3rd, 2021. Multiple reviewers independently selected randomized controlled trials (RCTs) comparing very-high-dose vitamin C (≥ 12 g/day), high-dose vitamin C (< 12, ≥ 6 g/day), vitamin C (< 6 g/day), glucocorticoid (< 400 mg/day of hydrocortisone), vitamin B1, combinations of these drugs, and placebo/usual care. We performed random-effects network meta-analysis and, where applicable, a random-effects component network meta-analysis. We used the Confidence in Network Meta-Analysis framework to assess the degree of treatment effect certainty. The primary outcome was longer-term mortality (90-days to 1-year). Secondary outcomes were severity of organ dysfunction over 72 h, time to cessation of vasopressor therapy, and length of stay in intensive care unit (ICU). Forty-three RCTs (10,257 patients) were eligible. There were no significant differences in longer-term mortality between treatments and placebo/usual care or between treatments (10 RCTs, 7,096 patients, moderate to very-low-certainty). We did not find any evidence that vitamin C or B1 affect organ dysfunction or ICU length of stay. Adding glucocorticoid to other treatments shortened duration of vasopressor therapy (incremental mean difference, - 29.8 h [95% CI - 44.1 to - 15.5]) and ICU stay (incremental mean difference, - 1.3 days [95% CI - 2.2 to - 0.3]). Metabolic resuscitation with vitamin C, glucocorticoids, vitamin B1, or combinations of these drugs was not significantly associated with a decrease in longer-term mortality.

Conclusion : On network meta-analysis, metabolic resuscitation with vitamin C, glucocorticoids, vitamin B1, or combinations of these drugs was not proven to reduce longer-term mortality. However, network meta-analysis and component network meta-analysis suggested an association of high dose and very high dose vitamin C and decreased mortality with low certainty. Glucocorticoid therapy was associated with a decreased duration of vasopressor support and ICU therapy. Further RCTs evaluating very high dose intravenous vitamin C therapy appear justified.

Conclusion (proposition de traduction) : Dans une méta-analyse en réseau, il n'a pas été prouvé que la réanimation métabolique avec de la vitamine C, des glucocorticoïdes, de la vitamine B1 ou des combinaisons de ces médicaments réduisait la mortalité à plus long terme. Cependant, la méta-analyse en réseau et la méta-analyse en réseau des composants ont suggéré une association entre une dose élevée et une dose très élevée de vitamine C et une diminution de la mortalité avec une faible certitude. Le traitement par les glucocorticoïdes était associée à une diminution de la durée des besoins en vasopresseur et du séjours en soins intensifs. D'autres essais contrôlés randomisés évaluant une thérapie intraveineuse à très haute dose de vitamine C semblent justifiés.

Commentaire : Pour l'explication physiopathologie de l'action des micronutriments, comme la vitamine C, voir l'article : Berger MM, Chioléro RL. Apport d’antioxydants en réanimation : pourquoi, lesquels, avec quels objectifs ? Réanimation 2001;10:527-34  .
Autre références récente : Lavillegrand JR, Raia L, Urbina T and al. Vitamin C improves microvascular reactivity and peripheral tissue perfusion in septic shock patients. Crit Care. 2022 Jan 21;26(1):25  .
Les posologies proposées dans cette indication sont : 1 g quatre fois par jour chez les patients de moins de 70 kg, et 1,5 g quatre fois par jour chez les patients de plus de 70 kg, pendant 4 jours.

Toutefois, la vitamine C n'est pas recommandée dans la dernière édition (octobre 2021) du « Surviving sepsis campaign » : Recommendation 70. Pour les adultes en sepsis ou en choc septique, nous déconseillons l'utilisation de vitamine C intraveineux. Recommandation faible, preuves de faible qualité.
Evans L, Rhodes A, Alhazzani W and al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247  .

Dexamethasone 12 mg versus 6 mg for patients with COVID-19 and severe hypoxaemia: a pre-planned, secondary Bayesian analysis of the COVID STEROID 2 trial.
Granholm A, Munch MW, Myatra SN and al. | Intensive Care Med. 2022 Jan;48(1):45-55
DOI:  | Télécharger l'article au format  
Keywords: Bayesian analysis; COVID-19; Corticosteroids; Critical illness; Hypoxaemia.


Introduction : We compared dexamethasone 12 versus 6 mg daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia in the international, randomised, blinded COVID STEROID 2 trial. In the primary, conventional analyses, the predefined statistical significance thresholds were not reached. We conducted a pre-planned Bayesian analysis to facilitate probabilistic interpretation.

Méthode : We analysed outcome data within 90 days in the intention-to-treat population (data available in 967 to 982 patients) using Bayesian models with various sensitivity analyses. Results are presented as median posterior probabilities with 95% credible intervals (CrIs) and probabilities of different effect sizes with 12 mg dexamethasone.

Résultats : The adjusted mean difference on days alive without life support at day 28 (primary outcome) was 1.3 days (95% CrI -0.3 to 2.9; 94.2% probability of benefit). Adjusted relative risks and probabilities of benefit on serious adverse reactions was 0.85 (0.63 to 1.16; 84.1%) and on mortality 0.87 (0.73 to 1.03; 94.8%) at day 28 and 0.88 (0.75 to 1.02; 95.1%) at day 90. Probabilities of benefit on days alive without life support and days alive out of hospital at day 90 were 85 and 95.7%, respectively. Results were largely consistent across sensitivity analyses, with relatively low probabilities of clinically important harm with 12 mg on all outcomes in all analyses.

Conclusion : We found high probabilities of benefit and low probabilities of clinically important harm with dexamethasone 12 mg versus 6 mg daily in patients with COVID-19 and severe hypoxaemia on all outcomes up to 90 days.

Conclusion (proposition de traduction) : Nous avons trouvé des probabilités élevées de bénéfice et de faibles probabilités de préjudice cliniquement important avec la dexaméthasone 12 mg par rapport à 6 mg par jour chez les patients atteints de la COVID-19 et d'hypoxémie sévère sur tous les critères de jugement jusqu'à 90 jours.

Understanding purpura fulminans in adult patients.
Contou D, Urbina T, de Prost N. | Intensive Care Med. 2022 Jan;48(1):106-110
Keywords: Aucun

Understanding the Disease

Editorial : Purpura fulminans (PF) is a rare life-threatening infectious disease characterized by the association of a sudden and extensive purpuric rash together with an acute circulatory failure. PF accounts for less than 0.5% of the sources of septic shock. Neisseria meningitidis and Streptococcus pneumoniae are the leading causative bacteria. Despite these pathogens being highly susceptible to broadly available antibiotics, mortality and morbidity of PF remain high. A better knowledge of its pathophysiology, clinical presentation and management seems paramount to guide both clinicians and future clinical research.

Conclusion : The growing understanding of PF could lead to therapeutic innovations. As of today, the early management of PF should focus on interventions likely to impact outcomes: First, to maintain a high index of suspicion to avoid misdiagnosis and delay in treatment initiation; Second, to initiate immediate antibiotic treatment, and manage organ-failures and DIC in the intensive care unit; Third, to decide whether or not and when to perform limb amputations requires an experienced multidisciplinary team. PF survivors should benefit from long-term follow-up, physical rehabilitation and psychological support to minimize the impact of such amputations on their quality of life.

Conclusion (proposition de traduction) : La compréhension croissante du purpura fulminans pourrait conduire à des innovations thérapeutiques. À ce jour, la prise en charge précoce du purpura fulminans doit se concentrer sur les interventions susceptibles d'avoir un impact sur les résultats : premièrement, maintenir un indice de suspicion élevé pour éviter les erreurs de diagnostic et les retards dans l'initiation du traitement ; Deuxièmement, pour initier un traitement antibiotique immédiat et gérer les défaillances d'organes et la coagulation intravasculaire disséminée dans l'unité de soins intensifs ; Troisièmement, pour décider si oui ou non et quand procéder à des amputations de membres, il faut une équipe multidisciplinaire expérimentée. Les survivants du purpura fulminans devraient bénéficier d'un suivi à long terme, d'une réadaptation physique et d'un soutien psychologique afin de minimiser l'impact de telles amputations sur leur qualité de vie.

Internal and Emergency Medicine

Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial.
Cédric GJ, Patricia J, Frederic A, Thomas N, Patrick E, Bertrand G, Cyril F, Valery B, Xavier C. | Intern Emerg Med. 2022 Jan 17
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Keywords: Adults; Cardiac arrest; Emergency; Obesity; Out-of-hospital; Rapid sequence intubation; Tracheal intubation.


Introduction : The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients.

Méthode : This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence.

Résultats : A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO2) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting.

Conclusion : We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.

Conclusion (proposition de traduction) : Nous avons identifié plusieurs facteurs de risque indépendants d'arrêt cardiaque péri-intubation, notamment l'obésité, l'hypoxémie avant l'intubation et l'intubation difficile.

Vitamin D deficiency is associated with higher risks for SARS-CoV-2 infection and COVID-19 severity: a retrospective case-control study.
Israel A, Cicurel A, Feldhamer I, Stern F, Dror Y, Giveon SM, Gillis D, Strich D, Lavie G. | Intern Emerg Med. 2022 Jan 9:1–11
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Keywords: COVID-19; Large population; Retrospective study; SARS-CoV-2; Vitamin D.

Content type: IM - ORIGINAL

Introduction : Robust evidence of whether vitamin D deficiency is associated with COVID-19 infection and its severity is still lacking.

Méthode : The aim of the study was to evaluate the association between vitamin D levels and the risks of SARS-CoV-2 infection and severe disease in those infected. A retrospective study was carried out among members of Clalit Health Services (CHS), the largest healthcare organization in Israel, between March 1 and October 31, 2020.

Résultats : We created two matched case-control groups of individuals for which vitamin D levels and body mass index (BMI) were available before the pandemic: group (A), in which 41,757 individuals with positive SARS-CoV-2 PCR tests were matched with 417,570 control individuals without evidence of infection, and group (B), in which 2533 patients hospitalized in severe condition for COVID-19 were matched with 2533 patients who were tested positive for SARS-CoV-2, but were not hospitalized. Conditional logistic models were fitted in each of the groups to assess the association between vitamin D levels and outcome. An inverse correlation was demonstrated between the level of vitamin D and the risks of SARS-CoV-2 infection and of severe disease in those infected. Patients with very low vitamin D levels (< 30 nmol/L) had the highest risks for SARS-CoV-2 infection and also for severe COVID-19 when infected-OR 1.246 [95% CI 1.210-1.304] and 1.513 [95% CI 1.230-1.861], respectively.

Conclusion : In this large observational population study, we show a significant association between vitamin D deficiency and the risks of SARS-CoV-2 infection and of severe disease in those infected.

Conclusion (proposition de traduction) : Dans cette vaste étude observationnelle de la population, nous montrons une association significative entre la carence en vitamine D et les risques d'infection par le SRAS-CoV-2 et de maladie grave chez les personnes infectées.

Length of stay as quality indicator in emergency departments: analysis of determinants in the German Emergency Department Data Registry (AKTIN registry).
Otto R, Blaschke S, Schirrmeister W, Drynda S, Walcher F, Greiner F. | Intern Emerg Med. 2022 Jan 6
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Keywords: Emergency department; Length of stay; Quality indicator; Registry.


Introduction : Several indicators reflect the quality of care within emergency departments (ED). The length of stay (LOS) of emergency patients represents one of the most important performance measures. Determinants of LOS have not yet been evaluated in large cohorts in Germany.

Méthode : This study analyzed the fixed and influenceable determinants of LOS by evaluating data from the German Emergency Department Data Registry (AKTIN registry). We performed a retrospective evaluation of all adult (age ≥ 18 years) ED patients enrolled in the AKTIN registry for the year 2019. Primary outcome was LOS for the whole cohort; secondary outcomes included LOS stratified by (1) patient-related, (2) organizational-related and (3) structure-related factors.

Résultats : Overall, 304,606 patients from 12 EDs were included. Average LOS for all patients was 3 h 28 min (95% CI 3 h 27 min-3 h 29 min). Regardless of other variables, patients admitted to hospital stayed 64 min longer than non-admitted patients. LOS increased with patients' age, was shorter for walk-in patients compared to medical referral, and longer for non-trauma presenting complaints. Relevant differences were also found for acuity level, day of the week, and emergency care levels. We identified different factors influencing the duration of LOS in the ED. Total LOS was dependent on patient-related factors (age), disease-related factors (presentation complaint and triage level), and organizational factors (weekday and admitted/non-admitted status).

Conclusion : These findings are important for the development of management strategies to optimize patient flow through the ED and thus to prevent overcrowding.

Conclusion (proposition de traduction) : Ces résultats sont importants pour l'élaboration de stratégies de gestion visant à optimiser le flux des patients dans les services d'urgence et ainsi à prévenir l'engorgement.

International Journal of Emergency Medicine

Patient satisfaction, needs, and preferences concerning information dispensation at the emergency department: a cross-sectional observational study.
de Steenwinkel M, Haagsma JA, van Berkel ECM, Rozema L, Rood PPM, Bouwhuis MG. | Int J Emerg Med. 2022 Jan 24;15(1):5
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Keywords: Emergency department; Information dispensation; Patient satisfaction; Waiting times.

Original Research

Introduction : Patient satisfaction is an important indicator of emergency care quality and has been associated with information dispensation at the emergency department (ED). Optimal information dispensation could improve patient experience and expectations. Knowing what kind of information patients want to receive and the preferred way of information dispensation are essential to optimize information delivery at the ED. The purpose of this cross-sectional observational study was to evaluate patient satisfaction concerning information dispensation (including general, medical, and practical information), the need for additional information, and preferences with regard to the way of information dispensation at the ED of a teaching hospital in the Netherlands.

Résultats : Four hundred twenty-three patients (patients ≥ 18 years with Glasgow Coma Scale 15) were enrolled (response rate 79%). The median patient satisfaction score concerning the overall information dispensation at the ED was 7.5 on a rating scale 0-10. Shorter length of ED stay was associated with higher patient satisfaction in multivariate analysis (P < 0.001). The majority of respondents were satisfied regarding medical (n = 328; 78%) and general information (n = 233; 55%). Patients were less satisfied regarding practical information (n = 180; 43%). Respondents who indicated that they received general, medical and practical information were significantly more often satisfied compared to patients who did not receive this information (P < 0.001). Two thirds (n = 260; 62%) requested more general information. Half of the respondents (n = 202; 48%) requested more practical information and a third (n = 152; 36%) requested more medical information. The preferred way for receiving information was orally (n = 189; 44.7%) or by leaflets (n = 108; 25.5%).

Conclusion : The majority of respondents were satisfied concerning information dispensation at the ED, especially regarding medical information. Respondents requested more general and practical information and preferred to receive the information orally or by leaflets.

Conclusion (proposition de traduction) : La majorité des répondants étaient satisfaits de la communication des informations au service des urgences, notamment en ce qui concerne les informations médicales. Les personnes interrogées ont demandé des informations plus générales et pratiques et ont préféré recevoir les informations orales ou par le biais de dépliants.

Tenecteplase vs. alteplase for acute ischemic stroke: a systematic review.
Potla N, Ganti L. | Int J Emerg Med. 2022 Jan 4;15(1):1
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Keywords: Aucun


Introduction : Thrombolysis for acute ischemic stroke (AIS) with alteplase is the currently approved therapy for patients who present within 4.5 h of symptom onset and meet criteria. Recently, there has been interest in the thrombolytic tenecteplase, a modified version of alteplase, due to its lower cost, ease of administration, and studies reporting better outcomes when compared to alteplase. This systematic review compares the efficacy of tenecteplase vs. alteplase with regard to three outcomes: (1) rate of symptomatic hemorrhage, (2) functional outcome at 90 days, and (3) reperfusion grade after thrombectomy to compare the efficacy of both thrombolytics in AIS METHODS: The search was conducted in August 2021 in PubMed, filtered for randomized controlled trials, and studies in English. The main search term was "tenecteplase for acute stroke."

Résultats : A total of 6 randomized clinical trials including 1675 patients with AIS was included. No one's study compared alteplase to tenecteplase with all three outcomes after acute ischemic stroke; however, by using a combination of the results, this systematic review summarizes whether tenecteplase outperforms alteplase.

Conclusion : The available evidence suggests that tenecteplase appears to be a better thrombolytic agent for acute ischemic stroke when compared to alteplase.

Conclusion (proposition de traduction) : Les preuves disponibles suggèrent que la ténectéplase semble être un meilleur agent thrombolytique dans l'AVC ischémique aigu par rapport à l'altéplase.

Journal of Intensive Care

Noninvasive respiratory support for COVID-19 patients: when, for whom, and how?.
Sullivan ZP, Zazzeron L, Berra L, Hess DR, Bittner EA, Chang MG. | J Intensive Care. 2022 Jan 15;10(1):3
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Keywords: Acute respiratory distress syndrome (ARDS); Acute respiratory failure (ARF); COVID-19; Continuous positive airway pressure (CPAP); H1N1; High flow nasal cannula (HFNC); Hypoxemic respiratory failure; Invasive mechanical ventilation (IMV); MERS; Noninvasive respiratory support (NIRS); Noninvasive ventilation (NIV); SARS.


Editorial : The significant mortality rate and prolonged ventilator days associated with invasive mechanical ventilation (IMV) in patients with severe COVID-19 have incited a debate surrounding the use of noninvasive respiratory support (NIRS) (i.e., HFNC, CPAP, NIV) as a potential treatment strategy. Central to this debate is the role of NIRS in preventing intubation in patients with mild respiratory disease and the potential beneficial effects on both patient outcome and resource utilization. However, there remains valid concern that use of NIRS may prolong time to intubation and lung protective ventilation in patients with more advanced disease, thereby worsening respiratory mechanics via self-inflicted lung injury. In addition, the risk of aerosolization with the use of NIRS has the potential to increase healthcare worker (HCW) exposure to the virus. We review the existing literature with a focus on rationale, patient selection and outcomes associated with the use of NIRS in COVID-19 and prior pandemics, as well as in patients with acute respiratory failure due to different etiologies (i.e., COPD, cardiogenic pulmonary edema, etc.) to understand the potential role of NIRS in COVID-19 patients. Based on this analysis we suggest an algorithm for NIRS in COVID-19 patients which includes indications and contraindications for use, monitoring recommendations, systems-based practices to reduce HCW exposure, and predictors of NIRS failure. We also discuss future research priorities for addressing unanswered questions regarding NIRS use in COVID-19 with the goal of improving patient outcomes.

Conclusion : The mortality rate and prolonged ventilator days associated with invasive mechanical ventilation (IMV) of patients with severe COVID-19 have incited a debate surrounding the use of noninvasive respiratory support (NIRS) (i.e., HFNC, CPAP, NIV) as a potential treatment strategy.
We review the existing literature with a focus on rationale, patient selection and outcomes associated with the use of NIRS in COVID-19 and prior pandemics, as well as in patients with acute respiratory failure due to different etiologies (i.e., COPD, cardiogenic pulmonary edema, etc.) to understand the potential role of NIRS in COVID-19 patients. Based on this analysis we suggest an algorithm for NIRS in COVID-19 patients which includes indications and contraindications for use, monitoring recommendations, systems-based practices to reduce healthcare worker (HCW) exposure, and predictors of NIRS failure.

Conclusion (proposition de traduction) : Le taux de mortalité et la prolongation des jours de ventilation associés à la ventilation mécanique invasive (IMV) des patients atteints de la COVID-19 sévère ont suscité un débat autour de l'utilisation de la ventilation non invasive (NIRS) (c'est-à-dire HFNC, CPAP, NIV) comme stratégie de traitement potentielle.
Nous passons en revue la littérature existante en mettant l'accent sur la justification, la sélection des patients et les résultats associés à l'utilisation de la ventilation non invasive dans la COVID-19 et les pandémies antérieures, ainsi que chez les patients souffrant d'insuffisance respiratoire aiguë due à différentes étiologies (c.-à-d. BPCO, œdème pulmonaire cardiogénique, etc.) pour comprendre le rôle potentiel de la VNI chez les patients COVID-19. Sur la base de cette analyse, nous proposons un algorithme pour de ventilation non invasive chez les patients COVID-19 qui comprend des indications et des contre-indications d'utilisation, des recommandations de surveillance, des pratiques basées sur les organisations pour réduire l'exposition des travailleurs de la santé (HCW) et des prédicteurs de l'échec de la ventilation on invasive.

Commentaire :  Proposition d'un algorithme de Ventilation Non Invasive
(HNF : oxygénothérapie nasale à haut débit)

Journal of Intensive Care Medicine

Failure of High Flow Nasal Cannula and Subsequent Intubation Is Associated With Increased Mortality as Compared to Failure of Non-Invasive Ventilation and Mechanical Ventilation Alone: A Real-World Retrospective Analysis.
Miller DC, Pu J, Kukafka D, Bime C. | J Intensive Care Med. 2022 Jan;37(1):41-45
Keywords: non-invasive ventilation; oxygen inhalation therapy; respiratory insufficiency.

Original Research

Introduction : Despite the increasing use of high flow nasal cannula oxygenation systems (HFNC) in clinical practice, little is known about its role in all cause respiratory failure as compared to traditional non-invasive ventilation (BiPAP). Furthermore, the effect of HFNC on mortality is unknown.

Méthode : We conducted a retrospective analysis of 49,853 patients with respiratory failure treated with non-invasive respiratory support (HFNC or BiPAP) and/or invasive mechanical ventilation (IMV) between 2017 and 2018.

Résultats : Patients initially treated with HFNC who underwent subsequent intubation and IMV had a higher mortality rate as compared to patients who were initially treated with BiPAP and underwent subsequent intubation and IMV (34.8% vs 26.3%, p < 0.0001, OR 1.49, 95% CI 1.26,1.76). Patients first treated with HFNC who underwent subsequent intubation and IMV had a significantly increased mortality compared to patients who underwent immediate intubation and IMV (34.8% vs. 21.5%, p ≤ 0.0001, OR 1.94, 95% CI 1.67, 2.27). Stratified based on ICD-10 diagnosis, patients with a diagnosis of COPD exacerbation or heart failure treated with HFNC and subsequent intubation and IMV had higher mortality as compared to those treated with immediate IMV alone. This trend did not hold true for patients with a diagnosis of pneumonia.

Conclusion : In a real-world retrospective analysis, use of HFNC was associated with increased mortality as compared to BiPAP and IMV alone. Further study is needed to confirm these associations.

Conclusion (proposition de traduction) : Dans une analyse rétrospective du monde réel, l'utilisation de l'oxygénothérapie nasale à haut débit a été associée à une mortalité accrue par rapport à la BiPAP et à la ventilation mécanique invasive seuls. Une étude plus approfondie est nécessaire pour confirmer ces associations.

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality.
Goel NN, Durst MS, Vargas-Torres C, Richardson LD, Mathews KS. | J Intensive Care Med. 2022 Jan;37(1):52-59
Keywords: ED boarding; ED crowding; critically ill; emergency department (ED); time-to-treatment.

Original Research

Introduction : Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition.

Méthode : We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition.

Résultats : Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload.

Conclusion : Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

Conclusion (proposition de traduction) : L'augmentation du développement d'un dysfonctionnement organique persistant et/ou d'un décès au 28e jour d'hospitalisation est associé à une reconnaissance tardive. Des facteurs liés au patient et au système, tels que la gravité de la maladie et la charge de travail à l'urgence, influent sur les probabilités de retarder la reconnaissance d’une maladie grave et doivent être explorés plus avant.

Journal of the American College of Cardiology

Volgman AS, Nair G, Lyubarova R, Merchant FM, Mason P, Curtis AB, Wenger NK, Aggarwal NT, Kirkpatrick JN, Benjamin EJ. | J Am Coll Cardiol. 2022 Jan 18;79(2):166-179
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Keywords: aged; aged 80 and over; antiarrhythmic drugs; catheter ablation; frailty; left atrial appendage occlusion; oral anticoagulation; strokes.

JACC State-of-the-Art Review

Editorial : The prevalence of atrial fibrillation (AF) is increasing as the population ages. AF treatment-related complications also increase markedly in older adults (defined as ≥75 years of age for this review). The older AF population has a high risk of stroke, bleeding, and death. Syncope and fall-related injuries are the most common reasons for nonprescription of oral anticoagulation (OAC), and are more common in older adults when OACs are used with antiarrhythmic drugs. Digoxin may be useful for rate control, but associations with increased mortality limit its use. Beyond rate and rhythm control considerations, stroke prophylaxis is critical to AF management, and the benefits of direct OACs, compared with warfarin, extend to older adults. Invasive procedures such as AF catheter ablation, pacemaker implantation/atrioventricular junction ablation, and left atrial appendage occlusion may be useful in appropriately selected cases. However, older adults have generally been under-represented in clinical trials.

Conclusion : This review of patients ≥75 years of age with AF highlights that this patient population has a high risk of strokes, bleeding, and mortality. Table 5 summarizes the important concepts. The Central Illustration summarizes our findings and recommendations. Pharmacologistsmay help identify drug–drug interactions and appropriate dosing for this older population, and occupational and physical therapists may help identify ways to avoid falls.

Conclusion (proposition de traduction) : Cette revue de patients âgés de ≥ 75 ans présentant une FA souligne que cette population de patients présente un risque élevé d'accident vasculaire cérébral, d'hémorragie et de mortalité. Le tableau, ci-dessous, résume les concepts importants et résume les constatations et les recommandations. Les pharmaciens peuvent aider à identifier les interactions médicamenteuses et la posologie appropriée pour cette population âgée, et les ergothérapeutes et les physiothérapeutes peuvent aider à identifier les moyens pour éviter les chutes.

Commentaire : Clic droit pour ouvrir l'image dans une nouvelle fenêtre La prise en charge des patients âgés présentant une fibrillation atriale (illustration centrale)

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Writing Committee Members, Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. | J Am Coll Cardiol. 2022 Jan 18;79(2):e21-e129
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Keywords: ACC/AHA Clinical Practice Guidelines; angiogram; angiography; angioplasty; arterial graft; cardiac surgery; coronary artery bypass graft surgery; coronary atherosclerosis; internal mammary artery graft; internal thoracic artery graft; left ventricular dysfunction; multivessel PCI; myocardial infarction; myocardial revascularization; non–ST-segment–elevated myocardial infarction; percutaneous coronary intervention; percutaneous transluminal coronary angioplasty; post-bypass; saphenous vein graft; stent(s); vein graft lesions.

Practice guideline

Introduction : The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

Méthode : A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

Conclusion : Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Conclusion (proposition de traduction) : La maladie coronarienne reste l'une des principales causes de morbi-mortalité dans le monde. La revascularisation coronarienne est une option thérapeutique importante dans la prise en charge des patients présentant une coronaropathie. La recommandation de 2021 sur la revascularisation des artères coronaires fournit des recommandations fondées sur des données probantes contemporaines pour la prise en charge des patients présentant une coronaropathie pour lesquels une revascularisation coronarienne est envisagée, dans le but d'améliorer la qualité des soins et de s'aligner sur les intérêts des patients.

Evolution of Incidence, Management, and Outcomes Over Time in Sports-Related Sudden Cardiac Arrest.
Weizman O, Perrot D, Waldmann V, Beganton F, Perier MC, Rischard J, Loeb T, Agostinucci JM, Lecarpentier E, Jabre P, Jost D, Dumas F, Cariou A, Jouven X, Marijon E. | J Am Coll Cardiol. 2022 Jan 25;79(3):238-246
Keywords: basic life support; prevention; resuscitation; sports; sudden death; temporal trends.

Research article

Introduction : Major efforts have been made to reduce the burden of sports-related sudden cardiac arrest (SrSCA). The extent to which the incidence, management, and outcomes changed over time has not been investigated.
Objectives: The purpose of this study was to assess temporal trends in SrSCA incidence, management, and survival.

Méthode : Using data from the French National Institute of Health and Medical Research, we evaluated the evolution of incidence, prehospital management, and survival at hospital discharge of SrSCA among subjects aged 18 to 75 years, over 6 successive 2-year periods between 2005 and 2018.

Résultats : Among the 377 SrSCA, 20 occurred in young competitive athletes (5.3%), whereas 94.7% occurred in middle-aged recreational sports participants. Comparing the last 2-year to the first 2-year period, SrSCA incidence remained stable (6.24 vs 7.00 per million inhabitants/y; P = 0.51), with no significant differences in patients' mean age (46.6 ± 13.8 years vs 51.0 ± 16.4 years; P = 0.42), sex (men 94.7% vs 95.2%; P = 0.99), and history of heart disease (12.5% vs 15.9%; P = 0.85). However, frequency of bystander cardiopulmonary resuscitation and public automated external defibrillator use increased significantly (34.9% vs 94.7%; P < 0.001 and 1.6% vs 28.8%; P = 0.006, respectively). Survival to hospital discharge improved steadily, reaching 66.7% in the last study period compared with 23.8% in the first (P < 0.001).

Conclusion : Incidence of SrSCA remained relatively stable over time, suggesting a need for improvement in screening strategies. However, major improvements in on-field resuscitation led to a 3-fold increase in survival, underlining the value of public education in basic life support that should serve as an example for SCA in general.

Conclusion (proposition de traduction) : L'incidence de la mort subite dans la pratique sportive est restée relativement stable au fil du temps, ce qui suggère un besoin d'amélioration des stratégies de dépistage. Cependant, des améliorations majeures de la réanimation sur le terrain ont conduit à une multiplication par 3 de la survie, soulignant la valeur de l'éducation du public au Gestes Elémentaires de Survie (GES) qui devrait servir d'exemple pour la mort subite en général.

Médecine Intensive Réanimation

Poiroux L | Méd. Intensive Réa. [Internet]. 2022 Jan;13
Keywords: Norepinephrine administration, changeover, critical care nursing, evidence based nursing, Norepinephrine administration; changeover; critical care nursing; evidence based nursing ; patient safety


Editorial : Catecholamines are the first-line treatment in the management of patients in shock. These drugs, and norepinephrine in particular, have a very short half-life and an extremely narrow therapeutic range. Their administration requires precautions to ensure optimal treatment efficacy and safety of use. The choice of biomedical equipment, medical devices, and administration strategies can have a major influence on the steadiness of drug mass flow. These variations can have clinical consequences ranging from small changes in blood pressure to more serious adverse events. Although the literature that has addressed these issues is sparse and of uneven quality, it nonetheless reports interesting data to guide critical care nursing practice. The aim of this article is to propose a state of the art on the management of catecholamines with a particular focus on the management of norepinephrine changeovers.

Pediatric Emergency Care

Seated Position Does Not Change Lumbar Dimensions Compared With Lateral Position.
Long MT, Del Re AM, Uya A, Kanegaye JT, Nguyen MB. | Pediatr Emerg Care. 2022 Jan 1;38(1):e23-e26
Keywords: Aucun

Original article

Introduction : The infant lumbar puncture (LP) can be a technically challenging procedure. Understanding the anatomical lumbar dimensions may optimize LP conditions. Data from preterm neonates, older children, and adults indicate measurements of the lumbar spine in the seated LP position may be superior when compared with the lateral position. We use point-of-care ultrasound (US) to determine if the seated position, when compared with the lateral decubitus position, significantly affected the lumbar dimensions of infants 12 months or younger presenting to the pediatric emergency department.

Méthode : We conducted a prospective observational study of a convenience sample of patients 12 months or younger. We used US to obtain 3 still images oriented longitudinally in the midline over the L3 to L4 interspace in the lateral decubitus and seated positions. A US fellowship-trained emergency physician, blinded to patient position, measured interspinous space, subarachnoid space width, and spinal canal depth. We then compared the means of all 3 dimensions in the lateral and seated positions.

Résultats : From 50 subjects, 49 subjects provided 46 evaluable sets of images for each measure. Interspinous space, spinal canal depth, and subarachnoid space width did not differ significantly between positions. Mean differences did not exceed 0.02 cm for any of the measured dimensions. We report no significant differences in the 3 lumbar dimensions at the seated position when compared with the lateral decubitus position.

Conclusion : For infants younger than 12 months, sonographic measurements of lumbar dimensions did not differ between the positions commonly used for LP.

Conclusion (proposition de traduction) : Pour les nourrissons de moins de 12 mois, les mesures échographiques des dimensions des interlignes lombaires ne différaient pas entre les positions couramment utilisées pour la PL.

The Effect of Lidocaine Delivered by Jet Injection on First Attempt Venous Access Success Rates in the Pediatric Emergency Department.
Redmond P, Blackshear C, Davis J. | Pediatr Emerg Care. 2022 Jan 1;38(1):e34-e36
Keywords: Aucun

Original article

Introduction : Jet injection of 1% lidocaine (J-Tip) has been used in the pediatric emergency department (PED) to reduce pain associated with venipuncture, but there are limited data on the effect of J-Tip on first-attempt venous access success rates. We sought to determine if using a J-Tip altered the first-attempt venous access success rate in the PED. Then, we examined the effect of J-Tip use on pain scores and resource utilization during peripheral venous access.

Méthode : We prospectively evaluated children over 6 months of age who required peripheral venous access in the PED. The exposure group received 0.25 mL of 1% buffered lidocaine via jet injection 90 seconds before peripheral venous access. The control group received no local anesthesia. Parent and nurse surveys were completed during the visit.

Résultats : There was no difference in first attempt success rate between the exposure (n = 136) and control (n = 90) groups (87% vs 88%, P = 0.82). J-Tip use was associated with improved pain scores based on child report (median 1 vs 3; P < 0.001), parent report (median 1 vs 3; P < 0.001), and nurse assessment (median 0 vs 3; P < 0.001).

Conclusion : Use of J-Tip in the PED to reduce pain associated with peripheral venous access did not lead to a reduction in first-attempt success rates for peripheral venous access. J-Tip was well received among nurses and parents and was associated with improved pain scores.

Conclusion (proposition de traduction) : L'utilisation de J-Tip (ndlr : injection sous-cutanée sans aiguille, injecteur de lidocaïne sans effraction cutanée) dans le service des urgences pédiatriques pour réduire la douleur associée à la pose d'une voie veineuse périphérique n'a pas entraîné de réduction des taux de réussite de la première tentative de l'accès veineux. J-Tip a été bien accueilli par les infirmières et les parents et a été associé à une amélioration des scores de douleur.

Commentaire :  J-Tip
Ce dispositif permet de faire une anesthésie locale sans effraction cutanée grâce à un matériel qui propulse sous pression une petite quantité (< 0,5 mL) de lidocaïne tamponnée.
Le prix de ce matériel à usage unique semble de l’ordre de 1 US$.

Outcomes and Factors Associated With Prehospital Treatment of Pediatric Anaphylaxis.
Trainor JL, Pittsenbarger ZE, Joshi D, Adler MD, Smith B, Gupta RS. | Pediatr Emerg Care. 2022 Jan 1;38(1):e69-e74
Keywords: Aucun

Original article

Introduction : Anaphylaxis is a potentially life-threatening reaction requiring prompt treatment with intramuscular epinephrine (EPI). We sought to describe presenting features of pediatric anaphylaxis and compare patient characteristics and outcomes of children treated with prehospital EPI with those untreated.

Méthode : We abstracted data from emergency department (ED) records for children meeting the National Institute of Allergy & Infectious Disease criteria for anaphylaxis (2015-2017) in one tertiary care children's hospital. We analyzed associations between patient characteristics and outcomes and receipt of prehospital EPI using descriptive statistics and multivariate logistic regression.

Résultats : Of 414 children presenting with anaphylaxis, 39.4% received IM EPI and 62.1% received antihistamines before hospital arrival. Children with Medicaid received pre-emergency department EPI less frequently than did children with private insurance (24.5% vs 43.8%, P = 0.001). Factors positively associated with prehospital EPI administration were history of food allergy (odds ratio [OR], 4.4 [95% confidence interval {CI}, 2.4-8.2]) or arrival by emergency medical services (OR, 8.0 [95% CI, 4.2-15.0]). Medicaid insurance was associated with decreased odds of prehospital EPI (OR, 0.33 [95% CI, 0.16-0.66]) and prehospital H1-antihistamine use (OR, 0.30 [95% CI, 0.17-0.56]). Prehospital EPI treatment was also associated with decreased rates of observation (37% vs 63%), inpatient admission (38% vs 62%), and intensive care unit admission (20% vs 80%) compared with no pretreatment (P = 0.03).

Conclusion : Prehospital treatment with EPI remains low, and barriers to optimal treatment are more pronounced in children with public insurance. Prehospital treatment with EPI was associated with decreased morbidity including hospitalization and intensive care unit admission.

Conclusion (proposition de traduction) : Le traitement préhospitalier par adrénaline intramusculaire reste peu utilisé et les obstacles à un traitement optimal sont plus importants chez les enfants bénéficiant d'une assurance publique. Le traitement préhospitalier par adrénaline intramusculaire était associé à une diminution de la morbidité, y compris l'hospitalisation et l'admission en unité de soins intensifs.

Interhospital Transport of Children With Peripheral Venous Catheters by Private Vehicle: A Mixed Methods Assessment.
Mangus CW, Canares T, Klein BL, Costabile P, Monroe D, Noje C, Stevens MW. | Pediatr Emerg Care. 2022 Jan 1;38(1):e105-e110
Keywords: Aucun

Original article

Introduction : Many children seeking emergency care at community hospitals require transport to tertiary centers for definitive management. Interhospital transport via ambulance versus patient's own vehicle (POV) are 2 possible modes of transport; however, presence of a peripheral venous catheter (PIV) can determine transport by ambulance. Caregiver satisfaction, patient comfort, and PIV complications related to POV transport have not been described.
Objective: The aims of the study were to examine caregivers' satisfaction and perceptions of POV transport in children with/without PIVs and to assess PIV-related complications during transport.

Méthode : We performed a mixed-methods, prospective cohort study of children who presented with low-acuity conditions to a community hospital and subsequently required transfer to a pediatric tertiary center. Caregivers of patients with/without PIVs were given the choice of transport by POV or ambulance. Surveys completed after transport used dichotomous, 5-point Likert scale, and open-ended responses to assess satisfaction, perceptions, and PIV-related complications. Responses were quantitatively and qualitatively analyzed accordingly. The receiving hospital assessed PIV integrity.

Résultats : Sixty-nine of 78 eligible patients were enrolled; of those, 67 (97%) elected transport by POV and 55 (82%) completed surveys. Most caregivers had positive responses related to satisfaction, comfort, and safety. Results did not differ significantly between those with/without PIVs. The majority (96%) would choose POV transport again. There were no reported PIV complications; all PIVs were functional upon arrival. Qualitative analysis identified themes of comfort, convenience, and efficiency.

Conclusion : In select scenarios, interfacility transport by POV is preferred by families and doing so with a saline-locked PIV does not result in complications.

Conclusion (proposition de traduction) : Dans certains scénarios, le transport inter-établissements avec le véhicule personnel du patient est préféré par les familles et le faire avec un cathéter veineux périphérique avec une solution saline n'entraîne pas de complications.

Comparison of Ultrasound-Marked Versus Standard Lumbar Puncture Success in Infants.
Grady M, Runyon M, Weekes A, Hogg M, Chaudoin L. | Pediatr Emerg Care. 2022 Jan 1;38(1):e121-e125.
Keywords: Aucun

Original article

Introduction : The aim of this study was to compare ultrasound (US)-marked versus standard lumbar puncture success in infants.

Méthode : This was a prospective cohort study at an academic pediatric emergency department. Standard lumbar puncture success in a retrospective control was compared with success in a US-marked group. Spinal US was performed with infants in the sitting and lateral decubitus position to identify the interspinous space with the most cerebrospinal fluid. The optimal position was determined, and this space was marked. The proceduralist performed the lumbar puncture at the level of the markings. The primary outcome was a successful lumbar puncture by the first provider, defined as a collection of cerebrospinal fluid with less than 1000 red blood cells/mm3. Secondary outcomes were successful lumbar puncture after attempts by more than 1 provider and collection of any spinal fluid.

Résultats : Between June 2017 and April 2019, we enrolled 284 infants younger than 12 months, 210 in the retrospective standard group and 74 in the prospective US-marked group. Baseline characteristics of both groups were similar. The primary outcome showed no difference between US-marked group and control (38% vs 36%; difference: 1.6% [95% confidence interval (CI), -14.7 to 10.7]). Secondary outcomes showed no significant success differences by more than 1 provider (51% vs 39%; difference: 12.8% [95% CI, -25.7 to 0.3]) or in obtaining any spinal fluid (82% vs 79%; difference: 3.9% [95% CI -13.3 to 7.5]).

Conclusion : There were no differences in success between US-marked and standard lumbar punctures in infants by different providers.

Conclusion (proposition de traduction) : Il n'y avait aucune différence de réussite entre les ponctions lombaires repérées par échographie et les ponctions lombaires standard chez les nourrissons par différents prestataires.

Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department.
Pokrajac N, Sbiroli E, Hollenbach KA, Kohn MA, Contreras E, Murray M. | Pediatr Emerg Care. 2022 Jan 1;38(1):e126-e131
Keywords: Aucun

Original article

Introduction : Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED.

Méthode : We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment.

Résultats : In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97).

Conclusion : Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.

Conclusion (proposition de traduction) : L'hypoxie (ou une valeur d'oxymétrie de pouls impossible à obtenir) était le facteur prédictif le plus fort de l'arrêt cardiaque péri-intubation chez les enfants après une intubation endotrachéale d'urgence dans notre échantillon. Un modèle de risque simple combinant une hypoxie pendant l'intubation endotrachéale et un enfant de moins d'un an a montré une excellente discrimination dans cet échantillon. Nos résultats nécessitent une validation indépendante.

Pain Reduction Emergency Protocol: A Prospective Study Evaluating Impact of a Nurse-initiated Protocol on Pain Management and Parental Satisfaction.
Guiner A, Street MH, Oke O, Young VB, Hennes H. | Pediatr Emerg Care. 2022 Jan 1;38(1):e157-e164.
Keywords: Aucun

Original article

Introduction : Pain control remains suboptimal in pediatric emergency departments (EDs). Only 60% of pediatric patients requiring pain medications receive them in the ED, with an average time of administration being 90 minutes after arrival. Although pain protocols (PP) have been proposed and evaluated in children with long-bone fractures, data on PP utility for general pediatric patients with acute pain are limited. Our objective is to introduce a nursing-initiated PP with medication algorithms for use in triage, measure the improvement in management of severe pain on arrival to the ED and determine the effect on parental satisfaction.

Méthode : Prospective prestudy and poststudy conducted from June to October 2017. Patients aged 3 to 17 years presenting to a large tertiary pediatric ED with acute pain were eligible. Preprotocol demographics, clinical data, and pain interventions were obtained over a 6-week period. A convenience sample of parents completed a satisfaction survey rating their experience with ED pain management during this time. In the 4-week intervention phase, the PP was introduced to our ED nurses. Postintervention data were collected in the same fashion as the preintervention phase. Analysis was done using independent sample t test and χ2 models.

Résultats : There were 1590 patients evaluated: preprotocol (n = 816), postprotocol (n = 774). Approximately 10% more patients with severe pain received pain medication in the post-PP sample compared with pre-PP (85.6% and 75.9% respectively). Parental satisfaction was higher in patients who received analgesic medications within 90 minutes of arrival to the ED (P = 0.007).

Conclusion : The introduction of a PP in the ED setting improved the treatment of pain. There was a significant increase in patients with severe pain receiving analgesic medications. Additionally, parents were more satisfied if their children received pain medication in a more timely fashion. Pediatric EDs should consider introducing PPs to improve appropriate and timely administration of pain medication in triage.

Conclusion (proposition de traduction) : L'introduction d'un protocole de prise en charge de la douleur dans le cadre du service des urgences a amélioré le traitement de la douleur. Il y avait une augmentation significative du nombre de patients souffrant de douleurs intenses recevant des médicaments analgésiques. De plus, les parents étaient plus satisfaits si leurs enfants recevaient des analgésiques plus rapidement. Les services d'urgence pédiatriques devraient envisager d'introduire des protocoles de gestion de la douleur afin d'améliorer l'administration appropriée et opportune des analgésiques lors du triage.

Endotracheal Administered Epinephrine Is Effective in Return of Spontaneous Circulation Within a Pediatric Swine Hypovolemic Cardiac Arrest Model.
Yauger YJ, Beaumont DM, Brady K, Schauer SG, O'Sullivan J, Hensler JG, Johnson D. | Pediatr Emerg Care. 2022 Jan 1;38(1):e187-e192
Keywords: Aucun

Original article

Introduction : Early administration of epinephrine increases the incidence of return of spontaneous circulation (ROSC) and improves outcomes among pediatric cardiac arrest victims. Rapid endotracheal (ET) intubation can facilitate early administration of epinephrine to pediatric victims. To date, no studies have evaluated the use of ET epinephrine in a pediatric hypovolemic cardiac arrest model to determine the incidence of ROSC.

Méthode : This prospective, experimental study evaluated the pharmacokinetics and/or incidence of ROSC following ET administered epinephrine and compared it to these experimental groups: intravenous (IV) administered epinephrine, cardiopulmonary resuscitation only (CPR), and CPR + defibrillation (CPR + Defib).

Résultats : Endotracheal administered epinephrine, at the Pediatric Advanced Life Support (PALS) recommended dose, was not significantly different than IV administered epinephrine in maximum plasma concentrations, time to maximum plasma concentration, area under the curve, or ROSC, or mean plasma concentrations at various time points (P > 0.05). The odds of ROSC in the ET group were 2.4 times greater than the IV group. The onset to ROSC in the ET group was significantly shorter than the IV group (P < 0.0001).

Conclusion : These data support that ET epinephrine administration remains an alternative to IV administered epinephrine and faster at restoring ROSC among pediatric hypovolemic cardiac arrest victims in the acute setting when an endotracheal tube is present. Although further research is required to determine long-term outcomes of high-dose ET epinephrine administration, these data reinforce the therapeutic potential of ET administration of epinephrine to restore ROSC before IV access.

Conclusion (proposition de traduction) : Ces données confirment que l'administration d'adrénaline endotrachéale reste une alternative à d'adrénaline administrée par voie intraveineuse et plus rapide pour obtenir une reprise d'activité circulatoire spontanée chez les enfants victimes d'un arrêt cardiaque hypovolémique dans un contexte aigu lorsqu'un tube endotrachéal est en place. Bien que des recherches supplémentaires soient nécessaires pour déterminer les résultats à long terme de l'administration d'adrénaline endotrachéale à forte dose, ces données renforcent le potentiel thérapeutique de l'administration endotrachéale d'adrénaline pour restaurer la reprise d'activité circulatoire spontanée avant l'accès veineux.

Point-of-Care Ultrasound for Central Venous Assessment in the Emergency Department: A Prospective Study Comparing the Femoral and Internal Jugular Veins.
Pandya L, Cooper M, Patel N, Leonard D, Fernandes N, Spear D, Nesiama JA. | Pediatr Emerg Care. 2022 Jan 1;38(1):e278-e282
Keywords: Aucun

Original article

Introduction : The objective of this study was to estimate the width, height, and depth of the femoral vein (FV) and internal jugular vein (IJV), both sites of potential central line placement in children, using point-of-care ultrasound.

Méthode : This was a prospective observational study. Point-of-care ultrasound was used to measure the width, height, and depth of the right FV and IJV in 100 children. The primary outcome was a comparison of the widths of the FV and the IJV in the same child. Our primary hypothesis was that the IJV would be wider than the FV. Secondary outcome measures included comparison of the heights and depths the FV and IJV and description of vessel overlap frequency between the 2 sites.

Résultats : A total of 106 children were enrolled, with 6 subjects excluded, and equally divided into 5 age groups (0-30 days, 1-24 months, 2-5 years, 6-11 years, and 12-17 years). The FV/IJV width ratios (95% confidence interval) by age were 0.58 (0.49-0.68), 0.53 (0.43-0.66), 0.57 (0.49-0.67), 0.68 (0.55-0.85), and 0.73 (0.62-0.85), all P < 0.002. The FV/IJV height ratios were <1 in all age groups, with P < 0.003 in the 4 youngest age groups. The FV/IJV depth ratios were >1 in 6 to 11 years (P = 0.018) and 12 to 17 years (P < 0.001).

Conclusion : The IJV was significantly wider and taller than the FV in the same child in all age groups. The FV was significantly deeper than the IJV in children 6 years and older. This supports the use of the IJV as a potential site when placing ultrasound-guided central lines in children.

Conclusion (proposition de traduction) : La veine jugulaire interne était significativement plus large et plus haute que la veine fémorale chez le même enfant dans tous les groupes d'âge. La veine fémorale était significativement plus profonde que la veine jugulaire interne chez les enfants de 6 ans et plus. Cela appuie l'utilisation de la veine jugulaire interne comme site potentiel de pose des voies centrales guidées par échographie chez les enfants.

Use of Inotropics by Peripheral Vascular Line in the First Hour of Treatment of Pediatric Septic Shock: Experience at an Emergency Department.
Kohn-Loncarica G, Hualde G, Fustiñana A, Monticelli MF, Reinoso G, Cortéz M, Segovia L, Mareco-Naccarato G, Rino P. | Pediatr Emerg Care. 2022 Jan 1;38(1):e371-e377
Keywords: Aucun

Original article

Introduction : Mortality in pediatric septic shock remains unacceptably high. Delays in vasopressor administration have been associated with an increased risk of mortality. Current treatment guidelines suggest the use of a peripheral vascular line (PVL) for inotropic administration in fluid-refractory septic shock when a central vascular line is not already in place. The aim of this study was to report local adverse effects associated with inotropic drug administration through a PVL at a pediatric emergency department setting in the first hour of treatment of septic shock.

Méthode : A prospective, descriptive, observational cohort study of patients with septic shock requiring PVL inotropic administration was conducted at the pediatric emergency department of a tertiary care pediatric hospital. For the infusion and postplacement care of the PVL for vasoactive drugs, an institutional nursing protocol was used.

Résultats : We included 49 patients; 51% had an underlying disease. Eighty-four percent of the children included had a clinical "cold shock." The most frequently used vasoactive drug was epinephrine (72%). One patient presented with local complications.

Conclusion : At our center, infusion of vasoactive drugs through a PVL was shown to be safe and allowed for adherence to the current guidelines for pediatric septic shock.

Conclusion (proposition de traduction) : Dans notre service, la perfusion de médicaments inotropes par voie veineuse périphérique s'est avérée sûre et a permis de respecter les recommandations actuelles dans le choc septique en pédiatrie.

Commentaire :  Recommandations institutionnelles pour la prise en charge du choc septique dans la première heure.

Ketofol for Procedural Sedation and Analgesia in the Pediatric Population.
Iqbal AU, Shuster ME, Baum CR. | Pediatr Emerg Care. 2022 Jan 1;38(1):28-33
Keywords: Aucun

CME Review Article

Editorial : The combination of ketamine and propofol, commonly referred to as ketofol, is sometimes used for procedural sedation and analgesia in the pediatric emergency department. This article reviews the pharmacology, dosing, and indications, as well as adverse effects and contraindications of ketamine, propofol, and ketofol.

Conclusion : Ketamine and propofol are 2 agents that are commonly used for PSA. Ketamine has benefits of preservation of cardiac and respiratory function, and also provides analgesic support. Propofol has a shorter onset of action and shorter duration of action, which decreases time to recovery, but lacks any analgesic properties. In addition, propofol has been shown to have a higher risk of apnea and cardiovascular depression. Ketofol is an alternative for PSA that seeks to maximize the benefits of each individual drug while minimizing adverse events. Although literature remains inconclusive for the use of ketofol, most literature to date suggests that ketofol is a safe, efficacious, and well-tolerated combination, with risks that are comparable to the individual components.

Conclusion (proposition de traduction) : La kétamine et le propofol sont 2 agents couramment utilisés pour la sédation procédurale et l'analgésie. La kétamine a l'avantage de préservation de la fonction cardiaque et respiratoire, et fournit également une action analgésique. Le propofol a un début d'action plus court et une durée d'action plus courte, ce qui réduit le temps de récupération, mais ne possède aucune propriété analgésique. De plus, il a été démontré que le propofol présente un risque plus élevé d'apnée et de dépression cardiovasculaire. Le kétofol est une alternative à la sédation et à l'analgésie procédurales qui cherche à maximiser les avantages de chaque médicament tout en minimisant les effets indésirables. Bien que la littérature reste peu concluante pour l'utilisation du kétofol, la plupart des publications à ce jour suggèrent que le kétofol est une combinaison sûre, efficace et bien tolérée, avec des risques comparables aux composants individuels.


Mechanical active compression-decompression versus standard mechanical cardiopulmonary resuscitation: A randomised haemodynamic out-of-hospital cardiac arrest study.
Berve PO, Hardig BM, Skålhegg T, Kongsgaard H, Kramer-Johansen J, Wik L. | Resuscitation. 2022 Jan;170:1-10
Keywords: ACD-CPR; Active compression decompression; Capnography; Cardiac arrest; Cardiopulmonary resuscitation; Cerebral oximetry; ETCO(2); Haemodynamic; Invasive arterial blood pressure; Mechanical chest compression; NIRS; SctO(2); rSO(2).

Clinical paper

Introduction : Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) utilises a suction cup to lift the chest-wall actively during the decompression phase (AD). We hypothesised that mechanical ACD-CPR (Intervention), with AD up to 30 mm above the sternal resting position, would generate better haemodynamic results than standard mechanical CPR (Control).

Méthode : This out-of-hospital adult non-traumatic cardiac arrest trial was prospective, block-randomised and non-blinded. We included intubated patients with capnography recorded during mechanical CPR. Exclusion criteria were pregnancy, prisoners, and prior chest surgery. The primary endpoint was maximum tidal carbon dioxide partial pressure (pMTCO2) and secondary endpoints were oxygen saturation of cerebral tissue (SctO2), invasive arterial blood pressures and CPR-related injuries. Intervention device lifting force performance was categorised as Complete AD (≥30 Newtons) or Incomplete AD (≤10 Newtons). Haemodynamic data, analysed as one measurement for each parameter per ventilation (Observation Unit, OU) with non-linear regression statistics are reported as mean (standard deviation). A two-sided p-value < 0.05 was considered as statistically significant.

Résultats : Of 221 enrolled patients, 210 were deemed eligible (Control 109, Intervention 101). The Control vs. Intervention results showed no significant differences for pMTCO2: 29(17) vs 29(18) mmHg (p = 0.86), blood pressures during compressions: 111(45) vs. 101(68) mmHg (p = 0.93) and decompressions: 21(20) vs. 18(18) mmHg (p = 0.93) or for SctO2%: 55(36) vs. 57(9) (p = 0.42). The 48 patients who received Complete AD in > 50% of their OUs had higher SctO2 than Control patients: 58(11) vs. 55(36)% (p < 0.001).

Conclusion : Mechanical ACD-CPR provided similar haemodynamic results to standard mechanical CPR. The Intervention device did not consistently provide Complete AD.

Conclusion (proposition de traduction) : La réanimation cardiopulmonaire mécanique active par compression-décompression a fourni des résultats hémodynamiques similaires à ceux de la RCP mécanique standard. Le dispositif d'intervention n'a pas systématiquement fourni une activité complète pendant la phase de décompression.

Distal femur versus humeral or tibial IO, access in adult out of hospital cardiac resuscitation.
Rayas EG, Winckler C, Bolleter S, Stringfellow M, Miramontes D, Shumaker J, Lewis A, Wampler D. | Resuscitation. 2022 Jan;170:11-16
Keywords: Distal femur; EMS; Intraosseous.

Clinical paper

Introduction : Intraosseous (IO) vascular access is a well-established method for fluid and drug administration in the critically ill. The Food and Drug Administration has approved adult IO access at the proximal humerus, proximal tibia, and the sternum; all three sites have significant limitations. The Distal Femur is away from the chest, with high flow rates. The objective of this study was to evaluate the distal femur site during resuscitation of adult out-of-hospital cardiac arrest.

Méthode : A retrospective analysis of adult out of hospital cardiac arrest patients treated by the San Antonio Fire Department. IO access was obtained by first-responders (paramedics or EMT-basic) or EMS paramedics. All resuscitation attempts from 2017 to 2018 data were analyzed. The protocol did not dictate the preference of IO site. The primary measure: number of OHCA patients in each subgroup: IO femur, IO humerus, IO tibia. Secondary measures: paramedic or basic operator, dislodgement rate, and total fluid infused.

Résultats : There were 2,198 patients meeting inclusion criteria: 888 femur, 696 humerus, 432 tibia. Distal femur increased 2.5 times in the 2018 cohort compared to the 2017 cohort, with a corresponding decrease in humerus (factor of 0.29). Proximal tibia remained unchanged. Dislodgement rates and total infusion (ml) remained unchanged.

Conclusion : The distal femur IO was feasible and associated with similar measured performance parameters as other IO sites in adult OHCA for both advanced and basic life support personnel.

Conclusion (proposition de traduction) : La voie intra-osseux au niveau du fémur distal était faisable et associé à des paramètres de performance mesurés similaires à ceux des autres sites intra-osseux en réanimation cardiaque chez l'adulte en dehors de l'hôpital pour le personnel de réanimation avancé et de base.

Faster time to automated elevation of the head and thorax during cardiopulmonary resuscitation increases the probability of return of spontaneous circulation.
Moore JC, Duval S, Lick C, Holley J, Scheppke KA, Salverda B, Rojas-Salvador C, Jacobs M, Nystrom P, Quinn R, Adams PJ, Debaty GP, Hutchison M, Mason C, Martinez E, Mason S, Clift A, Antevy P, Coyle C, Grizzard E, Garay S, Lurie KG, Pepe PE. | Resuscitation. 2022 Jan;170:63-69
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Clinical paper

Introduction : Resuscitation in the Head Up position improves outcomes in animals treated with active compression decompression cardiopulmonary resuscitation and an impedance threshold device (ACD + ITD CPR).We assessed impact of time to deployment of an automated Head Up position (AHUP) based bundle of care after out-of-hospital cardiac arrest on return of spontaneous circulation (ROSC).

Méthode : Observational data were analyzed from a patient registry. Patients received treatment with 1) ACD + and/or automated CPR 2) an ITD and 3) an AHUP device. Probability of ROSC (ROSCprob) from the 9-1-1 call to AHUP device placement was assessed with a restricted cubic spline model and linear regression.

Résultats : Of 11 sites, 6 recorded the interval from 9-1-1 to AHUP device (n = 227). ROSCprobfor all rhythms was 34%(77/227). Median age (range) was 66 years (19-101) and 68% men. TheROSCprobfor shockable rhythms was 47%(18/38). Minutes from 9-1-1 to AHUP device (median, range) varied between sites: 1) 6.4(4,15), 2) 8.0(5,19), 3) 9.9(4, 12), 4) 14.1(6, 36), 5) 15.9(6, 34), 6) 19.0(8, 38),(p = 0.0001).ROSCprobalso varied; 1) 55.1%(16/29), 2) 60%(3/5), 3) 50%(3/6), 4) 22.7%(17/75), 5) 26.4%(9/34), and 6) 37.1%(29/78), (p = 0.019). For all rhythms between 4 and 12 min (n = 85),ROSCprobdeclined 5.6% for every minute elapsed (p = 0.024). For shockable rhythms, between 6 and 15 min (n = 23),ROSCprobdeclined 9.0% for every minute elapsed (p = 0.006).

Conclusion : Faster time to deployment of an AHUP based bundle of care is associated with higher incidence of ROSC. This must be considered when evaluating and implementing this bundle.

Conclusion (proposition de traduction) : Un délai de mise en oeuvre plus rapide d'un ensemble de soins automatisé basé sur la position tête haute est associé à une incidence plus élevée de retour à une circulation spontanée. Cela doit être pris en compte lors de l'évaluation et de la mise en œuvre de ce processus de soins.

Commentaire :  Le processus de soins concerne un nouvel ensemble de réanimation, composé d'un dispositif automatisé de position tête haute (AHUP), d'un dispositif automatisé de réanimation cardiopulmonaire (RCP) basé sur une ventouse et d'un dispositif à seuil d'impédance (ITD). Un appareil de RCP manuel à compression-décompression active (non illustré) peut également être utilisé en remplacement ou en combinaison avec l'appareil de RCP automatisé à ventouse dans le cadre de l'ensemble de réanimation. La figure montre le dispositif AHUP complètement relevé, avec la tête et le thorax du patient relevés d'environ 22 cm et 9 cm respectivement.

Incidence of hyperoxia and factors associated with cerebral oxygenation during cardiopulmonary resuscitation.
Nelskylä A, Skrifvars MB, Ångerman S, Nurmi J. | Resuscitation. 2022 Jan;170:276-282
DOI:  | Télécharger l'article au format  
Keywords: CPR; Cerebral oxygenation; Hyperoxia; Near-infrared spectroscopy; Out-of-hospital cardiac arrest; Oxygen tension.

Clinical paper

Introduction : High oxygen levels may worsen cardiac arrest reperfusion injury. We determined the incidence of hyperoxia during and immediately after successful cardiopulmonary resuscitation and identified factors associated with intra-arrest cerebral oxygenation measured with near-infrared spectroscopy (NIRS).

Méthode : A prospective observational study of out-of-hospital cardiac arrest patients treated by a physician-staffed helicopter unit. Collected data included intra-arrest brain regional oxygen saturation (rSO2) with NIRS, invasive blood pressures, end-tidal CO2 (EtCO2) and arterial blood gas samples. Moderate and severe hyperoxia were defined as arterial oxygen partial pressure (paO2) 20.0-39.9 and ≥40 kPa, respectively. Intra-arrest factors correlated with the NIRS value, rSO2, were assessed with the Spearman's correlation test.

Résultats : Of 80 recruited patients, 73 (91%) patients had rSO2 recorded during CPR, and 46 had an intra-arrest paO2 analysed. ROSC was achieved in 28 patients, of whom 20 had paO2 analysed. Moderate hyperoxia was seen in one patient during CPR and in four patients (20%, 95% CI 7-42%) after ROSC. None had severe hyperoxia during CPR, and one patient (5%, 95% 0-25%) immediately after ROSC. The rSO2 during CPR was correlated with intra-arrest systolic (r = 0.28, p < 0.001) and diastolic blood pressure (p = 0.32, p < 0.001) but not with paO2 (r = 0.13, p = 0.41), paCO2 (r = 0.18, p = 0.22) or etCO2 (r = 0.008, p = 0.9).

Conclusion : Hyperoxia during or immediately after CPR is rare in patients treated by physician-staffed helicopter units. Cerebral oxygenation during CPR appears more dependent, albeit weakly, on hemodynamics than arterial oxygen concentration.

Conclusion (proposition de traduction) : L'hyperoxie pendant ou immédiatement après la RCR est rare chez les patients traités par les unités d'hélicoptères avec du personnel médical. L'oxygénation cérébrale pendant la RCP semble plus dépendante, bien que faiblement, de l'hémodynamique que la concentration artérielle en oxygène.

Association of end-tidal carbon dioxide levels during cardiopulmonary resuscitation with survival in a large paediatric cohort.
Sorcher JL, Hunt EA, Shaffner DH, O'Brien CE, Jeffers JM, Jones SI, Newton H, Duval-Arnould J. | Resuscitation. 2022 Jan;170:316-323
Keywords: Aucun

Clinical paper

Introduction : To examine the associations between ETCO2, ROSC, and chest compression quality markers in paediatric patients during active resuscitation.

Méthode : This was a single-centre cohort study of data collected as part of an institutional prospective quality initiative improvement program that included all paediatric patients who received chest compressions of any duration from January 1, 2013, through July 10, 2018, in the Johns Hopkins Children's Center. Data was collected from Zoll R Series® defibrillators. Events were included if Zoll data files contained both chest compression and ETCO2 data. 2,746 minutes corresponding to 143 events were included in the analyses.

Résultats : The median event ETCO2 for all 143 events was 16.8 [9.3-26.3] mmHg. There was a significant difference in median event ETCO2 between events that achieved ROSC and those that did not (ROSC: 19.3 [14.4-26.6] vs. NO ROSC: 13.9 [6.6-25.5] mmHg; p < 0.05). When the events were based on patient age, this relationship held in adolescents (ROSC: 18.8 [15.5-22.3] vs. NO ROSC: 9.6 [4.4-15.9] mmHg; p < 0.05), but not in children or infants. Median event ETCO2 was significantly associated with chest compression rate less than 140 (p < 0.0001) and chest compression fraction 90-100 (p < 0.0001).

Conclusion : Cela représente la plus grande collection de données sur l'ETCO2 et la compression thoracique chez les patients pédiatriques à ce jour et des analyses non ajustées suggèrent une association entre l'ETCO2 et le ROSC chez certains patients pédiatriques.

Conclusion (proposition de traduction) : This represents the largest collection of ETCO2 and chest compression data in paediatric patients to date and unadjusted analyses suggests an association between ETCO2 and ROSC in some paediatric patients.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers.
Nutbeam T, Fenwick R, May B, Stassen W, Smith JE, Bowdler J, Wallis L, Shippen J. | Scand J Trauma Resusc Emerg Med. 2022 Jan 15;30(1):7
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original research

Introduction : Motor vehicle collisions are a common cause of death and serious injury. Many casualties will remain in their vehicle following a collision. Trapped patients have more injuries and are more likely to die than their untrapped counterparts. Current extrication methods are time consuming and have a focus on movement minimisation and mitigation. The optimal extrication strategy and the effect this extrication method has on spinal movement is unknown. The aim of this study was to evaluate the movement at the cervical and lumbar spine for four commonly utilised extrication techniques.

Méthode : Biomechanical data was collected using inertial Measurement Units on 6 healthy volunteers. The extrication types examined were: roof removal, b-post rip, rapid removal and self-extrication. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement (travel), maximal movement, mean, standard deviation and confidence intervals are reported for each extrication type.

Résultats : Data from a total of 230 extrications were collected for analysis. The smallest maximal and total movement (travel) were seen when the volunteer self-extricated (AP max = 2.6 mm, travel 4.9 mm). The largest maximal movement and travel were seen in rapid extrication extricated (AP max = 6.21 mm, travel 20.51 mm). The differences between self-extrication and all other methods were significant (p < 0.001), small non-significant differences existed between roof removal, b-post rip and rapid removal. Self-extrication was significantly quicker than the other extrication methods (mean 6.4 s).

Conclusion : In healthy volunteers, self-extrication is associated with the smallest spinal movement and the fastest time to complete extrication. Rapid, B-post rip and roof off extrication types are all associated with similar movements and time to extrication in prepared vehicles.

Conclusion (proposition de traduction) : Chez les volontaires sains, la sortie des patients par leurs propres moyens est associée au plus petit mouvement de la colonne vertébrale et au temps le plus rapide d'extraction. Tous les types de désincarcération qu'elles soient rapide, par bloc avant et par dépavillonnage sont associées à des mouvements du rachis et à un temps de réalisation similaire sur les véhicules découpés.

Optimal cardiopulmonary resuscitation duration for favorable neurological outcomes after out-of-hospital cardiac arrest.
Park S, Lee SW, Han KS, Lee EJ, Jang DH, Lee SJ, Lee JS, Kim SJ; Korean Cardiac Arrest Research Consortium (KoCARC) Investigators. | Scand J Trauma Resusc Emerg Med. 2022 Jan 15;30(1):5
DOI:  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Neurological outcome; Out-of-hospital cardiac arrest; Resuscitation.

Original research

Introduction : A favorable neurological outcome is closely related to patient characteristics and total cardiopulmonary resuscitation (CPR) duration. The total CPR duration consists of pre-hospital and in-hospital durations. To date, consensus is lacking on the optimal total CPR duration. Therefore, this study aimed to determine the upper limit of total CPR duration, the optimal cut-off time at the pre-hospital level, and the time to switch from conventional CPR to alternative CPR such as extracorporeal CPR.

Méthode : We conducted a retrospective observational study using prospective, multi-center registry of out-of-hospital cardiac arrest (OHCA) patients between October 2015 and June 2019. Emergency medical service-assessed adult patients (aged ≥ 18 years) with non-traumatic OHCA were included. The primary endpoint was a favorable neurological outcome at hospital discharge.

Résultats : Among 7914 patients with OHCA, 577 had favorable neurological outcomes. The optimal cut-off for pre-hospital CPR duration in patients with OHCA was 12 min regardless of the initial rhythm. The optimal cut-offs for total CPR duration that transitioned from conventional CPR to an alternative CPR method were 25 and 21 min in patients with initial shockable and non-shockable rhythms, respectively. In the two groups, the upper limits of total CPR duration for achieving a probability of favorable neurological outcomes < 1% were 55-62 and 24-34 min, respectively, while those for a cumulative proportion of favorable neurological outcome > 99% were 43-53 and 45-71 min, respectively.

Conclusion : Herein, we identified the optimal cut-off time for transitioning from pre-hospital to in-hospital settings and from conventional CPR to alternative resuscitation. Although there is an upper limit of CPR duration, favorable neurological outcomes can be expected according to each patient's resuscitation-related factors, despite prolonged CPR duration.

Conclusion (proposition de traduction) : Ici, nous avons identifié l'heure limite optimale pour la transfert du milieu préhospitalier au milieu hospitalier et de la RCP conventionnelle à la réanimation alternative (12 min). Bien qu'il existe une limite supérieure de durée de la RCP, des résultats neurologiques favorables peuvent être attendus en fonction des facteurs liés à la réanimation de chaque patient, malgré la durée prolongée de la RCP.

Maximum movement and cumulative movement (travel) to inform our understanding of secondary spinal cord injury and its application to collar use in self-extrication.
Nutbeam T, Fenwick R, May B, Stassen W, Smith J, Shippen J. | Scand J Trauma Resusc Emerg Med. 2022 Jan 15;30(1):4
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original research

Introduction : Motor vehicle collisions remain a common cause of spinal cord injury. Biomechanical studies of spinal movement often lack "real world" context and applicability. Additional data may enhance our understanding of the potential for secondary spinal cord injury. We propose the metric 'travel' (total movement) and suggest that our understanding of movement related risk of injury could be improved if travel was routinely reported. We report maximal movement and travel for collar application in vehicle and subsequent self-extrication.

Méthode : Biomechanical data on application of cervical collar with the volunteer sat in a vehicle were collected using Inertial Measurement Units on 6 healthy volunteers. Maximal movement and travel are reported. These data and a re-analysis of previously published work is used to demonstrate the utility of travel and maximal movement in the context of self-extrication.

Résultats : Data from a total of 60 in-vehicle collar applications across three female and three male volunteers was successfully collected for analysis. The mean age across participants was 50.3 years (range 28-68) and the BMI was 27.7 (range 21.5-34.6). The mean maximal anterior-posterior movement associated with collar application was 2.3 mm with a total AP travel of 4.9 mm. Travel (total movement) for in-car application of collar and self-extrication was 9.5 mm compared to 9.4 mm travel for self-extrication without a collar.

Conclusion : We have demonstrated the application of 'travel' in the context of self-extrication. Total travel is similar across self-extricating healthy volunteers with and without a collar. We suggest that where possible 'travel' is collected and reported in future biomechanical studies in this and related areas of research. It remains appropriate to apply a cervical collar to self-extricating casualties when the clinical target is that of movement minimisation.

Conclusion (proposition de traduction) : Nous avons démontré l'application du « déplacement » dans le contexte de la sortie des patients par leurs propres moyens. Le déplacement total est similaire chez les volontaires sains qui sont sortis par leurs propres moyens avec et sans collier. Nous suggérons que, dans la mesure du possible, les « déplacement » soient recueillis et consignés dans les futures études biomécaniques dans ce domaine de recherche et dans des domaines connexes. Il reste pertinent de poser un collier cervical aux victimes sortis par leurs propres moyens lorsque l'objectif clinique est celui de la minimisation des mouvements.

The American Journal of Emergency Medicine

Bicycle handlebar injuries - a systematic review of pediatric chest and abdominal injuries.
Cheung R, Shukla M, Akers KG, Farooqi A, Sethuraman U. | Am J Emerg Med. 2022 Jan;51:13-21
Keywords: Abdominal injuries; Bicycling; Pediatrics; Thoracic injuries.

Research article

Introduction : The severity of handlebar injuries can be overlooked due to subtle signs and wide range of associated internal injuries. Our objective was to describe thoracoabdominal injuries due to bicycle handlebars and their outcomes in children.

Méthode : Articles that reported thoracoabdominal injuries were identified from database conception to March 3, 2019 using PubMed, EMBASE, Cochrane Library, CINHAHL Complete, Web of Science and Scopus. A systematic review of studies of thoracoabdominal handlebar injuries in children ≤21 years on human-powered bicycles in English was performed. Information on demographics, clinical features, injuries, interventions and outcomes was noted.

Résultats : A total of 138 articles were identified from 1952 to 2019. There were 1072 children (males, 85.1%) and 1255 thoracoabdominal injuries. Mean age was 9.7 ± 3.3 years old. Common clinical features included abdominal pain and guarding, vomiting, fever and a handlebar imprint. The liver was the most frequently injured organ. Surgery was performed in 338 children with a mean age of 10.0 ± 3.3 years. Twenty-seven children (2.5%) were discharged and returned due to worsening symptoms, of whom 23 (85.2%) required surgery. Thirty-one children (2.9%) transferred to a higher level of care due to injury severity. Two deaths were reported.

Conclusion : Bicycle handlebars can cause significant thoracoabdominal injuries. Presence of abdominal pain, vomiting, fever or a circular imprint on the chest or abdomen should prompt further workup. Future studies on diagnostic modalities and best practices are needed to lower the chance of missed injuries.

Conclusion (proposition de traduction) : Les guidons de vélo peuvent provoquer des lésions thoraco-abdominales importantes. La présence de douleurs abdominales, de vomissements, de fièvre ou d'une empreinte circulaire sur le thorax ou l'abdomen doit inciter à un examen plus poussé. De futures études sur les modalités de diagnostic et les meilleures pratiques sont nécessaires pour réduire le risque de blessures manquées.

CHA2DS2-VASc and has-BLED scores do not accurately stratify risk for stroke or bleed in fall victims with atrial fibrillation.
Carr BW, Wooster ME, Nemani LA, Severance SE, Hartwell JL. | Am J Emerg Med. 2022 Jan;51:119-123
Keywords: Anticoagulation; Atrial fibrillation; Bleeding; Falls; Geriatrics; Stroke.

Research article

Introduction : Falls are the leading cause of morbidity and mortality in the elderly. Non-valvular Atrial fibrillation (AF) is present in up to 9% of this group and often requires oral anticoagulation (OAC). The CHA2DS2-VASc and HAS-BLED scores are validated tools assessing risk of ischemic stroke from AF and major bleeding (MB) from OAC. It is unclear if these predictions remain accurate in post-fall patients. This study seeks to determine the stroke and major bleeding rate in atrial fibrillation patients after a ground level fall and identify if validated risk scoring systems accurately stratify risk in this cohort.

Méthode : Retrospective review of patients with AF presented to the emergency department after a fall. CHA2DS2-VASc and HAS-BLED scores were calculated. Follow up information was reviewed to 1 year. Patients were grouped according to discharge thromboprophylaxis plan (DTP): no treatment, Anti-platelet (AP), OAC, and AP + OAC. Outcomes were ischemic stroke, MB, or death at 1 year. Ischemic stroke and MB rates were calculated. Kruskal-Wallis, Χ2, Fisher's exact, and multivariable logistic regression were used to evaluate for clinical associations.

Résultats : 192 patients were included. MB rate was 14.5 bleeds/100 person-years, and ischemic stroke rate was 10.9/100 person-years. There were no observed differences between DTPs. Overall, one-year mortality was 22.1%. On unadjusted analysis, CHA2DS2-VASc did associate with ischemic stroke (p = 0.03); HAS-BLED did not associate with MB (p = 0.17). After logistic regression accounting for known risk factors, neither system associated with ischemic stroke or MB.

Conclusion : Fall patients are at higher risk for both ischemic stroke and MB compared to previously published reports. Current risk assessment tools should be used with caution. Further study of risk factors is warranted to guide medication decisions in these patients.

Conclusion (proposition de traduction) : Les patients victimes d'une chute courent un risque plus élevé d'AVC ischémique et d'hémorragie majeure que les études publiées antérieurement. Les outils actuels d'évaluation des risques doivent être utilisés avec prudence. Une étude plus approfondie des facteurs de risque est justifiée pour guider les décisions de médication chez ces patients.

How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis.
Downing J, Al Falasi R, Cardona S, Fairchild M, Lowie B, Chan C, Powell E, Pourmand A, Tran QK. | Am J Emerg Med. 2022 Jan;51:127-138
Keywords: ECPR; Extracorporeal cardiopulmonary resuscitation; OHCA; Out-of-hospital cardiac arrest; VA-ECMO; Venoarterial extracorporeal membrane oxygenation.

Research article

Introduction : Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA.

Méthode : We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity.

Résultats : We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies.

Conclusion : Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.

Conclusion (proposition de traduction) : La réanimation cardiopulmonaire extracorporelle est une intervention prometteuse mais gourmande en ressources qui peut augmenter les taux de survie à la sortie de l'hôpital chez les patients qui subissent un arrêt cardiaque en dehors de l'hôpital.

Usefulness of a modified poisoning severity score for predicting prognosis in acute carbon monoxide poisoning.
Lee JS, Kim TY, Bae KS, Kim H. | Am J Emerg Med. 2022 Jan;51:156-162
Keywords: Carbon monoxide poisoning; Carboxyhemoglobin; Lactate; Outcome; Poisoning severity score.

Research article

Introduction : The poisoning severity score (PSS) was developed to grade the severity of various types of poisoning. However, in its current form, it requires investigating many variables, some of which have been found not to be associated with carbon monoxide (CO) poisoning severity. Therefore, in this study, we modified the PSS for CO poisoning and compared its usefulness to that of the original PSS, as an early prognostic factor of short-term outcome in CO poisoning patients.

Méthode : This was a retrospective observational study conducted in patients with CO poisoning who visited the emergency department between January 2014 and December 2020. Patients' primary outcome was their Cerebral Performance Category (CPC) scale score at discharge, which classified those with CPC 1-2 as having a favorable outcome and those with CPC 3-5 as having a poor outcome. We calculated the patients' PSS and their CO-modified PSS by replacing blood and metabolic balance category in the original PSS with carboxyhemoglobin (COHb) and lactate levels, respectively.

Résultats : This study included 891 patients, of which 852 (95.6%) and 39 (4.4%) were classified into the favorable and poor outcome groups, respectively. Using multivariate analysis, the PSS (odds ratio [OR], 22.961; 95% confidence interval [CI], 10.641-49.546; p < 0.001) and CO-modified PSS (OR, 28.856; 95% CI, 12.874-64.679; p < 0.001) were both found to be associated with poor outcomes at hospital discharge. The areas under the receiver operating characteristic curves for the PSS and CO-modified PSS were 0.874 (95% CI, 0.850-0.895) and 0.881 (95% CI, 0.858-0.901), respectively.

Conclusion : The CO-modified PSS, with fewer variables than the original PSS, was not inferior to predict poor outcomes, and if COHb level is considered together with other parameters, then it can be used both for predicting prognosis and in diagnosis.

Conclusion (proposition de traduction) : Le PSS modifié par le CO, avec moins de variables que le PSS original, n'était pas inférieur pour prédire les mauvais résultats, et si le niveau de carboxyhémoglobine est pris en compte avec d'autres paramètres, il peut être utilisé à la fois pour prédire le pronostic et pour le diagnostic.

Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis.
Janapala RN, Tran QK, Patel J, Mehta E, Pourmand A. | Am J Emerg Med. 2022 Jan;51:169-175
Keywords: Emergency department; Epistaxis; Nasal bleeding; TXA; Tranexamic acid.

Review article

Introduction : Epistaxis is a very common presentation in the emergency department (ED), accounting for approximately 1 in 200 ED visits in the United States. Currently, standard practice includes the initial use of topical anesthetics and vasoconstrictors, followed by more invasive treatments such as nasal packing, cauterization or surgical ligation for refractory cases. Over the years several studies have investigated the potential use of topical Tranexamic Acid (TXA) in the management of epistaxis. We have conducted a meta-analysis to assess the efficacy of topical TXA versus other standard practices or placebo in the management of epistaxis.

Méthode : PubMed and Scopus databases were searched from inception to April 2021. We included randomized controlled trials and observational studies investigating the efficacy of TXA in bleeding cessation in epistaxis in adults. The primary outcome measured was the prevalence of bleeding cessation after treatment at first assessment. Other outcomes were bleeding reoccurrence between 24 and 72 h and at 7-8 days. A random-effects model was used to estimate odds ratio (OR) for outcomes.

Résultats : A total of eight studies were included in the analysis, including seven randomized trials and one retrospective study. We included a total of 1299 patients, 596 (46%) received TXA while 703 (54%) received control treatment (placebo, lidocaine plus vasoconstrictors or local anesthetics). Patients who were treated with TXA were 3.5 times (OR 3.5, 95% CI 1.3-9.7) more likely to achieve bleeding cessation at the first assessment. Patients treated with TXA had 63% (OR 0.37, 95% CI 0.20-0.66) less likelihood of returning due to rebleeding at 24-72 h.

Conclusion : Topical TXA is associated with better bleeding cessation rates after treatment compared to the standard practices.

Conclusion (proposition de traduction) : L'acide tranexamique topique est associé à de meilleurs taux d'arrêt des saignements après le traitement par rapport aux pratiques standard.

Intravenous diltiazem versus metoprolol for atrial fibrillation with rapid ventricular rate: A meta-analysis.
Lan Q, Wu F, Han B, Ma L, Han J, Yao Y. | Am J Emerg Med. 2022 Jan;51:248-256
Keywords: Atrial fibrillation; Diltiazem; Metoprolol; Rapid ventricular rate.

Review article

Introduction : Intravenous diltiazem and metoprolol are both commonly used to treat atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED), but the advantages and disadvantages of these drugs cannot be verified. This meta-analysis aimed to assess the efficacy and safety of intravenous diltiazem versus metoprolol for AF with RVR.

Méthode : We systematically searched PubMed, Web of Science, Embase, Cochrane library, the China National Knowledge Infrastructure (CNKI), Wanfang, China Biology Medicine disc (CBM) and the WeiPu (VIP). Meta-analysis was performed using weighted mean difference (WMD), relative risk (RR) and 95% confidence interval (CI). Statistical analysis was performed using Review Manager 5.4.1.

Résultats : Seventeen studies involving 1214 patients in nine randomized controlled trials (RCTs) and eight cohort studies were included in meta-analysis, including 643 patients in the intravenous diltiazem group and 571 patients group in the intravenous metoprolol. The results of the meta-analysis showed that compared with intravenous metoprolol, intravenous diltiazem was found higher efficacy (RR =1.11; 95% CI = 1.06 to 1.16, p < 0.00001), shorter average onset time (RR = -1.13; 95% CI = -1.97 to -0.28, p = 0.009), lower ventricular rate (RR = -9.48; 95% CI = -12.13 to -6.82, p<0.00001), less impact on systolic blood pressure (WMD = 3.76; 95% CI: 0.20 to 7.33, P = 0.04), and no significant difference in adverse events (RR = 0.80, 95% CI = 0.55 to 1.14, P = 0.22) and diastolic blood pressure (WMD = -1.20; 95% CI: -3.43 to 1.04, P = 0.29) was found between intravenous diltiazem and metoprolol.

Conclusion : Intravenous diltiazem has higher efficacy, shorter average onset time, lower ventricular rate, less impact on blood pressure, and with no increase in adverse events compared to intravenous metoprolol.

Conclusion (proposition de traduction) : Le diltiazem intraveineux a une efficacité supérieure, un temps d'apparition moyen plus court, une fréquence ventriculaire plus faible, moins d'impact sur la pression artérielle et sans augmentation des effets indésirables par rapport au métoprolol intraveineux.

Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis.
deSouza IS, Thode HC Jr, Shrestha P, Allen R, Koos J, Singer AJ. | Am J Emerg Med. 2022 Jan;51:363-373
Keywords: Agitation; Delirium; Sedation; Tranquilization; Network meta-analysis

Review article

Introduction : Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED).

Méthode : The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event – cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome.

Résultats : Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated “very low” for safety.

Conclusion : Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.

Conclusion (proposition de traduction) : Les preuves disponibles suggèrent que la kétamine et le dropéridol ont une efficacité intermédiaire pour la sédation rapide du patient sévèrement agité au service des urgences. Il n'y a pas suffisamment de preuves pour déterminer avec certitude quel(s) agent(s) peut(vent) être le(s) plus sûr(s) ou agissant le plus rapidement. En outre, une étude de comparaison directe de la kétamine et du dropéridol est recommandée.

The Journal of Emergency Medicine

Diagnosis and Management of Cellulitis and Abscess in the Emergency Department Setting: An Evidence-Based Review.
Long B, Gottlieb M. | J Emerg Med. 2022 Jan;62(1):16-27
Keywords: abscess; antibiotics; cellulitis; incision and drainage; skin; soft tissue.

Research article

Introduction : Cellulitis and abscess are a common reason for presentation to the emergency department, although there are several nuances to the care of these patients.

Méthode : The purpose of this narrative review article was to provide a summary of the background, pathophysiology, diagnosis, and management of cellulitis and abscesses with a focus on emergency clinicians.

Résultats : The most common bacteria causing cellulitis are Staphylococcus aureus, Streptococcus pyogenes, and other β-hemolytic streptococci, and methicillin-resistant S. aureus is most common in abscesses. The history and physical examination are helpful in differentiating cellulitis and abscess in many cases, and point-of-care ultrasound can be a useful tool in unclear cases. Treatment for cellulitis typically involves a penicillin or cephalosporin, and treatment of abscesses is incision and drainage. Loop drainage is preferred over the traditional incision and drainage technique, and adjunctive antibiotics can be considered. Most patients can be managed as outpatient.

Conclusion : It is essential for emergency physicians to be aware of the current evidence regarding the diagnosis and management of patients with cellulitis and abscess.

Conclusion (proposition de traduction) : Il est essentiel que les urgentistes connaissent les recommandations actuelles concernant le diagnostic et la prise en charge des patients présentant une dermohypodermite et un abcès.

Commentaire : Voir la recommandation de bonne pratique de 2019 de la HAS : Prise en charge des infections cutanées bactériennes courantes  .

Multisystem Inflammatory Syndrome in Children.
Waseem M, Shariff MA, Tay ET, Mortel D, Savadkar S, Lee H, Kondamudi N, Liang T. | J Emerg Med. 2022 Jan;62(1):28-37
DOI:  | Télécharger l'article au format  
Keywords: COVID-19; Kawasaki disease; PMIS; SARS-CoV-2; multisystem inflammatory syndrome in children.

Research article

Introduction : Multisystem inflammatory syndrome in children (MIS-C) is a newly recognized condition affecting children with recent infection or exposure to coronavirus disease 2019 (COVID-19). MIS-C has symptoms that affect multiple organs systems, with some clinical features resembling Kawasaki disease (KD) and toxic shock syndrome (TSS).

Méthode : Our goal was to review the current literature and describe the evaluation and treatment algorithms for children suspected of having MIS-C who present to the emergency department.

Discussion : MIS-C has a wide clinical spectrum and diagnosis is based on a combination of both clinical and laboratory findings. The exact mechanism of immune dysregulation of MIS-C is not well understood. Physical findings may evolve and do not necessarily appear at the same time. Gastrointestinal, cardiac, inflammatory, and coagulopathy manifestations and dysfunction are seen frequently in MIS-C.

Conclusion : The diagnosis of MIS-C is based on clinical presentation and specific laboratory findings. In the emergency setting, a high level of suspicion for MIS-C is required in patients exposed to COVID-19. Early diagnosis and prompt initiation of therapy offer the best chance for optimal outcomes.

Conclusion (proposition de traduction) : Le diagnostic de PIMS est basé sur la présentation clinique et les résultats de laboratoire spécifiques. En situation d'urgence, un niveau élevé de suspicion de PIMS est requis chez les patients exposés au COVID-19. Un diagnostic précoce et une initiation rapide du traitement offrent les meilleures chances d'obtenir des résultats optimaux.

Commentaire :  Diagnostic algorithm for suspected multisystem inflammatory syndrome in children.
BP = blood pressure; CBD = com- plete blood count; COVID-19 = coronavirus disease 2019; Echo = echocardiogram; ECMO = extracorporeal membrane oxygena- tion; ECG = electrocardiogram; ESR = erythrocyte sedimentation rate; HIV = human immunodeficiency virus; LDH = lactate dehydrogenase; POCUS = point-of-care ultrasound; PT = prothrombin time; PTT = partial thromboplastin time; TB = tubercu- losis; TSS = toxic shock syndrome; VBG = venous blood gas. *POCUS Echo.

Surveillance des cas de syndrome inflammatoire multi-systémique pédiatrique (PIMS ou MIS-C)  . Direction des maladies infectieuses, Santé publique France Bilan au 30 décembre 2021, mise à jour le 27 janvier 2022  .

Ultrasonographic Inferior Vena Cava Measurement is More Sensitive Than Vital Sign Abnormalities for Identifying Moderate and Severe Hemorrhage.
Clemency BM, Bola A, Schlader ZJ, Hostler D, Lin H, St James E, Lema PC, Johnson BD. | J Emerg Med. 2022 Jan;62(1):64-71
Keywords: POCUS; hemorrhage; inferior vena cava; lower body negative pressure; shock; ultrasound.

Research article

Introduction : Ultrasound inferior vena cava (IVC) diameter has been shown to decrease in response to hemorrhage. IVC diameter cut points to identify moderate and severe blood loss have not been established.
Objectives : This study sought to find ultrasound IVC diameter cut points to identify moderate and severe hemorrhage and assess the performance of these cut points vs. vital sign abnormalities.

Méthode : This is a secondary analysis of data from a study that described changes in vital signs and sonographic measurements of the IVC during a lower body negative pressure model of hemorrhage. Using receiver operator curve analyses, optimal cut points for identifying moderate and severe hemorrhage were identified. The ability of these cut points to identify hemorrhage in patients with no vital sign abnormalities was then assessed.

Résultats : In both long- and short-axis views, maximum and minimum IVC diameters (IVCmax and IVCmin) were significantly lower than baseline in severe blood loss. The optimal cut point for IVCmax in both axes was found to be ≤ 0.8 cm. This cut point is able to distinguish between no blood loss vs. moderate blood loss, and no blood loss vs. severe blood loss. The optimal cut point for IVCmin was variable between axes and blood loss severity. IVC diameter cut points obtained were able to identify hemorrhage in patients with no vital sign abnormalities.

Conclusion : An ultrasound IVCmax of ≤ 0.8 cm may be useful in identifying moderate and severe hemorrhage before vital sign abnormalities are evident.

Conclusion (proposition de traduction) : Une échographie de la veine cave inférieure max de ≤ 0,8 cm peut être utile pour identifier une hémorragie modérée et sévère avant que des anomalies des signes vitaux ne soient évidentes.

The Journal of Trauma and Acute Care Surgery

Blood product resuscitation mitigates the effects of aeromedical evacuation after polytrauma.
Wallen TE, Singer KE, Morris MC, Blakeman T, Stevens-Topie SM, Strilka R, Pritts TA, Goodman MD. | J Trauma Acute Care Surg. 2022 Jan 1;92(1):12-20
Keywords: Aucun


Introduction : The combined injury of traumatic brain injury and hemorrhagic shock has been shown to worsen coagulopathy and systemic inflammation, thereby increasing posttraumatic morbidity and mortality. Aeromedical evacuation to definitive care may exacerbate postinjury morbidity because of the inherent hypobaric hypoxic environment. We hypothesized that blood product resuscitation may mitigate the adverse physiologic effects of postinjury flight.

Méthode : An established porcine model of controlled cortical injury was used to induce traumatic brain injury. Intracerebral monitors were placed to record intracranial pressure, brain tissue oxygenation, and cerebral perfusion. Each of the 42 pigs was hemorrhaged to a goal mean arterial pressure of 40 ± 5 mm Hg for 1 hour. Pigs were grouped according to resuscitation strategy used-Lactated Ringer's (LR) or shed whole blood (WB)-then placed in an altitude chamber for 2 hours at ground, 8,000 ft, or 22,000 ft, and then observed for 4 hours. Hourly blood samples were analyzed for proinflammatory cytokines and lactate. Internal jugular vein blood flow was monitored continuously for microbubble formation with altitude changes.

Résultats : Cerebral perfusion, tissue oxygenation, and intracranial pressure were unchanged among the six study groups. Venous microbubbles were not observed even with differing altitude or resuscitation strategy. Serum lactate levels from hour 2 of flight to the end of observation were significantly elevated in 22,000 + LR compared with 8,000 + LR and 22,000 + WB. Serum IL-6 levels were significantly elevated in 22,000 + LR compared with 22,000 + WB, 8,000 + LR and ground+LR at hour 1 of observation. Serum tumor necrosis factor-α was significantly elevated at hour 2 of flight in 8,000 + LR versus ground+LR, and in 22,000 + LR vs. 22,000 + WB at hour 1 of observation. Serum IL-1β was significantly elevated hour 1 of flight between 8,000 + LR and ground+LR.

Conclusion : Crystalloid resuscitation during aeromedical transport may cause a prolonged lactic acidosis and proinflammatory response that can predispose multiple-injury patients to secondary cellular injury. This physiologic insult may be prevented by using blood product resuscitation strategies.

Conclusion (proposition de traduction) : La réanimation par les cristalloïde pendant le transport aéromédical peut provoquer une acidose lactique prolongée et une réponse pro-inflammatoire qui peuvent prédisposer les patients traumatisés sévères à des lésions cellulaires secondaires. Cette atteinte physiologique peut être prévenue en utilisant des stratégies de réanimation par les produits sanguins.

Not so FAST-Chest ultrasound underdiagnoses traumatic pneumothorax.
Santorelli JE, Chau H, Godat L, Casola G, Doucet JJ, Costantini TW. | J Trauma Acute Care Surg. 2022 Jan 1;92(1):44-48. 2022 Jan 1;92(1):44-48
Keywords: Aucun


Introduction : Ultrasonography for trauma is a widely used tool in the initial evaluation of trauma patients with complete ultrasonography of trauma (CUST) demonstrating equivalence to computed tomography (CT) for detecting clinically significant abdominal hemorrhage. Initial reports demonstrated high sensitivity of CUST for the bedside diagnosis of pneumothorax. We hypothesized that the sensitivity of CUST would be greater than initial supine chest radiograph (CXR) for detecting pneumothorax.

Méthode : A retrospective analysis of patients diagnosed with pneumothorax from 2018 through 2020 at a Level I trauma center was performed. Patients included had routine supine CXR and CUST performed prior to intervention as well as confirmatory CT imaging. All CUST were performed during the initial evaluation in the trauma bay by a registered sonographer. All imaging was evaluated by an attending radiologist. Subgroup analysis was performed after excluding occult pneumothorax. Immediate tube thoracostomy was defined as tube placement with confirmatory CXR within 8 hours of admission.

Résultats : There were 568 patients screened with a diagnosis of pneumothorax, identifying 362 patients with a confirmed pneumothorax in addition to CXR, CUST, and confirmatory CT imaging. The population was 83% male, had a mean age of 45 years, with 85% presenting due to blunt trauma. Sensitivity of CXR for detecting pneumothorax was 43%, while the sensitivity of CUST was 35%. After removal of occult pneumothorax (n = 171), CXR was 78% sensitive, while CUST was 65% sensitive (p < 0.01). In this subgroup, CUST had a false-negative rate of 36% (n = 62). Of those patients with a false-negative CUST, 50% (n = 31) underwent tube thoracostomy, with 85% requiring immediate placement.

Conclusion : Complete ultrasonography of trauma performed on initial trauma evaluation had lower sensitivity than CXR for identification of pneumothorax including clinically significant pneumothorax requiring tube thoracostomy. Using CUST as the primary imaging modality in the initial evaluation of chest trauma should be considered with caution.

Conclusion (proposition de traduction) : L'échographie complète du traumatisme réalisée lors de l'évaluation initiale du traumatisme avait une sensibilité inférieure à la radiographie pulmonaire pour l'identification du pneumothorax, y compris le pneumothorax cliniquement significatif nécessitant la pose d’un drain thoracique. L'utilisation de l'échographie complète du traumatisme comme modalité d'imagerie principale dans l'évaluation initiale du traumatisme thoracique doit être envisagée avec prudence.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm.
de Moya M, Brasel KJ, Brown CVR, Hartwell JL, Inaba K, Ley EJ, Moore EE, Peck KA, Rizzo AG, Rosen NG, Sperry J, Weinberg JA, Martin MJ. | J Trauma Acute Care Surg. 2022 Jan 1;92(1):103-107
Keywords: Consensus algorithm from the Western Trauma Association, Level V.


Editorial : This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians.

Conclusion : Pneumothoraces are common following trauma and require an objective approach. Using a more objective measure will help to guide the practitioner. The use of smaller bore chest tubes has been well established for PTXs, and the presence of a small hemothorax was thought to not have any bearing on type of tube to be used. There are many areas of controversy that remain and will require ongoing investigations. However, the literature and this algorithm strongly support an individualized approach, the avoidance of routine large-bore chest tube placement for simple PTX, and the safety and efficacy of observation only for select patients based on clinical symptoms and PTX size.

Conclusion (proposition de traduction) : Les pneumothorax sont fréquents suite à un traumatisme et nécessitent une approche objective. L'utilisation d'une mesure plus objective aidera à guider le praticien. L'utilisation de drains thoraciques de plus petit diamètre a été bien établie pour les pneumothorax traumatiques, et on pensait que la présence d'un petit hémothorax n'avait aucune incidence sur le type de tube à utiliser. De nombreux sujets de controverse subsistent et nécessiteront des enquêtes continues. Cependant, la littérature et cet algorithme soutiennent fortement une approche individualisée, l'évitement du placement systématique d'un drain thoracique de gros calibre pour un pneumothorax traumatique simple, et la sécurité et l'efficacité de l'observation uniquement pour certains patients en fonction des symptômes cliniques et de la taille du pneumothorax traumatique.

The New England Journal of Medicine

Snake Envenomation.
Seifert SA, Armitage JO, Sanchez EE. | N Engl J Med. 2022 Jan 6;386(1):68-78
Keywords: Aucun

Review article

Editorial : Snake envenomation represents an important health problem in much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma. In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.

Conclusion : Snakebite envenomation continues to be a major global health burden. Current technical advances are focused on snake envenomation treatments, including more effective and safer antivenoms. Current efforts aimed at prevention, diagnosis, and increased access to timely and effective treatments are still in early stages of development in much of the world.

Conclusion (proposition de traduction) : L'envenimation par morsure de serpent continue d'être une charge majeur pour la santé mondiale. Les progrès techniques actuels se concentrent sur les traitements de l'envenimation des serpents, y compris des antivenins plus efficaces et plus sûrs. Les efforts actuels visant à la prévention, au diagnostic et à un accès accru à des traitements rapides et efficaces en sont encore aux premiers stades de développement dans une grande partie du monde.

The Ultrasound Journal

Inter-rater reliability of optic nerve sheath diameter measurement using real-time ultrasonography.
Jennings JB, Oliva C, Joyce M, Vitto MJ, Tozer J, Taylor LA, Evans DP. | Ultrasound J. 2022 Jan 10;14(1):6
DOI:  | Télécharger l'article au format  
Keywords: Emergency medicine; Inter-rater reliability; Optic nerve sheath diameter; Point-of-care ultrasound.

Original article

Introduction : Ultrasound measurement of the optic nerve sheath diameter (ONSD) is a rapid, non-invasive means to indirectly assess intracranial pressure. Previous research has demonstrated the ability of emergency physicians to measure ONSD accurately with bedside ultrasound when compared to CT scan or MRI, however the reliability of this measurement between two or more operators has been called into question (Hassen et al. in J Emerg Med 48:450-457, 2015; Shirodkar et al. in Ind J Crit Care Med 19:466-470, 2015). Given the need for accurate and precise measurement to use this as a screening exam, we sought to determine the inter-rater reliability between ONSD measurements obtained in real time by fellowship-trained emergency ultrasound physicians.

Méthode : Three ultrasound fellowship-trained emergency physicians measured bilateral ONSD of 10 healthy volunteers using a high-frequency linear transducer. The physicians were blinded to the other scanners' measurements, and no instructions were given other than to obtain the ONSD. Each sonographer measured the ONSD in real time and it was recorded by a research coordinator. All measurements were recorded in millimeters. Intraclass correlation coefficients (ICCs) were calculated to estimate the inter-rater reliability.

Résultats : A total of 60 measurements of ONSD were obtained. The average measurement was 4.3 mm (3.83-4.77). Very little variation was found between the three physicians, with a calculated ICC of 0.82 (95% confidence interval 0.63-0.92).

Conclusion : ONSD measurement obtained by ultrasound fellowship-trained emergency medicine physicians is a reliable measurement with a high degree of correlation between scanners.

Conclusion (proposition de traduction) : La mesure du diamètre de la gaine du nerf optique obtenue par des médecins urgentistes formés en échographie est une mesure fiable avec un degré élevé de corrélation entre les scanners.

The impact of lung ultrasound on clinical-decision making across departments: a systematic review.
Heldeweg MLA, Vermue L, Kant M, Brouwer M, Girbes ARJ, Haaksma ME, Heunks LMA, Mousa A, Smit JM, Smits TW, Paulus F, Ket JCF, Schultz MJ, Tuinman PR. | Ultrasound J. 2022 Jan 10;14(1):5
DOI:  | Télécharger l'article au format  
Keywords: Chest; Clinical-decision making; Lung; Management; Ultrasonography.


Introduction : Lung ultrasound has established itself as an accurate diagnostic tool in different clinical settings. However, its effects on clinical-decision making are insufficiently described. This systematic review aims to investigate the impact of lung ultrasound, exclusively or as part of an integrated thoracic ultrasound examination, on clinical-decision making in different departments, especially the emergency department (ED), intensive care unit (ICU), and general ward (GW).

Méthode : This systematic review was registered at PROSPERO (CRD42021242977). PubMed, EMBASE, and Web of Science were searched for original studies reporting changes in clinical-decision making (e.g. diagnosis, management, or therapy) after using lung ultrasound. Inclusion criteria were a recorded change of management (in percentage of cases) and with a clinical presentation to the ED, ICU, or GW. Studies were excluded if examinations were beyond the scope of thoracic ultrasound or to guide procedures. Mean changes with range (%) in clinical-decision making were reported. Methodological data on lung ultrasound were also collected. Study quality was scored using the Newcastle-Ottawa scale.

Résultats : A total of 13 studies were included: five studies on the ED (546 patients), five studies on the ICU (504 patients), two studies on the GW (1150 patients), and one study across all three wards (41 patients). Lung ultrasound changed the diagnosis in mean 33% (15-44%) and 44% (34-58%) of patients in the ED and ICU, respectively. Lung ultrasound changed the management in mean 48% (20-80%), 42% (30-68%) and 48% (48-48%) of patients in the ED, in the ICU and in the GW, respectively. Changes in management were non-invasive in 92% and 51% of patients in the ED and ICU, respectively. Lung ultrasound methodology was heterogeneous across studies. Risk of bias was moderate to high in all studies.

Conclusion : Lung ultrasound, exclusively or as a part of thoracic ultrasound, has substantial impact on clinical-decision making by changing diagnosis and management in the EDs, ICUs, and GWs. The current evidence level and methodological heterogeneity underline the necessity for well-designed trials and standardization of methodology.

Conclusion (proposition de traduction) : L'échographie pulmonaire, exclusivement ou dans le cadre de l'échographie thoracique, a un impact substantiel sur la prise de décision clinique en modifiant le diagnostic et la prise en charge dans le service des urgences, l'unité de soins intensifs et le service général. Le niveau de preuve actuel et l'hétérogénéité méthodologique soulignent la nécessité d'essais bien conçus et d'une normalisation de la méthodologie.

Mois de janvier 2022