Ketamine administration for acute painful sickle cell crisis: A randomized controlled trial.
Alshahrani MS, AlSulaibikh AH, ElTahan MR, AlFaraj SZ, Asonto LP, AlMulhim AA, AlAbbad MF, Almaghraby N, AlJumaan MA, AlJunaid TO, Darweesh MN, AlHawaj FM, Mahmoud AM, Alossaimi BK, Alotaibi SK, AlMutairi TM, AlSulaiman PharmD DA, Alfaraj D, Alhawwas R, Mbuagbaw L, Lewis K, Verhovsek M, Crowther M, Guyatt G, Alhazzani W; GUIDE Group. | Acad Emerg Med. 2022 Feb;29(2):150-158
DOI: https://doi.org/10.1111/acem.14382  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : The objective was to evaluate the efficacy and safety of single-dose ketamine infusion in adults with sickle cell disease (SCD) who presented with acute sickle vasoocclusive crisis (VOC).

Méthode : This study was a parallel-group, prospective, randomized, double-blind, pragmatic trial. Participants were randomized to receive a single dose of either ketamine or morphine, infused over 30 min. Primary outcome was mean difference in the numerical pain rating scale (NPRS) score over 2 h. NPRS was recorded every 30 min for a maximum of 180 min and secondary outcomes were cumulative dose of opioids, emergency department (ED) length of stay, hospital admission, change in vital signs, and drug-related side effects. Authors performed the analysis using intention-to-treat principle.

Résultats : A total of 278 adults with SCD and who presented with acute sickle VOC participated in this trial. A total of 138 were allocated to the ketamine group. Mean (±standard deviation [SD]) NPRS scores over 2 h were 5.7 (±2.13) and 5.6 (±1.90) in the ketamine and morphine groups. The ketamine group received significantly lower cumulative doses of morphine during their ED stay (mean ± SD = 4.5 ± 4.6 mg) than of the morphine group (mean ± SD = 8.5 ± 7.55 mg). Both groups had similar rates of hospital admission: 6.3% in the ketamine group had drug-related side effects compared to 2.2% in the morphine group.

Conclusion : Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED with no significant drug-related side effects in the ketamine-treated group.

Conclusion (proposition de traduction) : L'utilisation précoce de la kétamine chez les adultes en crise vasoocclusive a entraîné une réduction significative des scores de douleur sur une période de 2 heures et a réduit la dose cumulée de morphine aux urgences sans effets secondaires significatifs liés au médicament dans le groupe traité à la kétamine.

High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19.
Ranieri VM, Tonetti T, Navalesi P, Nava S, Antonelli M, Pesenti A, Grasselli G, Grieco DL, Menga LS, Pisani L, Boscolo A, Sella N, Pasin L, Mega C, Pizzilli G, Dell'Olio A, Dongilli R, Rucci P, Slutsky AS. | Am J Respir Crit Care Med. 2022 Feb 15;205(4):431-439
DOI: https://doi.org/10.1164/rccm.202109-2163oc  | Télécharger l'article au format  
Keywords: ARDS; COVID-19; HFNO; mechanical ventilation; noninvasive ventilation.

COVID-19/Critical Care

Introduction : The "Berlin definition" of acute respiratory distress syndrome (ARDS) does not allow inclusion of patients receiving high-flow nasal oxygen (HFNO). However, several articles have proposed that criteria for defining ARDS should be broadened to allow inclusion of patients receiving HFNO.

Méthode : To compare the proportion of patients fulfilling ARDS criteria during HFNO and soon after intubation, and 28-day mortality between patients treated exclusively with HFNO and patients transitioned from HFNO to invasive mechanical ventilation (IMV). Methods: From previously published studies, we analyzed patients with coronavirus disease (COVID-19) who had PaO₂/FiO₂ of ⩽300 while treated with ⩾40 L/min HFNO, or noninvasive ventilation (NIV) with positive end-expiratory pressure of ⩾5 cm H₂O (comparator). In patients transitioned from HFNO/NIV to invasive mechanical ventilation (IMV), we compared ARDS severity during HFNO/NIV and soon after IMV. We compared 28-day mortality in patients treated exclusively with HFNO/NIV versus patients transitioned to IMV.

Résultats : We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. A total of 112 HFNO and 69 NIV patients transitioned to IMV. Of those, 104 (92.9%) patients on HFNO and 66 (95.7%) on NIV continued to have PaO₂/FiO₂ ⩽300 under IMV. Twenty-eight-day mortality in patients who remained on HFNO was 4.2% (3/72), whereas in patients transitioned from HFNO to IMV, it was 28.6% (32/112) (P < 0.001). Twenty-eight-day mortality in patients who remained on NIV was 1.6% (1/62), whereas in patients who transitioned from NIV to IMV, it was 44.9% (31/69) (P < 0.001). Overall mortality was 19.0% (35/184) and 24.4% (32/131) for HFNO and NIV, respectively (P = 0.2479).

Conclusion : Broadening the ARDS definition to include patients on HFNO with PaO₂/FiO₂ ⩽300 may identify patients at earlier stages of disease but with lower mortality.

Conclusion (proposition de traduction) : Élargir la définition du SDRA pour inclure les patients sous HFNO avec PaO₂/FiO₂ ⩽300 peut identifier les patients à des stades précoces de la maladie mais avec une mortalité plus faible.

Inotropes and vasopressors are associated with increased short-term mortality but not long-term survival in critically ill patients.
Motiejunaite J, Deniau B, Blet A, Gayat E, Mebazaa A. | Anaesth Crit Care Pain Med. 2022 Feb;41(1):101012
DOI: https://doi.org/10.1016/j.accpm.2021.101012
Keywords: Inotropes; Long-term outcomes; Mortality; Propensity score matching; Vasopressors.

Original article

Introduction : Limited information is currently available on the impact of vasoactive medications in intensive care (ICU) and long-term outcomes. The main objective of our study was to describe the association between the use of inotropes and/or vasopressors and ICU mortality. Secondary objectives were to evaluate the association between the use of vasoactive drugs and in-hospital as well as 1-year all-cause mortality in ICU survivors.

Méthode : FROG-ICU was a prospective, observational, multi-centre cohort designed to investigate long-term mortality of critically ill adult patients. Cox proportional hazards models were used to evaluate the association between the use of inotropes and/or vasopressors and ICU mortality, as well as in-hospital and 1-year all-cause mortality in a propensity-score matched cohort.

Résultats : The study included 2087 patients, 939 of whom received inotropes and/or vasopressors during the initial ICU stay. Patients treated with vasoactive medications were older and had a more severe clinical presentation. In a propensity score-matched cohort of 1201 patients, ICU mortality was higher in patients who received vasoactive medications (HR of 1.40 [1.10-1.78], p = 0.007). One thousand six hundred thirty-five patients survived the index ICU hospitalisation. There was no significant difference according to the use of inotropes and/or vasopressors in the propensity-score matched cohort on in-hospital mortality (HR of 0.94 [0.60-1.49], p = 0.808) as well as one-year all-cause mortality (HR 0.94 [0.71-1.24], p = 0.643).

Conclusion : Inotropic and/or vasopressor therapy is a strong predictor of in-ICU death. However, the use of inotropes and/or vasopressors during ICU admission was not associated with a worse prognosis after ICU discharge.

Conclusion (proposition de traduction) : Le traitement inotrope et/ou vasopresseur est un puissant facteur prédictif de décès en USI. Cependant, l'utilisation d'inotropes et/ou de vasopresseurs lors de l'admission aux soins intensifs n'était pas associée à un pronostic plus défavorable après la sortie des soins intensifs.

Modified long-axis in-plane ultrasound-guided radial artery cannulation in adult patients: A randomized controlled trial.
Wang J, Weng X, Huang Q, Lai Z, Zhao Z, Lan J, Wu G, Lin L, Su J, Liu J, Zhang L. | Anaesth Crit Care Pain Med. 2022 Feb;41(1):100989
DOI: https://doi.org/10.1016/j.accpm.2021.100989  | Télécharger l'article au format  
Keywords: Anaesthesia; Intensive care; Surgery; Ultrasound.

Original article

Introduction : For adults with small radial arteries, ultrasound-guided radial artery cannulation remains challenging and the relevant data is currently lacking. The study aimed to test the hypothesis that modified long-axis in-plane ultrasound guidance (M-LAIP) would improve success rates of radial artery cannulation in this population.

Méthode : This was a prospective, randomised, and controlled clinical study that enrolled 201 adult patients with diameters of the radial artery less than 2.2 mm. Patients were randomised to M-LAIP, short-axis out-of-plane (SAOP), or conventional palpation (C-P) group according to different approaches of radial artery cannulation (M-LAIP, SAOP, and C-P). Outcome measurements included the success rate, cannulation time, and cannulation-related adverse events.

Résultats : The cannulation success rate was significantly higher in the M-LAIP group than in the SAOP or C-P groups (first success rate: 80.3% vs. 53.8% or 33.8%; P < 0.001; total success rate: 93.9% vs. 78.5% or 50.8%; P < 0.001). Total cannulation time in the M-LAIP group was shorter than that in the SAOP group (P = 0.002) or the C-P group (P < 0.001). The rates of posterior wall puncture and haematoma in the M-LAIP group were lower than that in the SAOP group or C-P group (P < 0.008).

Conclusion : The use of the M-LAIP approach significantly improved the success rate of radial artery cannulation, shortened procedure time, and lowered the rates of posterior wall puncture and haematoma in adults with radial artery diameters less than 2.2 mm, compared with that achieved by the SAOP or C-P approach.

Conclusion (proposition de traduction) : L'utilisation de l'approche écho-guidage modifiée dans le plan grand axe a considérablement amélioré le taux de réussite de la canulation de l'artère radiale, raccourci la durée de la procédure et réduit les taux de ponction de la paroi postérieure et d'hématome chez les adultes dont le diamètre de l'artère radiale est inférieur à 2,2 mm, par rapport avec celle obtenue par l'approche de palpation hors plan ou conventionnelle à axe court.

Commentaire :  La projection de l’artère radiale sur la surface du corps est représentée par une ligne noire. Les caractéristiques de l’artère radiale dans la section échographique étaient différentes selon les positions de la sonde, y compris le diamètre de l’artère radiale (flèches blanches), le signal Doppler du débit sanguin artériel (A, C). La position correspondant au diamètre radial maximal et au signal sanguin Doppler optimal est la meilleure position de la sonde (B).

Les deux lignes de signal (ligne médiane et ligne de contact) sont placées perpendiculairement l’une à l’autre. L’aiguille a été insérée à l’endroit où l’axe de la sonde a touché la peau. L’angle entre l’aiguille de ponction et la ligne de contact est supérieur à 90° (A) ou inférieur à 90° (C). Il provoquerait une déviation de la pointe de l’axe central de l’artère pendant le processus. L’approche est optimale lorsque l’aiguille est perpendiculaire à la ligne de contact (l’angle est de 90°) (B).

Use of Dried Plasma in Prehospital and Austere Environments.
Pusateri AE, Malloy WW, Sauer D, Benov A, Corley JB, Rambharose S, Wallis L, Tiller MM, Cardin S, Glassberg E, Weiskopf RB. | Anesthesiology. 2022 Feb 1;136(2):327-335
DOI: https://doi.org/10.1097/aln.0000000000004089
Keywords: Aucun

Education: Clinical Focus Review

Editorial : The importance of early transfusion for patients with hemorrhagic shock, particularly early administration of plasma in proportion with red cells, has become widely recognized during the past decade. Recent studies have demonstrated survival benefit when transfusion is initiated before arrival at the trauma center.A retrospective study of more than 500 military casualties found that mortality was reduced when transfusion was initiated prehospital (mortality hazard ratio, 0.39; 95% CI, 0.16 to 0.92). A multicenter, prospective, randomized study of 501 civilian trauma patients with hemorrhagic shock demonstrated that plasma administration during helicopter transport reduced mortality by approximately one third (23.2% vs. 33.0%, P = 0.03). However, a similar single-center study in a system with rapid ground transport found no survival benefit for prehospital plasma. This apparent discrepancy was addressed in a post hoc analysis, which found that when prehospital transport time was greater than 20min, mortality increased in patients that received crystalloid-based resuscitation (hazard ratio, 2.12; 95% CI, 1.05 to 4.30; P = 0.04) but not when patients received plasma (hazard ratio, 0.78; 95% CI, 0.40 to 1.51; P = 0.46).

Conclusion : Lyophilized plasma has coagulation factor and related protein concentrations that are similar to standard plasma products and, for pooled lyophilized plasmas, less variable. Published reports of use and hemovigilance data suggest that currently available lyophilized plasmas have similar effi- cacy and safety to their counterpart frozen products.The growing recognition of the potential application of lyo- philized plasma when other plasma products are not avail- able in a clinically timely manner will likely lead to the expanded use of dried plasma products when they become more widely available. However, attention should be paid to training requirements and the need for prospective clinical trials to extend safety and efficacy data.

Conclusion (proposition de traduction) : Le plasma lyophilisé a des facteurs de coagulation et des concentrations de protéines associées qui sont similaires aux produits plasmatiques standard et, pour les pools de plasmas lyophilisés, moins variables. Les rapports publiés sur l'utilisation et les données d'hémovigilance suggèrent que les plasmas lyophilisés actuellement disponibles ont une efficacité et une innocuité similaires à leurs homologues congelés. La reconnaissance croissante de l'application potentielle du plasma lyophilisé lorsque d'autres produits plasmatiques ne sont pas disponibles dans un en temps opportun conduira probablement à une utilisation accrue des produits à base de plasma séché lorsqu'ils seront plus largement disponibles. Cependant, il convient de prêter attention aux exigences de formation et à la nécessité d'essais cliniques prospectifs pour étendre les données d'innocuité et d'efficacité.

Commentaire : Le plasma lyophilisé (PLYO) ou French LYophilised Plasma (FLYP) est produit par le Centre de transfusion sanguine des armées (CTSA) sous forme de poudre et conditionné en flacon de verre. Un flacon de plasma lyophilisé est équivalent à une unité de plasma thérapeutique congelé. Le plasma lyophilisé est un produit autorisé par les autorités sanitaires françaises (ANSM). Le PLYO n’est pas un médicament mais un Produit Sanguin Labile (PSL) qui doit tout de même respecter la partie des Bonnes Pratiques de Fabrication (BPF) relative à la fabrication des médicaments stériles. Sa température de conservation est entre +2 et +25° C (au lieu de –30° C pour un plasma thérapeutique classique) et sa péremption de deux ans (au lieu de 1 an) et la sélection des groupes sanguins dans la constitution du mélange avant lyophilisation permet d'obtenir un plasma compatible quel que soit le groupe sanguin ABO du receveur.
L'autre fabricant reconnu de plasma lyophilisé est la Croix-Rouge allemande. Mais il comporte un groupe sanguin, avec des règles de délivrance restrictives respectant les compatibilités ABO.
Tiré de : Fichier CTSA site internet PLYO   (PDF - 275.98 Ko)

Javaud N, Adnet F, Fain O. | Ann Fr Med Urgence. Publié en ligne : 8 février 2022
DOI: https://doi.org/10.3166/afmu-2022-0376
Keywords: Angioedema; Bradykinin; Histamine; Urticaria; Anaphylaxis

MISE AU POINT / UPDATE

Editorial : Les angioedèmes (AE) sont un motif de recours fréquent aux urgences. Leur morbimortalité n’est pas négligeable compte tenu de l’atteinte fréquente des voies aériennes supérieures. On distingue les AE histaminiques et bradykiniques. Aux urgences, la démarche diagnostique et la conduite à tenir doit être systématique et standardisée afin de ne pas méconnaître un potentiel AE bradykinique. Les AE histaminiques, accompagnés dans la plupart des cas d’une urticaire superficielle, sont de loin les plus fréquents et sont associés parfois à une anaphylaxie, ce qui nécessite alors un traitement par adrénaline immédiat. Ils peuvent être allergiques (médiés par les IgE) et sont alors associés à une anaphylaxie ou non allergiques, et se traduisent cliniquement par une urticaire aiguë ou chronique associée à l’AE. Les AE bradykiniques, d’incidence plus rare, sont également pourvoyeurs de recours aux urgences et particulièrement les AE secondaires aux inhibiteurs de l’enzyme de conversion de l’angiotensine compte tenu de leur importante prescription et de leurs atteintes cliniques de la face, de la langue et du larynx, elles-mêmes pourvoyeuses de recours aux urgences. Les traitements spécifiques d’urgence comprennent principalement l’icatibant et le concentré de C1-inhibiteur. Ils doivent être administrés le plus tôt possible devant l’inefficacité des traitements antiallergiques. Un avis auprès d’un expert du centre de référence pour les AE à kinines peut améliorer les prises en charge en aidant à la démarche diagnostique et en organisant la mise à disposition des traitements spécifiques d’urgence.

Conclusion (proposition de traduction) : En conclusion, les angiœdèmes histaminiques et bradykiniques entraînent de nombreux recours aux urgences. La fréquence des angiœdèmes histaminiques est plus importante que celle des angiœdèmes bradykiniques. Les AE histaminiques sont associés parfois à une anaphylaxie et nécessitent alors un traitement immédiat par adrénaline concomitamment aux antihistaminiques. L’angiœdèmes bradykinique responsable du plus grand nombre de recours aux urgences est l’ angiœdème secondaire aux IEC. Toutefois, son diagnostic est un préalable à son traitement spécifique. Tous les patients doivent avoir un accès aux traitements spécifiques d’urgence et les liens entre urgentistes et médecins experts des centres de référence pour les CRéAk (centres de référence pour les angiœdèmes à kinines) doivent se développer, y compris en urgence, afin d’assurer une meilleure prise en charge des patients.

Moumneh T, Penaloza A, Armand A, Robert-Ebadi H, Righini M, Douillet D, Le Gal G, Roy PM. | Ann Fr Med Urgence. Publié en ligne : 8 février 2022
DOI: https://doi.org/10.3166/afmu-2022-0375
Keywords: Pulmonary embolism; Pregnancy; Diagnostic strategy

MISE AU POINT / UPDATE

Editorial : Les problématiques posées par la prise en charge de la femme enceinte suspecte d’embolie pulmonaire (EP) aux urgences sont multiples. Les modifications physiologiques au cours de la grossesse majorent les sollicitations médicales pour des tableaux de douleur thoracique, de dyspnée, de malaise… En parallèle, ces manifestations aux cours de la grossesse peuvent se confondre avec les éléments évocateurs d’une EP et interférer sur nos capacités d’appréciation de sa probabilité. Enfin, l’élévation physiologique des D-dimères et le taux d’imageries thoraciques non conclusives complexifient la démarche diagnostique. C’est pourtant dans le contexte de la grossesse qu’il est particulièrement souhaitable de ne pas manquer un diagnostic d’EP, tout en évitant d’exposer inutilement la patiente et son foetus à l’imagerie thoracique. Pour aider dans les prises de décision, deux stratégies ont été validées dans le contexte de la grossesse. La première repose sur le score de Genève, incluant la réalisation d’une échographie de compression proximale chez les patientes à probabilité forte ou ayant un D-dimère supérieur à 500 μg/L. La seconde repose sur l’algorithme YEARS, avec réalisation d’une échographie uniquement chez les patientes ayant des symptômes évocateurs d’une thrombose veineuse des membres inférieurs associée, puis un dosage des D-dimères avec un seuil à 500 ou 1 000 μg/L en fonction de la probabilité clinique. La fiabilité de ces deux stratégies a été démontrée. La première stratégie présente l’avantage de ne reposer que sur des données objectives, et la deuxième de reposer le seuil décisionnel à 1 000 μg/L chez les patientes n’ayant aucun des critères YEARS.

Conclusion (proposition de traduction) : La suspicion d’EP chez les femmes enceintes reste un défi pour les urgentistes. Une fois la maladie suspectée, il est important de débuter une démarche diagnostique et de la suivre jusqu’à une réponse formelle de la présence ou l’absence du diagnostic. Il existe maintenant deux stratégies bien validées dans des études prospectives. Ces stratégies se fondent sur une estimation de la probabilité clinique par le score de Genève ou la règle YEARS, un dosage des D-dimères, l’échographie de compression veineuse des membres inférieurs et l’angioscanner thoracique. Le défi majeur réside maintenant dans l’implémentation de ces stratégies dans la vraie vie.

Rapid Rule-Out of Myocardial Infarction After 30 Minutes as an Alternative to 1 Hour: The RACING-MI Cohort Study.
Bang C, Andersen CF, Lauridsen KG, Frederiksen CA, Schmidt M, Jensen T, Hornung N, Løfgren B. | Ann Emerg Med. 2022 Feb;79(2):102-112
DOI: https://doi.org/10.1016/j.annemergmed.2021.08.024
Keywords: Aucun

Cardiology

Introduction : The aim of this study was to investigate whether myocardial infarction can be safely ruled in or out after 30 minutes as an alternative to 1 hour.

Méthode : This was a prospective, single-center clinical study enrolling patients admitted to the emergency department. Patients with chest pain suggestive of myocardial infarction were eligible for inclusion. There was no walk-in to the emergency department, and patients with highly elevated out-of-hospital troponin were transferred directly to an invasive heart center. High-sensitivity troponin I was measured at admission (0 hour), 30 minutes, 1 hour, and 3 hours. Diagnostic performance was assessed using the sensitivity and negative predictive value (primary endpoints) as measures of ability to rule out myocardial infarction. Specificity and positive predictive value of myocardial infarction were used as measures for the ability to rule in myocardial infarction (secondary endpoints).

Résultats : In total, 1,003 patients qualified for analysis. Median age was 64 (interquartile range 52 to 74) years, and 42% were women. Myocardial infarction was confirmed in 9% of patients. In the validation cohort (n=503), the 0-h/30-min algorithm assigned 242 (48%) patients to rule out, 54 (11%) to rule in, and 207 (41%) to the observational zone. This resulted in a sensitivity of 100% (92.0% to 100%), negative predictive value of 100% (95% confidence interval 98.5% to 100%), specificity of 96.7% (94.7% to 98.2%), and positive predictive value of 72.2% (58.4% to 83.5%). In comparison, the 0-h/1-h algorithm performed with a sensitivity of 100% (92.0% to 100%), negative predictive value of 100% (98.5% to 100%), specificity of 97.2% (95.2% to 98.5%), and positive predictive value of 75.5% (61.7% to 86.2%).

Conclusion : The accelerated 0-h/30-min algorithm allowed for safe rule-out of myocardial infarction 30 minutes after admission. The rule-in ability of the 0-h/30-min algorithm was comparable to that of the 0-h/1h algorithm.

Conclusion (proposition de traduction) : L'algorithme accéléré 0 h/30 min a permis d'exclure en toute sécurité l'infarctus du myocarde 30 minutes après l'admission. La capacité de reconnaissance d'un SCA de l'algorithme 0-h/30-min était comparable à celle de l'algorithme 0-h/1h.

Association of Advanced Airway Insertion Timing and Outcomes After Out-of-Hospital Cardiac Arrest.
Okubo M, Komukai S, Izawa J, Aufderheide TP, Benoit JL, Carlson JN, Daya MR, Hansen M, Idris AH, Le N, Lupton JR, Nichol G, Wang HE, Callaway CW. | Ann Emerg Med. 2022 Feb;79(2):118-131
DOI: https://doi.org/10.1016/j.annemergmed.2021.07.114
Keywords: Aucun

Emergency Medical Services

Introduction : While often prioritized in the resuscitation of patients with out-of-hospital cardiac arrest, the optimal timing of advanced airway insertion is unknown. We evaluated the association between the timing of advanced airway (laryngeal tube and endotracheal intubation) insertion attempt and survival to hospital discharge in adult out-of-hospital cardiac arrest.

Méthode : We performed a secondary analysis of the Pragmatic Airway Resuscitation Trial (PART), a clinical trial comparing the effects of laryngeal tube and endotracheal intubation on outcomes after adult out-of-hospital cardiac arrest. We stratified the cohort by randomized airway strategy (laryngeal tube or endotracheal intubation). Within each subset, we defined a time-dependent propensity score using patients, arrest, and emergency medical services systems characteristics. Using the propensity score, we matched each patient receiving an initial attempt of laryngeal tube or endotracheal intubation with a patient at risk of receiving laryngeal tube or endotracheal intubation attempt within the same minute.

Résultats : Of 2,146 eligible patients, 1,091 (50.8%) and 1,055 (49.2%) were assigned to initial laryngeal tube and endotracheal intubation strategies, respectively. In the propensity score-matched cohort, timing of laryngeal tube insertion attempt was not associated with survival to hospital discharge: 0 to lesser than 5 minutes (risk ratio [RR]=1.35, 95% confidence interval [CI] 0.53 to 3.44); 5 to lesser than10 minutes (RR=1.07, 95% CI 0.66 to 1.73); 10 to lesser than 15 minutes (RR=1.17, 95% CI 0.60 to 2.31); or 15 to lesser than 20 minutes (RR=2.09, 95% CI 0.35 to 12.47) after advanced life support arrival. Timing of endotracheal intubation attempt was also not associated with survival: 0 to lesser than 5 minutes (RR=0.50, 95% CI 0.05 to 4.87); 5 to lesser than10 minutes (RR=1.20, 95% CI 0.51 to 2.81); 10 to lesser than15 minutes (RR=1.03, 95% CI 0.49 to 2.14); 15 to lesser than 20 minutes (RR=0.85, 95% CI 0.30 to 2.42); or more than/equal to 20 minutes (RR=0.71, 95% CI 0.07 to 7.14).

Conclusion : In the PART, timing of advanced airway insertion attempt was not associated with survival to hospital discharge.

Conclusion (proposition de traduction) : Dans l'essai « Pragmatic Airway Resuscitation Trial » (PART), le moment de la tentative d'intubation orotrachéale n'était pas associé à la survie à la sortie de l'hôpital.

Commentaire : Les résultats de l'essai PART sont :
Wang HE, Schmicker RH, Daya MR, et al. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with Out-of-hospital cardiac arrest: a randomized clinical trial. JAMA. 2018;320:769-778  .
Wang HE, Prince DK, Stephens SW, et al. Design and implementation of the Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART). Resuscitation. 2016;101:57-64  .

The influence of timing of coronary angiography on acute kidney injury in out-of-hospital cardiac arrest patients: a retrospective cohort study.
Janssens GN, Daemen J, Lemkes JS, Spoormans EM, Janssen D, den Uil CA, Jewbali LSD, Heestermans TACM, Umans VAWM, Halfwerk FR, Beishuizen A, Nas J, Bonnes J, van de Ven PM, van Rossum AC, Elbers PWG, van Royen N. | Ann Intensive Care. 2022 Feb 11;12(1):12
DOI: https://doi.org/10.1186/s13613-022-00987-w
Keywords: Aucun

Research

Introduction : Acute kidney injury (AKI) is a frequent complication in cardiac arrest survivors and associated with adverse outcome. It remains unclear whether the incidence of AKI increases after the post-cardiac arrest contrast administration for coronary angiography and whether this depends on timing of angiography. Aim of this study was to investigate whether early angiography is associated with increased development of AKI compared to deferred angiography in out-of-hospital cardiac arrest (OHCA) survivors.

Méthode : In this retrospective multicenter cohort study, we investigated whether early angiography (within 2 h) after OHCA was non-inferior to deferred angiography regarding the development of AKI. We used an absolute difference of 5% as the non-inferiority margin. Primary non-inferiority analysis was done by calculating the risk difference with its 90% confidence interval (CI) using a generalized linear model for a binary outcome. As a sensitivity analysis, we repeated the primary analysis using propensity score matching. A multivariable model was built to identify predictors of acute kidney injury.

Résultats : A total of 2375 patients were included from 2009 until 2018, of which 1148 patients were treated with early coronary angiography and 1227 patients with delayed or no angiography. In the early angiography group 18.5% of patients developed AKI after OHCA and 24.1% in the deferred angiography group. Risk difference was - 3.7% with 90% CI ranging from - 6.7 to - 0.7%, indicating non-inferiority of early angiography. The sensitivity analysis using propensity score matching showed accordant results, but no longer non-inferiority of early angiography. The factors time to return of spontaneous circulation (odds ratio [OR] 1.12, 95% CI 1.06-1.19, p < 0.001), the (not) use of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (OR 0.20, 95% CI 0.04-0.91, p = 0.04) and baseline creatinine (OR 1.05, 95% CI 1.03-1.07, p < 0.001) were found to be independently associated with the development of AKI.

Conclusion : Although AKI occurred in approximately 20% of OHCA patients, we found that early angiography was not associated with a higher AKI incidence than a deferred angiography strategy. The present results implicate that it is safe to perform early coronary angiography with respect to the risk of developing AKI after OHCA.

Conclusion (proposition de traduction) : Bien qu'une lésion rénale aiguë soit survenue chez environ 20 % des patients en arrêt cardiaque en dehors de l'hôpital, nous avons constaté que l'angiographie précoce n'était pas associée à une incidence plus élevée de lésion rénale aiguë qu'une stratégie d'angiographie différée. Les présents résultats impliquent qu'il est sûr d'effectuer une coronarographie précoce en ce qui concerne le risque de développer une lésion rénale aiguë après un arrêt cardiaque en dehors de l'hôpital.

Prediction of return of spontaneous circulation during cardiopulmonary resuscitation by pulse-wave cerebral tissue oxygen saturation: a retrospective observational study.
Sakaguchi K, Takada M, Takahashi K, Onodera Y, Kobayashi T, Kawamae K, Nakane M. | BMC Emerg Med. 2022 Feb 28;22(1):30
DOI: https://doi.org/10.1186/s12873-022-00586-9  | Télécharger l'article au format  
Keywords: Cardiac arrest; NIRO; Near-infrared spectroscopy; Return of spontaneous circulation; SnO2.

Research

Introduction : It is difficult to predict the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR). Cerebral tissue oxygen saturation during CPR, as measured by near-infrared spectroscopy (NIRS), is anticipated to predict ROSC. General markers of cerebral tissue oxygen saturation, such as the tissue oxygenation index (TOI), mainly reflect venous oxygenation, whereas pulse-wave cerebral tissue oxygen saturation (SnO2), which represents hemoglobin oxygenation in the pulse wave within the cerebral tissue, is an index of arterial and venous oxygenation. Thus, SnO2 may reflect arterial oxygenation to a greater degree than does TOI. Therefore, we conducted this study to verify our hypothesis that SnO2 measured during CPR can predict ROSC.

Méthode : Cardiac arrest patients who presented at the Emergency Department of Yamagata University Hospital in Japan were included in this retrospective, observational study. SnO2 and TOI were simultaneously measured at the patient's forehead using an NIRS tissue oxygenation monitor (NIRO 200-NX; Hamamatsu Photonics, Japan). We recorded the initial, mean, and maximum values during CPR. We plotted receiver operating characteristic curves and calculated the area under the curve (AUC) to predict ROSC.

Résultats : Forty-two patients were included. SnO2 was significantly greater in the ROSC group than in the non-ROSC group in terms of the initial (37.5% vs 24.2%, p = 0.015), mean (44.6% vs 10.8%, p < 0.001), and maximum (79.7% vs 58.4%, p < 0.001) values. Although the initial TOI was not significantly different between the two groups, the mean (45.1% vs 36.8%, p = 0.018) and maximum (71.0% vs 46.3%, p = 0.001) TOIs were greater in the ROSC group than in the non-ROSC group. The AUC was 0.822 for the mean SnO2 (95% confidence interval [CI]: 0.672-0.973; cut-off: 41.8%), 0.821 for the maximum SnO2 (95% CI: 0.682-0.960; cut-off: 70.8%), and 0.809 for the maximum TOI (95% CI: 0.667-0.951; cut-off: 49.3%).

Conclusion : SnO2 values measured during CPR, including immediately after arrival at the emergency department, were higher in the ROSC group than in the non-ROSC group.

Conclusion (proposition de traduction) : Les valeurs de saturation tissulaire cérébrale en oxygène mesurées pendant la RCP, y compris immédiatement après l'arrivée aux urgences, étaient plus élevées dans le groupe reprise d'activité circulatoire spontanée (RACS) que dans le groupe sans reprise d'activité circulatoire spontanée.

Management of acute uncomplicated diverticulitis without antibiotics: compliance and outcomes -a retrospective cohort study.
Azhar N, Aref H, Brorsson A, Lydrup ML, Jörgren F, Schultz JK, Buchwald P. | BMC Emerg Med. 2022 Feb 21;22(1):28
DOI: https://doi.org/10.1186/s12873-022-00584-x  | Télécharger l'article au format  
Keywords: Antibiotics; Compliance; Diverticulitis.

Research article

Méthode : Recent randomized control trials (RCTs) have confirmed that antibiotics in acute uncomplicated diverticulitis (AUD) neither accelerate recovery nor prevent complications or recurrences. A retrospective cohort study was conducted, including all consecutive AUD patients hospitalized 2015- 2018 at Helsingborg Hospital (HH) and Skåne University Hospital (SUS), Sweden. HH had implemented a non-antibiotic treatment protocol in 2014 while SUS had not. Main outcomes were proportion of patients treated with antibiotics, complications, recurrences, and adherence to routinely colon evaluation.

Résultats : A total of 583 AUD patients were enrolled, 388 at SUS and 195 at HH. The diagnosis was CT-verified in 320 (83%) vs. 186 (95%) patients respectively (p < 0.001). Forty-three (11%) and 94 (48%) of patients respectively did not receive antibiotics during hospitalization (p < 0.001). CRP was higher in the antibiotic group compared to the non-antibiotic group, both at admission and peak (90 mg/L vs 65 mg/L; p = 0.016) and (138 mg/L and 97 mg/L; p < 0.001). There were no significant differences in recurrences (22.0% vs. 22.6%; p = 0.87) and complications (2.5% vs. 2.9%; p = 0.77) between the antibiotic/non-antibiotic groups.

Conclusion : The structured treatment protocol led to reduced antibiotic use and a higher standard of care in terms of CT-verification. Clinicians' compliance to the treatment protocol and best clinical practice was poor and warrants further studies.

Conclusion (proposition de traduction) : Le protocole de traitement structuré a conduit à une utilisation réduite d'antibiotiques et à une norme de soins plus élevée en termes de vérification par tomodensitométrie. La conformité des cliniciens au protocole de traitement et aux meilleures pratiques cliniques était médiocre et justifie des études supplémentaires.

The emergency department arrival mode and its relations to ED management and 30-day mortality in acute heart failure: an ancillary analysis from the EURODEM study.
Harjola P, Tarvasmäki T, Barletta C, Body R, Capsec J, Christ M, Garcia-Castrillo L, Golea A, Karamercan MA, Martin PL, Miró Ò, Tolonen J, van Meer O, Palomäki A, Verschuren F, Harjola VP, Laribi S; EURODEM Study Group. | BMC Emerg Med. 2022 Feb 14;22(1):27
DOI: https://doi.org/10.1186/s12873-022-00574-z  | Télécharger l'article au format  
Keywords: Acute heart failure; Arrival mode; Emergency medical services; Management; Prognosis; Ventilatory support.

Research article

Introduction : Acute heart failure patients are often encountered in emergency departments (ED) from 11% to 57% using emergency medical services (EMS). Our aim was to evaluate the association of EMS use with acute heart failure patients' ED management and short-term outcomes.

Méthode : This was a sub-analysis of a European EURODEM study. Data on patients presenting with dyspnoea were collected prospectively from European EDs. Patients with ED diagnosis of acute heart failure were categorized into two groups: those using EMS and those self-presenting (non- EMS). The independent association between EMS use and 30-day mortality was evaluated with logistic regression.

Résultats : Of the 500 acute heart failure patients, with information about the arrival mode to the ED, 309 (61.8%) arrived by EMS. These patients were older (median age 80 vs. 75 years, p < 0.001), more often female (56.4% vs. 42.1%, p = 0.002) and had more dementia (18.7% vs. 7.2%, p < 0.001). On admission, EMS patients had more often confusion (14.2% vs. 2.1%, p < 0.001) and higher respiratory rate (24/min vs. 21/min, p = 0.014; respiratory rate > 30/min in 17.1% patients vs. 7.5%, p = 0.005). The only difference in ED management appeared in the use of ventilatory support: 78.3% of EMS patients vs. 67.5% of non- EMS patients received supplementary oxygen (p = 0.007), and non-invasive ventilation was administered to 12.5% of EMS patients vs. 4.2% non- EMS patients (p = 0.002). EMS patients were more often hospitalized (82.4% vs. 65.9%, p < 0.001), had higher in-hospital mortality (8.7% vs. 3.1%, p = 0.014) and 30-day mortality (14.3% vs. 4.9%, p < 0.001). The use of EMS was an independent predictor of 30-day mortality (OR = 2.54, 95% CI 1.11-5.81, p = 0.027).

Conclusion : Most acute heart failure patients arrive at ED by EMS. These patients suffer from more severe respiratory distress and receive more often ventilatory support. EMS use is an independent predictor of 30-day mortality.

Conclusion (proposition de traduction) : La plupart des patients présentant une insuffisance cardiaque aiguë arrivent aux urgences avec les services médicaux d'urgence. Ces patients souffrent de détresse respiratoire plus sévère et reçoivent plus souvent une assistance ventilatoire. Le recours aux services médicaux d'urgence est un prédicteur indépendant de la mortalité à 30 jours.

Commentaire : Voir l'article :
Mourou H, Latournerie G, Delisle E, Charpentier S. En quoi les patients adressés dans les services d’urgences après avis médical sont-ils différents des patients venant d’eux-mêmes ? Ann Fr Med Urgence 2021;11(6):357–365  .

Airway management in a Helicopter Emergency Medical Service (HEMS): a retrospective observational study of 365 out-of-hospital intubations.
Pietsch U, Müllner R, Theiler L, Wenzel V, Meuli L, Knapp J, Sollid SJM, Albrecht R. | BMC Emerg Med. 2022 Feb 8;22(1):23
DOI: https://doi.org/10.1186/s12873-022-00579-8  | Télécharger l'article au format  
Keywords: Airway management; Difficult airway management; Difficult intubation; HEMS; Out-of-hospital intubation.

Research

Introduction : Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed.

Méthode : Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management.

Résultats : A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001.

Conclusion : Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology.

Conclusion (proposition de traduction) : Malgré des taux de réussite globaux élevés pour l’intubation endotrachéale dans le service composé de médecins, les médecins n’ont qu’une expérience limitée de la gestion spécialisée des voies respiratoires sur le terrain. Cela souligne l’importance d’une solide compétence de base dans une discipline comme l’anesthésiologie.

Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial.
Abbar M, Demattei C, El-Hage W, Llorca PM, Samalin L, Demaricourt P, Gaillard R, Courtet P, Vaiva G, Gorwood P, Fabbro P, Jollant F. | BMJ. 2022 Feb 2;376:e067194
DOI: https://doi.org/10.1136/bmj-2021-067194  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : o confirm the rapid onset anti-suicidal benefits of ketamine in the short term and at six weeks, overall and according to diagnostic group.
Design: Prospective, double blind, superiority, randomised placebo controlled trial.

Méthode : Seven French teaching hospitals between 13 April 2015 and 12 March 2019.
Eligibility criteria for participants: Aged 18 or older with current suicidal ideation, admitted to hospital voluntarily. Exclusion criteria included a history of schizophrenia or other psychotic disorders, substance dependence, and contraindications for ketamine.
Participants: 156 participants were recruited and randomised to placebo (n=83) or ketamine (n=73), stratified by centre and diagnosis: bipolar, depressive, or other disorders.
Intervention: Two 40 minute intravenous infusions of ketamine (0.5 mg/kg) or placebo (saline) were administered at baseline and 24 hours, in addition to usual treatment.
Main outcome measures: The primary outcome was the rate of patients in full suicidal remission at day 3, according to the scale for suicidal ideation total score ≤3. Analyses were conducted on an intention-to-treat basis.

Résultats : More participants receiving ketamine reached full remission of suicidal ideas at day 3 than those receiving placebo: 46 (63.0%) of 83 participants in the ketamine arm and 25 (31.6%) of 73 in the placebo arm (odds ratio 3.7 (95% confidence interval 1.9 to 7.3), P<0.001). This effect differed according to the diagnosis (treatment: P<0.001; interaction: P=0.02): bipolar (odds ratio 14.1 (95% confidence interval 3.0 to 92.2), P<0.001), depressive (1.3 (0.3 to 5.2), P=0.6), or other disorders (3.7 (0.9 to 17.3, P=0.07)). Side effects were limited. No manic or psychotic symptom was seen. Moreover, a mediating effect of mental pain was found. At week 6, remission in the ketamine arm remained high, although non-significantly versus placebo (69.5% v 56.3%; odds ratio 0.8 (95% confidence interval 0.3 to 2.5), P=0.7).

Conclusion : The findings indicate that ketamine is rapid, safe in the short term, and has persistent benefits for acute care in suicidal patients. Comorbid mental disorders appear to be important moderators. An analgesic effect on mental pain might explain the anti-suicidal effects of ketamine.

Conclusion (proposition de traduction) : Les résultats indiquent que la kétamine est rapide, sûre à court terme et présente des avantages persistants pour les soins aigus chez les patients suicidaires. Les troubles mentaux comorbides semblent être des modérateurs importants. Un effet analgésique sur la douleur mentale pourrait expliquer les effets anti-suicidaires de la kétamine.

Long covid in children and adolescents.
Zimmermann P, Pittet LF, Curtis N. | BMJ. 2022 Jan 20;376:o143
DOI: https://doi.org/10.1136/bmj.o143  | Télécharger l'article au format  
Keywords: Aucun

Research

Editorial : Symptoms involving almost every organ system have been reported after SARS-CoV-2 infection. Estimates of the prevalence of long covid (also called post-covid-19 condition, post-acute sequelae of covid-19, or chronic covid syndrome) vary considerably, partly because of confusion around the definition. The term long covid encompasses a broad range of symptoms, including objective complications of covid-19 (pulmonary fibrosis, myocardial dysfunction), mental health conditions, and more subjective, non-specific symptoms resembling those seen in post-viral chronic fatigue syndrome (myalgic encephalomyelitis). Most studies to date have substantial limitations, including small cohorts, absence of control groups, non-standardised capture of symptoms, lack of correction for pre-existing medical conditions, participant reported infection, and variation in follow-up, as well as selection, non-response, misclassification, and recall biases.

Conclusion : Currently a third of all children and adolescents reports negative emotions, such as sadness or anxiety, highlighting the toll from the pandemic in this age group. Vaccinating young people might help reduce some of the indirect harms caused by repeat testing and isolation, lockdowns, school closures, and reduced social activities. As SARS-CoV-2 remains predominantly a mild infection in the paediatric population, the incidence of long covid is a critical factor in the risk-benefit equation for policy and parental decisions on covid-19 vaccines for children.

Conclusion (proposition de traduction) : Actuellement, un tiers de tous les enfants et adolescents signalent des émotions négatives, telles que la tristesse ou l'anxiété, soulignant le bilan de la pandémie dans ce groupe d'âge. La vaccination des jeunes pourrait aider à réduire certains des dommages indirects causés par les tests répétés et l'isolement, les fermetures, les fermetures d'écoles et la réduction des activités sociales. Étant donné que le SRAS-CoV-2 reste principalement une infection bénigne dans la population pédiatrique, l'incidence du covid long est un facteur critique dans l'équation bénéfice-risque pour les décisions politiques et parentales sur la vaccination Covid-19 pour les enfants.

Diagnosis of deep vein thrombosis with D-dimer adjusted to clinical probability: prospective diagnostic management study..
Kearon C, de Wit K, Parpia S, Schulman S, Spencer FA, Sharma S, et al. | BMJ [Internet]. 2022;376:e067378
DOI: https://www.bmj.com/content/376/bmj-2021-067378  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To evaluate the safety and efficiency of a diagnostic algorithm for deep vein thrombosis (DVT) that uses clinical pretest probability based D-dimer thresholds to exclude DVT.
Design: Prospective diagnostic management study.

Méthode : University based emergency departments or outpatient clinics in Canada.
Participants: Patients with symptoms or signs of DVT.
Intervention: DVT was considered excluded without further testing by Wells low clinical pretest probability and D-dimer <1000 ng/mL or Wells moderate clinical pretest probability and D-dimer <500 ng/mL. All other patients had proximal ultrasound imaging. Repeat proximal ultrasonography was restricted to patients with initially negative ultrasonography, low or moderate clinical pretest probability, and D-dimer >3000 ng/mL or high clinical pretest probability and D-dimer >1500 ng/mL. If DVT was not diagnosed, patients did not receive anticoagulant treatment.
Main Outcome Measure: Symptomatic venous thromboembolism at three months.

Résultats : 1508 patients were enrolled and analysed, of whom 173 (11.5%) had DVT on scheduled diagnostic testing. Of the 1275 patients with no proximal DVT on scheduled testing who did not receive anticoagulant treatment, eight (0.6%, 95% confidence interval 0.3% to 1.2%) were found to have venous thromboembolism during follow-up. Compared with a traditional DVT testing strategy, this diagnostic approach reduced the need for ultrasonography from a mean of 1.36 scans/patient to 0.72 scans/patient (difference −0.64, 95% confidence interval −0.68 to −0.60), corresponding to a relative reduction of 47%.

Conclusion : The diagnostic strategy using a combination of clinical pretest probability and D-dimer identified a group of patients at low risk for DVT during follow-up while substantially reducing the need for ultrasound imaging.

Conclusion (proposition de traduction) : La stratégie de diagnostic utilisant une combinaison de probabilité prétest clinique et de D-dimères a identifié un groupe de patients à faible risque de TVP pendant le suivi tout en réduisant considérablement le besoin d'imagerie par ultrasons.

Risk of first ischaemic stroke and use of antidopaminergic antiemetics: nationwide case-time-control study.
Bénard-Laribière A, Hucteau E, Debette S, Kirchgesner J, Bezin J, Pariente A. | MJ. 2022 Mar 23;376:e066192
DOI: https://doi.org/10.1136/bmj-2021-066192  | Télécharger l'article au format  
Keywords: Aucun

RESEARCH

Introduction : To estimate the risk of ischaemic stroke associated with antidopaminergic antiemetic (ADA) use.
Design: Case-time-control study.

Méthode : Data from the nationwide French reimbursement healthcare system database Système National des Données de Santé (SNDS).
Participants: Eligible participants were ≥18 years with a first ischaemic stroke between 2012 and 2016 and at least one reimbursement for any ADA in the 70 days before stroke. Frequencies of ADA reimbursements were compared for a risk period (days -14 to -1 before stroke) and three matched reference periods (days -70 to -57, -56 to -43, and -42 to -29) for each patient. Time trend of ADA use was controlled by using a control group of 21 859 randomly selected people free of the event who were individually matched to patients with stroke according to age, sex, and risk factors of ischaemic stroke.
Main outcome measures: Association between ADA use and risk of ischaemic stroke was assessed by estimating the ratio of the odds ratios of exposure evaluated in patients with stroke and in controls. Analyses were adjusted for time varying confounders (anticoagulants, antiplatelets, and prothrombotic or vasoconstrictive drugs).

Résultats : Among the 2612 patients identified with incident stroke, 1250 received an ADA in the risk period and 1060 in the reference periods. The comparison with the 5128 and 13 165 controls who received an ADA in the same periods yielded a ratio of adjusted odds ratios of 3.12 (95% confidence interval 2.85 to 3.42). Analyses stratified by age, sex, and history of dementia showed similar results. Ratio of adjusted odds ratios for analyses stratified by ADA was 2.51 (2.18 to 2.88) for domperidone, 3.62 (3.11 to 4.23) for metopimazine, and 3.53 (2.62 to 4.76) for metoclopramide. Sensitivity analyses suggested the risk would be higher in the first days of use.

Conclusion : Using French nationwide exhaustive reimbursement data, this self-controlled study reported an increased risk of ischaemic stroke with recent ADA use. The highest increase was found for metopimazine and metoclopramide.

Conclusion (proposition de traduction) : Utilisant des données nationales exhaustives sur le remboursement, cette étude autocontrôlée a rapporté un risque accru d'AVC ischémique avec l'utilisation récente d'antiémétiques antidopaminergiques. La plus forte augmentation a été observée pour la métopimazine et le métoclopramide.

Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism.
Jaureguízar A, Jiménez D, Bikdeli B, Ruiz-Artacho P, Muriel A, Tapson V, López-Reyes R, Valero B, Kenet G, Monreal M; Registro Informatizado de la Enfermedad TromboEmbólica Investigators. | Chest. 2022 Feb;161(2):524-534
DOI: https://doi.org/10.1016/j.chest.2021.08.059
Keywords: heart rate; mortality; pulmonary embolism.

Original Research

Introduction : The association between heart rate (HR) and pulmonary embolism (PE) outcomes has not been well studied. Furthermore, optimal cutoffs to identify low-risk and intermediate- to high-risk patients are not well known.
Research question: Does an association exist between baseline HR and PE outcome across the continuum of HR values?

Méthode : The current study included 44,331 consecutive nonhypotensive patients with symptomatic PE from the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2021. Outcomes included 30-day all-cause and PE-specific mortality. We used hierarchical logistic regression to assess the association between admission HR and outcomes.

Résultats : A positive relationship was found between admission HR and 30-day all-cause and PE-related mortality. Considering an HR of 80 to 99 beats/min as a reference, patients in the higher HR strata showed higher rates of all-cause death (adjusted OR, 1.5 for HR of 100-109 beats/min; adjusted OR, 1.7 for HR of 110-119 beats/min; adjusted OR, 1.9 for HR of 120-139 beats/min; and adjusted OR, 2.4 for HR of ≥ 140 beats/min). Patients in the lower strata of HR showed significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR, 0.6 for HR of 60-79 beats/min; and adjusted OR, 0.5 for HR of < 60 beats/min). The findings for 30-day PE-related mortality were similar. For identification of low-risk patients, a cutoff value of 80 beats/min (vs 110 beats/min) increased the sensitivity of the simplified Pulmonary Embolism Severity Index (sPESI) from 93.4% to 98.8%. For identification of intermediate- to high-risk patients, a cutoff value of 140 beats/min (vs 110 beats/min) increased the specificity of the Bova score from 93.2% to 98.0%.

Conclusion : In nonhypotensive patients with acute symptomatic PE, a high HR portends an increased risk of all-cause and PE-related mortality. Modifying the HR cutoff in the sPESI and the Bova score improves prognostication of patients with PE.

Conclusion (proposition de traduction) : Chez les patients non hypotendus présentant une embolie pulmonaire aiguë symptomatique, une fréquence cardiaque élevée laisse présager un risque accru de mortalité toutes causes confondues et liée à l'embolie pulmonaire. La modification du seuil de fréquence cardiaque dans l'indice simplifié de gravité de l'embolie pulmonaire (PESI) et le score de Bova améliore le pronostic des patients présentant une embolie pulmonaire.

Management of Life-Threatening Asthma: Severe Asthma Series.
Garner O, Ramey JS, Hanania NA. | Chest. 2022 Feb 23:S0012-3692(22)00395-6
DOI: https://doi.org/10.1016/j.chest.2022.02.029
Keywords: critical care medicine; life-threatening asthma; mechanical ventilation; respiratory failure; sedation.

Review

Editorial : Asthma exacerbations can be life-threatening, with 25,000 to 50,000 such patients per year requiring admission to an ICU in the United States. Appropriate triage of life-threatening asthma is dependent on both static assessment of airway function and dynamic assessment of response to therapy. Treatment strategies focus on achieving effective bronchodilation with inhaled β2-agonists, muscarinic antagonists, and magnesium sulphate while reducing inflammation with systemic corticosteroids. Correction of hypoxemia and hypercapnia, a key in managing life-threatening asthma, occasionally requires the incorporation of noninvasive mechanical ventilation to decrease the work of breathing. Endotracheal intubation and mechanical ventilation should not be delayed if clinical improvement is not achieved with conservative therapies. However, mechanical ventilation in these patients often requires controlled hypoventilation, adequate sedation, and occasional use of muscle relaxation to avoid dynamic hyperinflation, which can result in barotrauma or volutrauma. Sedation with ketamine or propofol is preferred because of their potential bronchodilation properties. In this review, we outline strategies for the assessment and management of patients with acute life-threatening asthma focusing on those requiring admission to the ICU.

Conclusion : LTAE is a rare complication of asthma, but if not treated in a timely fashion, it can result in death. Patients should be started quickly on inhaled SABA, short-acting muscarinic antagonists, and IV corticosteroids. Systemic infusion of magnesium sulfate can be considered in some patients. In those with severe bronchospasm, heliox can be used to facilitate medication delivery, but therapy should be abandoned if no clinical improved is seen after 15 min of use. Patients who have progressive respiratory distress should be admitted to the ICU for close monitoring and should be administered NIV if tolerated. However, intubation should not be delayed if the patient does not improve in 30 to 60 min. Extra care should be taken if a patient requires mechanical ventilation. Intubation should be performed in a delayed sequence, and lung protective strategies should be adopted with IMV. Salvage therapies such as the use of inhaled anesthetics, bronchoscopy, and BAL with or without N-acetylcysteine or ECMO can be considered in individual patients with refractory disease.

Conclusion (proposition de traduction) : L'exacerbation d'asthme potentiellement mortelle est une complication rare de l'asthme, mais si elle n'est pas traitée en temps opportun, elle peut entraîner la mort. Les patients doivent bénéficier rapidement d'agoniste des récepteurs β₂-adrénergiques inhalé à courte durée d'action, des anticholinergiques à courte durée d'action et des corticostéroïdes IV. Une perfusion systémique de sulfate de magnésium peut être envisagée chez certains patients. Chez les personnes présentant un bronchospasme sévère, l'héliox peut être utilisé pour faciliter l'administration du médicament, mais le traitement doit être abandonné si aucune amélioration clinique n'est observée après 15 minutes d'utilisation. Les patients qui ont une détresse respiratoire progressive doivent être admis aux soins intensifs pour une surveillance étroite et doivent bénéficier d'une VNI si elle est tolérée. Cependant, l'intubation ne doit pas être retardée si l'état du patient ne s'améliore pas en 30 à 60 min. Des précautions supplémentaires doivent être prises si un patient nécessite une ventilation mécanique. L'intubation doit être effectuée en séquence retardée et des stratégies de protection pulmonaire doivent être adoptées avec la ventilation mécanique invasive. Des traitements de sauvetage telles que l'utilisation d'anesthésiques inhalés, la bronchoscopie et le lavage bronchoalvéolaire avec ou sans N-acétylcystéine ou une ECMO peuvent être envisagées chez les patients de façon individuelle présentant un asthme réfractaire.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : How to Manage Life-Threatening Asthma  . Rédigé le 22 avril 2022.

Regular Acetaminophen Use and Blood Pressure in People With Hypertension: The PATH-BP Trial.
MacIntyre IM, Turtle EJ, Farrah TE, Graham C, Dear JW, Webb DJ; PATH-BP (Paracetamol in Hypertension–Blood Pressure) Investigators. | Circulation. 2022 Feb 8;145(6):416-423
DOI: https://doi.org/10.1161/circulationaha.121.056015
Keywords: acetaminophen; blood pressure; cardiovascular disease; chronic pain; hypertension.

Original Research Article

Introduction : Acetaminophen is widely used as first-line therapy for chronic pain because of its perceived safety and the assumption that, unlike nonsteroidal anti-inflammatory drugs, it has little or no effect on blood pressure (BP). Although observational studies suggest that acetaminophen may increase BP, clinical trials are lacking. We, therefore, studied the effects of regular acetaminophen dosing on BP in individuals with hypertension.

Méthode : In this double-blind, placebo-controlled, crossover study, 110 individuals were randomized to receive 1 g acetaminophen 4× daily or matched placebo for 2 weeks followed by a 2-week washout period before crossing over to the alternate treatment. At the beginning and end of each treatment period, 24-hour ambulatory BPs were measured. The primary outcome was a comparison of the change in mean daytime systolic BP from baseline to end of treatment between the placebo and acetaminophen arms.

Résultats : One-hundred three patients completed both arms of the study. Regular acetaminophen, compared with placebo, resulted in a significant increase in mean daytime systolic BP (132.8±10.5 to 136.5±10.1 mm Hg [acetaminophen] vs 133.9±10.3 to 132.5±9.9 mm Hg [placebo]; P<0.0001) with a placebo-corrected increase of 4.7 mm Hg (95% CI, 2.9-6.6) and mean daytime diastolic BP (81.2±8.0 to 82.1±7.8 mm Hg [acetaminophen] vs 81.7±7.9 to 80.9±7.8 mm Hg [placebo]; P=0.005) with a placebo-corrected increase of 1.6 mm Hg (95% CI, 0.5-2.7). Similar findings were seen for 24-hour ambulatory and clinic BPs.

Conclusion : Regular daily intake of 4 g acetaminophen increases systolic BP in individuals with hypertension by ≈5 mm Hg when compared with placebo; this increases cardiovascular risk and calls into question the safety of regular acetaminophen use in this situation.

Conclusion (proposition de traduction) : La prise quotidienne régulière de 4 g de paracétamol augmente la pression artérielle systolique chez les personnes souffrant d'hypertension de ≈ 5 mmHg par rapport au placebo ; cela augmente le risque cardiovasculaire et remet en question la sécurité de l'utilisation régulière de paracétamol dans cette situation.

Impact of platelet transfusion on outcomes in trauma patients.
Hamada SR, Garrigue D, Nougue H, Meyer A, Boutonnet M, Meaudre E, Culver A, Gaertner E, Audibert G, Vigué B, Duranteau J, Godier A; TraumaBase Group. | Crit Care. 2022 Feb 21;26(1):49
DOI: https://doi.org/10.1186/s13054-022-03928-y  | Télécharger l'article au format  
Keywords: Haemorrhage; Outcome; Platelet count; Platelet transfusion; Trauma.

Research

Introduction : Trauma-induced coagulopathy includes thrombocytopenia and platelet dysfunction that impact patient outcome. Nevertheless, the role of platelet transfusion remains poorly defined. The aim of the study was 1/ to evaluate the impact of early platelet transfusion on 24-h all-cause mortality and 2/ to describe platelet count at admission (PCA) and its relationship with trauma severity and outcome.

Méthode : Observational study carried out on a multicentre prospective trauma registry. All adult trauma patients directly admitted in participating trauma centres between May 2011 and June 2019 were included. Severe haemorrhage was defined as ≥ 4 red blood cell units within 6 h and/or death from exsanguination. The impact of PCA and early platelet transfusion (i.e. within the first 6 h) on 24-h all-cause mortality was assessed using uni- and multivariate logistic regression.

Résultats : Among the 19,596 included patients, PCA (229 G/L [189,271]) was associated with coagulopathy, traumatic burden, shock and bleeding severity. In a logistic regression model, 24-h all-cause mortality increased by 37% for every 50 G/L decrease in platelet count (OR 0.63 95% CI 0.57-0.70; p < 0.001). Regarding patients with severe hemorrhage, platelets were transfused early for 36% of patients. Early platelet transfusion was associated with a decrease in 24-h all-cause mortality (versus no or late platelets): OR 0.52 (95% CI 0.34-0.79; p < 0.05).

Conclusion : PCA, although mainly in normal range, was associated with trauma severity and coagulopathy and was predictive of bleeding intensity and outcome. Early platelet transfusion within 6 h was associated with a decrease in mortality in patients with severe hemorrhage. Future studies are needed to determine which doses of platelet transfusion will improve outcomes after major trauma.

Conclusion (proposition de traduction) : La numération plaquettaire à l'admission, bien que principalement dans la plage normale, était associée à la gravité du traumatisme et à la coagulopathie et était prédictive de l'intensité et de l'issue des saignements. La transfusion précoce de plaquettes dans les 6 heures a été associée à une diminution de la mortalité chez les patients présentant une hémorragie sévère. De futures études sont nécessaires pour déterminer quelles doses de transfusion de plaquettes amélioreront les résultats après un traumatisme majeur.

Commentaire : Pour mémoire : Chez un adulte normal, le nombre de plaquettes est compris entre 150 000 à 450 000/mm³.

Recommendations for end-of-life care by emergency health services.
Boqué Oliva C, Romero Pareja R, Herreros B. | Emergencias. 2022;34:47-54 47
DOI: NC  | Télécharger l'article au format  
Keywords: Adequacy of life support; End of life; Palliative care; Life support care; End of life; Terminal care.

original article

Editorial : Emergency services' main purpose is to save lives, but that worthy mission cannot always be accomplished. When caring for patients toward the end of life, we have an ethical obligation to talk with them and their relatives to obtain consensus on treatment and possibly limit it or adjust management in accordance with the patient's condition. Emergency department protocols are necessary for optimizing care to provide the greatest possible comfort and control of symptoms in patients at the end of life to prevent unnecessary suffering and preserve dignity. This article sets out recommendations - including the principles and ethical standards that underlie them - so that emergency services can develop end-of-life care protocols for use in their own settings.

Conclusion : In accordance with the above (legislation, deontology, principles and general ethical standards), and having made the pertinent conceptual clarification with respect to adequacy of life support and sedation, the following recommendations are proposed for the development of protocols for quality care of patients at the end of life in the ED.

Conclusion (proposition de traduction) : Conformément à la législation, déontologie, principes et normes éthiques générales et après avoir apporté les précisions conceptuelles pertinentes concernant le caractère adéquat du maintien en vie et de la sédation, des recommandations sont proposées pour l'élaboration de protocoles de soins de qualité pour les patients en fin de vie aux urgences

Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department.
Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. | Emergencias. 2022 Feb;34(1):64-65
DOI: NC  | Télécharger l'article au format  
Keywords: Aucun

Pearls of wisdon for emergencies

Introduction : Chest X-ray (CXR) is a longstanding method for the diagnosis of pneumothorax but chest ultrasonography (CUS) may be a safer, more rapid, and more accurate modality in trauma patients at the bedside that does not expose the patient to ionizing radiation. This may lead to improved and expedited management of traumatic pneumothorax and improved patient safety and clinical outcomes.

Méthode : To compare the diagnostic accuracy of chest ultrasonography (CUS) by frontline non-radiologist physicians versus chest X-ray (CXR) for diagnosis of pneumothorax in trauma patients in the emergency department (ED). To investigate the effects of potential sources of heterogeneity such as type of CUS operator (frontline non-radiologist physicians), type of trauma (blunt vs penetrating), and type of US probe on test accuracy.

Résultats : We included 13 studies of which nine (410 traumatic pneumothorax patients out of 1271 patients) used patients as the unit of analysis; we thus included them in the primary analysis. The remaining four studies used lung field as the unit of analysis and we included them in the secondary analysis. We judged all studies to be at high or unclear risk of bias in one or more domains, with most studies (11/13, 85%) being judged at high or unclear risk of bias in the patient selection domain. There was substantial heterogeneity in the sensitivity of supine CXR amongst the included studies. In the primary analysis, the summary sensitivity and specificity of CUS were 0.91 (95% confidence interval (CI) 0.85 to 0.94) and 0.99 (95% CI 0.97 to 1.00); and the summary sensitivity and specificity of supine CXR were 0.47 (95% CI 0.31 to 0.63) and 1.00 (95% CI 0.97 to 1.00). There was a significant difference in the sensitivity of CUS compared to CXR with an absolute difference in sensitivity of 0.44 (95% CI 0.27 to 0.61; P < 0.001). In contrast, CUS and CXR had similar specificities: comparing CUS to CXR, the absolute difference in specificity was -0.007 (95% CI -0.018 to 0.005, P = 0.35). The findings imply that in a hypothetical cohort of 100 patients if 30 patients have traumatic pneumothorax (i.e. prevalence of 30%), CUS would miss 3 (95% CI 2 to 4) cases (false negatives) and overdiagnose 1 (95% CI 0 to 2) of those without pneumothorax (false positives); while CXR would miss 16 (95% CI 11 to 21) cases with 0 (95% CI 0 to 2) overdiagnosis of those who do not have pneumothorax.

Conclusion : The diagnostic accuracy of CUS performed by frontline non-radiologist physicians for the diagnosis of pneumothorax in ED trauma patients is superior to supine CXR, independent of the type of trauma, type of CUS operator, or type of CUS probe used. These findings suggest that CUS for the diagnosis of traumatic pneumothorax should be incorporated into trauma protocols and algorithms in future medical training programmes; and that CUS may beneficially change routine management of trauma.

Conclusion (proposition de traduction) : La précision diagnostique de l'échographie thoracique réalisée par des médecins de première ligne non radiologues pour le diagnostic du pneumothorax chez les patients traumatisés aux urgences est supérieure à la radiographie thoracique en décubitus dorsal, indépendamment du type de traumatisme, du type d'opérateur d'échographie thoracique ou du type de sonde d'échographie thoracique utilisée. Ces résultats suggèrent que l'échographie thoracique pour le diagnostic du pneumothorax traumatique devrait être incorporée dans les protocoles et les algorithmes de traumatologie dans les futurs programmes de formation médicale ; et que l'échographie thoracique peut modifier de manière bénéfique la gestion de routine des traumatismes.

Commentaire : Voir :
Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev. 2020 Jul 23;7(7):CD013031  .

Overview of Allergy and Anaphylaxis.
Dribin TE, Motosue MS, Campbell RL. | Emerg Med Clin North Am. 2022 Feb;40(1):1-17
DOI: https://doi.org/10.1016/j.emc.2021.08.007  | Télécharger l'article au format  
Keywords: Anaphylaxis; Diagnosis; Epidemiology; Epinephrine; Risk factors.

Review article

Editorial : Allergic reactions and anaphylaxis occur on a severity continuum from mild and self-limited to potentially life-threatening or fatal reactions. Anaphylaxis is typically a multiorgan phenomenon involving a broad range of effector cells and mediators. Emergency department visits for anaphylaxis are increasing, especially among children. There is a broad differential diagnosis for anaphylaxis, and the diagnosis of anaphylaxis can be aided by the use of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network clinical diagnostic criteria. Risk factors for severe anaphylaxis include older age, delayed epinephrine administration, and cardiopulmonary comorbidities.

Conclusion : Clinicians must maintain a broad differential when treating patients with suspected anaphylaxis, especially for patients who do not respond to standard anaphylaxis management. Additionally, because anaphylaxis is under-recognized and under-treated (specifically around treatment with epinephrine), it is critical for emergency department providers to consider anaphylaxis in the differential diagnosis for patients whose symptoms overlap with those of anaphylaxis (eg, upper airway obstruction, wheezing, angioedema, flushing, syncope, hypotension) given delayed treatment with epinephrine may be a risk factor for adverse outcomes including biphasic and fatal anaphylaxis. Likewise, recognition of anaphylaxis may be especially challenging for noncommunicative patients including infants and young children who may present with nonspecific symptoms that overlap with normal infant behavior (eg, fussiness, drooling, spitting up).

Conclusion (proposition de traduction) : Les cliniciens doivent maintenir un large éventail de diagnostics différentiels lorsqu'ils traitent des patients présentant une suspicion d'anaphylaxie, en particulier pour les patients qui ne répondent pas au traitement standard de l'anaphylaxie. De plus, étant donné que l'anaphylaxie est sous-reconnue et sous-traitée (notamment en ce qui concerne le traitement par adrénaline), il est essentiel que les urgentistes considèrent l'anaphylaxie dans le diagnostic différentiel pour les patients dont les symptômes se chevauchent avec ceux de l'anaphylaxie (p. ex. obstruction des voies aériennes supérieures, respiration sifflante, œdème de Quincke, bouffées vasomotrices, syncope, hypotension), étant donné qu'un traitement tardif par adrénaline peut être un facteur de risque d'effets indésirables, notamment d'anaphylaxie biphasique et fatale. De même, la reconnaissance de l'anaphylaxie peut être particulièrement difficile pour les patients non communicants, y compris les nourrissons et les jeunes enfants qui peuvent présenter des symptômes non spécifiques qui se superposent au comportement normal du nourrisson (par exemple, irritabilité, bave, régurgitation).

Commentaire : POINTS DE VUE CLINIQUES
• L'épinéphrine est indiquée pour les patients présentant des manifestations allergiques potentiellement mortelles, même si plusieurs systèmes organiques ne sont pas impliqués.
• Envisager le syndrome alpha-Gal (allergie déclenchée par un hydrate de carbone [consommation de viande rouge et autres produits fabriqués à partir de mammifères], caractérisé par des symptômes retardés par rapport aux autres allergies alimentaires) chez les patients sans déclencheur allergique clair.
• Informer les patients du risque de réaction biphasique et s'assurer qu'ils sont bien préparés à la gérer.
• Orienter les patients présentant une anaphylaxie vers un allergologue pour confirmer le diagnostic et le facteur déclenchant et pour une éventuelle immunothérapie.

Anaphylaxis: Emergency Department Treatment.
McHugh K, Repanshek Z. | Emerg Med Clin North Am. 2022 Feb;40(1):19-32
DOI: https://doi.org/10.1016/j.emc.2021.08.004  | Télécharger l'article au format  
Keywords: Airway management; Anaphylactic shock; Anaphylaxis; Awake intubation; Epinephrine.

Review article

Editorial : Anaphylaxis is a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise. Intramuscular epinephrine is the immediate treatment of all patients. Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation. Airway obstruction must be recognized, and early intubation may be necessary. For shock that is refractory to epinephrine, additional vasopressors may be needed. Disposition depends on patient presentation and response to treatment. Mandatory observation periods are not necessary, because biphasic reactions are difficult to predict and may occur outside of typical observation periods.

Conclusion : Anaphylaxis is a potentially deadly condition that, when treated correctly, can be reversed rapidly. Although randomized controlled data regarding treatment are lacking, consensus regarding management exists. As in any resuscitation, airway, breathing, and circulation are essential. Epinephrine should be administered immediately. Epinephrine possesses the ideal pharmacologic actions to counteract the pathologic processes at play. Adjunctive agents include inhaled bronchodilators, corticosteroids, and antihistamines but epinephrine administration should not be delayed. Airway management is necessary when there are severe obstructive or respiratory symptoms, and awake intubation may be the safest and preferred method. Anaphylactic shock should be treated with IV epinephrine and isotonic fluids, and refractory shock may require additional vasopressors. Biphasic reactions are relatively rare and difficult to predict, and any observation period should be tailored to the individual patient. Extended observation for uncomplicated cases with complete resolution is unnecessary. Patients should be educated about the signs and treatment of anaphylaxis, and all patients should be discharged with an epinephrine autoinjector and strict return precautions.

Conclusion (proposition de traduction) : L'anaphylaxie est un événement potentiellement mortel qui, lorsqu'il est traité correctement, peut être rapidement réversible. Bien qu'il n'y ait pas de données contrôlées randomisées concernant le traitement, il existe un consensus sur la prise en charge. Comme dans toute réanimation, les voies respiratoires, la respiration et la circulation sont essentielles. L'adrénaline doit être administrée immédiatement. L'adrénaline possède les actions pharmacologiques idéales pour neutraliser les processus pathologiques en jeu. Les agents adjuvants comprennent les bronchodilatateurs inhalés, les corticostéroïdes et les antihistaminiques, mais l'administration d'épinéphrine ne doit pas être retardée. La gestion des voies respiratoires est nécessaire en cas de symptômes obstructifs ou respiratoires graves, et l'intubation éveillée peut être la méthode la plus sûre et la meilleure. Le choc anaphylactique doit être traité avec de l'adrénaline IV et des solutés isotoniques, et un choc réfractaire peut nécessiter des vasopresseurs supplémentaires. Les réactions biphasiques sont relativement rares et difficiles à prévoir, et toute période d'observation doit être adaptée à chaque patient. Il n'est pas nécessaire de prolonger l'observation des cas non compliqués qui se sont complètement résorbés. Les patients doivent être informés des signes et du traitement de l'anaphylaxie, et tous les patients doivent sortir de l'hôpital avec un auto-injecteur d'adrénaline et des précautions rigoureuses de reconsultation.

Commentaire : Points clés
• Les réactions biphasiques cliniquement significatives sont rares et surviennent généralement après la période d'observation traditionnelle de 4 heures.
• Tous les patients qui sortent des urgences doivent se voir prescrire ou fournir 2 auto-injecteurs d'adrénaline et apprendre à les utiliser correctement.
• Les glucocorticoïdes n'ont pas démontré leur efficacité clinique dans la prévention de l'anaphylaxie biphasique.
• L'éducation du patient après une réaction anaphylactique doit commencer avant la sortie des urgences. Un plan d'action écrit doit être utilisé pour aider à guider les patients, les familles, les enseignants et le personnel médical communautaire.
• Les patients doivent être orientés vers un spécialiste des allergies capable de confirmer les déclencheurs et d'effectuer une immunothérapie si nécessaire.

Allergic Acute Coronary Syndrome-Kounis Syndrome.
Alblaihed L, Huis In 't Veld MA. | Emerg Med Clin North Am. 2022 Feb;40(1):69-78
DOI: https://doi.org/10.1016/j.emc.2021.08.010  | Télécharger l'article au format  
Keywords: Acute coronary syndrome; Allergic reaction; Kounis syndrome; Vasospastic angina.

Review article

Editorial : Acute coronary syndrome (ACS) in the setting of an allergic/immunologic reaction is known as Kounis syndrome. It is an underdiagnosed and underrecognized disease entity. One must keep a high index of suspicions when managing a patient presenting with cardiac as well as allergic symptoms. There are 3 main variants to the syndrome. Treating the allergic reaction may alleviate the pain; however, ACS guidelines should be followed if cardiac ischemia is present.

Conclusion : Acute coronary syndrome in the setting of an allergic/immunologic reaction is known as Kounis syndrome. It is an underdiagnosed and underrecognized disease entity. One must keep a high index of suspicions when managing a patient presenting with cardiac as well as allergic symptoms. There are 3 main variants to the syndrome. Treating the allergic reaction may alleviate the pain; however, acute coronary syndrome guidelines should be followed if cardiac ischemia is present.

Conclusion (proposition de traduction) : Le syndrome coronarien aigu dans le cadre d'une réaction allergique/immunologique est connu sous le nom de syndrome de Kounis. Il s'agit d'une entité pathologique sous-diagnostiquée et méconnue. Il faut garder un indice élevé de suspicion lors de la prise en charge d'un patient présentant des symptômes cardiaques et allergiques. Il existe trois variantes principales de ce syndrome. Le traitement de la réaction allergique peut soulager la douleur ; toutefois, les directives relatives au syndrome coronarien aigu doivent être suivies en cas d'ischémie cardiaque.

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema.
Wilkerson RG, Winters ME. | Emerg Med Clin North Am. 2022 Feb;40(1):79-98
DOI: https://doi.org/10.1016/j.emc.2021.09.004  | Télécharger l'article au format  
Keywords: ACE inhibitor–induced angioedema; Bradykinin; C1-inhibitor; Difficult airway; Quincke disease.

Review article

Editorial : Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.

Conclusion : Angioedema that develops as a result of treatment with an ACEi is a potentially lifethreatening complication that requires prompt evaluation by a physician trained in emergency stabilization and airway management. Although the entire pathophysiologic processes for why this complication develops is not entirely clear, it is thought to be largely driven by the accumulation of bradykinin with some possible role for substance P. Importantly, ACEi-induced angioedema is not a type I hypersensitivity reaction that results in the release of preformed mediators such as histamine from mast cells and basophils. There are no medications that have proved efficacy in the treatment of ACEi-induced angioedema. Given the relative frequency that this is seen in the ED, this is an important area for future research. The most important role that the emergency physician has is to evaluate and manage the airway based on the location of swelling and the severity of symptoms. Classification systems have been developed to describe the location of angioedema and provide some information on disposition and need for airway intervention. The emergency physician can use the systems to provide some context; however, the management of each patient should be individualized based on the global assessment performed by the treating physician.

Conclusion (proposition de traduction) : L'angioedème qui se développe à la suite d'un traitement par un inhibiteur de l'enzyme de conversion de l'angiotensine est une complication potentiellement mortelle qui nécessite une évaluation rapide par un médecin formé à la stabilisation d'urgence et à la gestion des voies respiratoires. Bien que l'ensemble des processus physiopathologiques à l'origine de cette complication ne soit pas entièrement élucidé, on pense qu'elle est en grande partie due à l'accumulation de bradykinine, la substance P pouvant également jouer un rôle. Il est important de noter que l'angioedème induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine n'est pas une réaction d'hypersensibilité de type I qui entraîne la libération de médiateurs préformés tels que l'histamine par les mastocytes et les basophiles. Aucun médicament n'a fait la preuve de son efficacité dans le traitement de l'angioedème induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine. Étant donné la fréquence relative de ce phénomène aux urgences, il s'agit d'un domaine important pour les recherches futures. Le rôle le plus important de l'urgentiste est d'évaluer et de prendre en charge les voies respiratoires en fonction de la localisation de l'œdème et de la gravité des symptômes. Des systèmes de classification ont été mis au point pour décrire la localisation de l'angio-oedème et fournir des informations sur la disposition et la nécessité d'une intervention sur les voies respiratoires. L'urgentiste peut utiliser ces systèmes pour fournir un certain cadre ; cependant, la prise en charge de chaque patient doit être individualisée en fonction de l'évaluation globale effectuée par le praticien.

Hereditary Angioedema.
Wilkerson RG, Moellman JJ. | Emerg Med Clin North Am. 2022 Feb;40(1):99-118
DOI: https://doi.org/10.1016/j.emc.2021.09.002  | Télécharger l'article au format  
Keywords: Bradykinin; C1-inhibitor; Complement; Difficult airway; Hereditary angioedema; Quincke disease.

Review article

Editorial : Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.

Conclusion : The ED management of a patient presenting with an acute attack of Hereditary angioedema requires recognition of the disease and careful evaluation for airway involvement. Angioedema itself is a clinical diagnosis of swelling of the subcutaneous and submucosal tissues. Broadly speaking, angioedema is usually caused by either the release of histamine or the presence of bradykinin. Understanding the underlying pathophysiology will help guide medical management with appropriate and effective medications while avoiding treatments that are ineffective and even potentially harmful. There have been major advances in the treatment of Hereditary angioedema since 2008. The cost of these treatments has been very high, so many hospitals may not have Hereditary angioedema-specific medications on formulary. Being aware of what treatment options are available before the critical Hereditary angioedema patient presents to the ED will help with the timely treatment of an acute attack.

Conclusion (proposition de traduction) : La prise en charge aux urgences d'un patient présentant une crise aiguë d'angio-oedème héréditaire nécessite de reconnaître la maladie et d'évaluer soigneusement l'atteinte des voies respiratoires. L'angio-oedème lui-même est un diagnostic clinique d'oedème des tissus sous-cutanés et sous-muqueux. D'une manière générale, l'angioedème est généralement causé par la libération d'histamine ou la présence de bradykinine. La compréhension de la physiopathologie sous-jacente permet d'orienter la prise en charge médicale avec des médicaments appropriés et efficaces tout en évitant les traitements inefficaces, voire potentiellement dangereux. Des progrès majeurs ont été réalisés dans le traitement de l'angioedème héréditaire depuis 2008. Le coût de ces traitements étant très élevé, il est possible que de nombreux hôpitaux n'aient pas de médicaments spécifiques de l'angio-oedème héréditaire sur leur liste de médicaments. Connaître les options de traitement disponibles avant que le patient critique atteint d'angioedème héréditaire ne se présente aux urgences aidera à traiter rapidement une crise aiguë.

Out-of-hospital cardiac arrest due to hanging: a retrospective analysis.
Turner J, Brown A, Boldy R, Lumley-Holmes J, Rosser A, James A. | Emerg Med J. 2022 Feb;39(2):106-110
DOI: https://doi.org/10.1136/emermed-2020-210839
Keywords: cardiac arrest; emergency care systems; pre-hospital; pre-hospital care; trauma.

OUT OF HOSPITAL CARDIAC ARREST

Introduction : There has been little research into the prehospital management of cardiac arrest following hanging despite it being among the most prevalent methods of suicide worldwide. The aim of this study was to report the characteristics, resuscitative treatment and outcomes of patients managed in the prehospital environment for cardiac arrest secondary to hanging and compare these with all-cause out-of-hospital cardiac arrest (OHCA).

Méthode : Data from a UK ambulance service cardiac arrest registry were extracted for all cases in which treatment was provided for OHCA due to hanging between 1 January 2013 and 30 June 2018. Cases were linked to outcome data obtained from the Trauma Audit and Research Network. Comparison of the cohort was made to previously published data from a UK study of all-cause OHCA with 95% CIs calculated for the proportional difference between the studies in selected presentation and outcome variables.

Résultats : 189 cases were identified. 95 patients were conveyed to hospital and four of these survived to discharge. 40 patients were conveyed despite absence of a spontaneous circulation and none of these patients survived. While only three patients were initially in a shockable rhythm, DC shocks were administered in 20 cases. There was one case of failed ventilation prompting front-of-neck access for oxygenation. By comparison with all-cause OHCA the proportion of patients with a spontaneous circulation at hospital handover was similar (27.0% vs 27.5%; 0.5% difference, 95% CI -5.9% to 6.8%, p=0.882) but survival to hospital discharge was significantly lower (2.2% vs 8.4%; 6.2% difference, 95% CI 4.1% to 8.3%, p=0.002).

Conclusion : Clinical outcomes following OHCA due to hanging are poor, particularly when patients are transported while in cardiac arrest. Failure to ventilate was uncommon, and clinicians should be alert to the possibility of shockable rhythms developing during resuscitation.

Conclusion (proposition de traduction) : Les résultats cliniques après un arrêt cardiaque par pendaison en dehors de l'hôpital sont médiocres, en particulier lorsque les patients sont transportés en arrêt cardiaque. L'absence de ventilation était rare et les praticiens doivent être attentifs à la possibilité que des rythmes choquants se développent pendant la réanimation.

Epidemiology, management and survival outcomes of adult out-of-hospital traumatic cardiac arrest due to blunt, penetrating or burn injury.
Doan TN, Wilson D, Rashford S, Sims L, Bosley E. | Emerg Med J. 2022 Feb;39(2):111-117
DOI: https://doi.org/10.1136/emermed-2021-211723
Keywords: epidemiology; prehospital care; trauma.

OUT OF HOSPITAL CARDIAC ARREST

Introduction : Survival from out-of-hospital traumatic cardiac arrest (TCA) is poor. Regional variation exists regarding epidemiology, management and outcomes. Data on prognostic factors are scant. A better understanding of injury patterns and outcome determinants is key to identifying opportunities for survival improvement.

Méthode : Included were adult (≥18 years) out-of-hospital TCA due to blunt, penetrating or burn injury, who were attended by Queensland Ambulance Service paramedics between 1 January 2007 and 31 December 2019. We compared the characteristics of patients who were pronounced dead on paramedic arrival and those receiving resuscitation from paramedics. Intra-arrest procedures were described for attempted-resuscitation patients. Survival up to 6 months postarrest was reported, and factors associated with survival were investigated.

Résultats : 3891 patients were included; 2394 (61.5%) were pronounced dead on paramedic arrival and 1497 (38.5%) received resuscitation from paramedics. Most arrests (79.8%) resulted from blunt trauma. Motor vehicle collision (42.4%) and gunshot wound (17.7%) were the most common injury mechanisms in patients pronounced dead on paramedic arrival, whereas the most prevalent mechanisms in attempted-resuscitation patients were motor vehicle (31.3%) and motorcycle (20.6%) collisions. Among attempted-resuscitation patients, rates of transport and survival to hospital handover, to hospital discharge and to 6 months were 31.9%, 15.3%, 9.8% and 9.8%, respectively. Multivariable model showed that advanced airway management (adjusted OR 1.84; 95% CI 1.06 to 3.17), intravenous access (OR 5.04; 95% CI 2.43 to 10.45) and attendance of high acuity response unit (highly trained prehospital care clinicians) (OR 2.54; 95% CI 1.25 to 5.18) were associated with improved odds of survival to hospital handover.

Conclusion : By including all paramedic-attended patients, this study provides a more complete understanding of the epidemiology of out-of-hospital TCA. Contemporary survival rates from adult out-of-hospital TCA who receive resuscitation from paramedics may be higher than historically thought. Factors identified in this study as associated with survival may be useful to guide prognostication and treatment.

Conclusion (proposition de traduction) : En incluant tous les patients traités par des ambulanciers paramédicaux, cette étude permet de mieux comprendre l’épidémiologie des arrêts cardiaques traumatiques en dehors de l’hôpital. Les taux de survie contemporains des adultes victimes d'un arrêt cardiaque traumatique en dehors de l’hôpital qui sont réanimés par des ambulanciers paramédicaux peuvent être plus élevés que ce que l’on croyait. Les facteurs identifiés dans cette étude comme étant associés à la survie peuvent servir à orienter le pronostic et le traitement.

Commentaire : Le modèle multivariable a montré que l'intubation, la pose d'une voie veineuse périphérique et la prise en charge par une unité d’intervention de haute technicité (cliniciens de soins préhospitaliers hautement qualifiés) étaient associés à une amélioration des chances de survie à l'admission à l’hôpital.

Systematic review of factors influencing decisions to limit treatment in the emergency department.
Walzl N, Sammy IA, Taylor PM, Smith JE, Lowe DJ. | Emerg Med J. 2022 Feb;39(2):147-156
DOI: https://doi.org/10.1136/emermed-2019-209398  | Télécharger l'article au format  
Keywords: emergency department.

SYSTEMATIC REVIEW

Introduction : Emergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment in the Emergency Department (ED) through a systematic search of the available literature.

Méthode : Prospectively registered systematic review of studies employing any methodology to investigate factors influencing decisions to limit treatment in the ED. Medline and EMBASE were searched from their inception until January 2019. Methodological quality was assessed using the Mixed Methods Appraisal Tool, but no studies were excluded based on quality. Findings were summarised by narrative analysis.

Résultats : 10 studies published between 1998 and 2016 were identified for inclusion in this review, including seven cross-sectional studies investigating factors associated with treatment-limiting decisions, two surveys of physicians making treatment-limiting decisions and one qualitative study of physicians making treatment-limiting decisions. There was significant heterogeneity in patient groups, outcome measures, methodology and quality. Only three studies received a methodology-specific rating of 'high quality'. Important limitations of the literature include the use of small single-centre retrospective cohorts often lacking a comparison group, and survey studies with low response rates employing closed-response questionnaires. Factors influencing treatment-limiting decisions were categorised into 'patient and disease factors' (age, chronic disease, functional limitation, patient and family wishes, comorbidity, quality of life, acute presenting disorder type, severity and reversibility), 'hospital factors' (colleague opinion, resource availability) and 'non-patient healthcare factors' (moral, ethical, social and cost factors)

Conclusion : Several factors influence decisions to limit treatment in the ED. Many factors are objective and quantifiable, but some are subjective and open to individual interpretation. This review highlights the complexity of the subject and the need for more robust research in this field.

Conclusion (proposition de traduction) : Plusieurs facteurs influencent les décisions de limiter le traitement aux urgences. De nombreux facteurs sont objectifs et quantifiables, mais certains sont subjectifs et ouverts à l'interprétation individuelle. Cette revue met en évidence la complexité du sujet et la nécessité d'une recherche plus solide dans ce domaine.

Commentaire : Les facteurs influençant les décisions de limitation des traitements ont été classés en « facteurs liés au patient et à la maladie » (âge, maladie chronique, limitation fonctionnelle, souhaits du patient et de la famille, comorbidité, qualité de vie, type de trouble aigu, gravité et réversibilité), « facteurs hospitaliers » (opinion d'un collègue, disponibilité des ressources) et les « facteurs de soins de santé non liés au patient » (facteurs moraux, éthiques, sociaux et de coût).

Radiological features of pulmonary fat embolism in trauma patients: a case series.
Dwivedi S, Kimmel LA, Kirk A, Varma D. | Emerg Radiol. 2022 Feb;29(1):41-47
DOI: https://doi.org/10.1007/s10140-021-01969-4
Keywords: CT; Pulmonary fat embolism; Respiratory; Trauma.

Original Article

Introduction : Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long bone fractures) in which migrating medullary fat precipitates multiorgan dysfunction, classically presenting with dyspnoea, petechiae and neurocognitive dysfunction. Although this triad of symptoms is rare, it nonetheless aids diagnosis of pulmonary fat embolism (PuFE). Typical imaging features of PuFE are not established, although increasing use of CT pulmonary angiography (CTPA) in this cohort may provide important diagnostic information. We therefore conducted a case series of FES patients with CTPA imaging at a Level 1 Trauma Centre in Melbourne, Australia.

Méthode : Medical records and various radiological investigations including CTPA of consecutive patients diagnosed clinically with FES between 2006 and 2018, including demographics, injury and their progress during their admission, were reviewed.

Résultats : Fifteen FES patients with retrievable CTPAs were included (mean age 31.2 years, range 17-69; 12 males [80%]). 93.3% had long bone fractures. CTPA was performed 2.00 ± 1.41 days post-admission. Review of these images showed pulmonary opacity in 14 (93.3%; ground-glass opacities in 9 [64.3%], alveolar opacities in 6 [42.9%]), interlobular septal thickening in 10 (66.7%), and pleural effusions in 7 (46.7%). Filling defects were identified in three (20%) CTPAs, with density measuring - 20HU to + 63HU. Ten patients (66.7%) had neuroimaging performed, with two patients demonstrating imaging findings consistent with cerebral fat emboli.

Conclusion : CTPA features of PuFE are variable, with ground-glass parenchymal changes and septal thickening most commonly seen. Filling defects were uncommon.

Conclusion (proposition de traduction) : Les caractéristiques de l'angiographie pulmonaire par tomodensitométrie pour une embolie graisseuse au niveau pulmonaire sont variables, les changements parenchymateux en verre dépoli et l'épaississement septal étant les plus fréquemment observés. Les défauts de remplissage étaient rares.

Shelling the myth: allergies to Iodine containing substances and risk of reaction to Iodinated contrast media.
Bruen R, Stirling A, Ryan M, Sheehan M, MacMahon P. | Emerg Radiol. 2022 Feb;29(1):67-73
DOI: https://doi.org/10.1007/s10140-021-01989-0
Keywords: Allergy; Contrast-enhanced scans; Iodinated contrast media; Radiology; Shellfish; Shellfish allergy.

Original Article

Introduction : In excess of 100 million procedures using iodinated radio-contrast media are conducted each year. There is a common misunderstanding regarding the links between allergy to iodinated substances and the risk of allergic reaction to intravenous iodinated contrast agents. These perceived risks are managed via administration of corticosteroids or avoidance of iodinated contrast altogether.

Méthode : An extensive review of published literature on scientific databases and international guidelines was conducted in order to inform the research question. A questionnaire was formulated and distributed to hospital doctors in four tertiary centres. Within this questionnaire, hospital doctors were presented with six different scenarios of bona fide allergy to iodinated substances (e.g. shellfish) and asked to select the treatment response option which they deemed to be the most suitable from a choice of three (standard contrast scan/delay scan with pre-medication/change to non-contrast scan).

Résultats : Eighty-seven questionnaire responses were received. Contrast (standard protocol) was the most appropriate regimen in the setting of all the listed allergies. This was identified correctly by 76%, 69%, 44%, 32%, 18% and 14% for kiwi, fish, poly-food, shellfish, betadine and tincture of iodine allergies, respectively.

Conclusion : There is a lack of understanding amongst local junior medical staff regarding administration of iodinated contrast media to patients with a history of allergy to iodinated substances. These misconceptions may potentiate the unnecessary usage of pre-medication and ordering of non-contrast scans in the setting of a gold-standard enhanced scan. Findings from this study suggest that there is a need for future education efforts targeted during the basic specialty training stage.

Conclusion (proposition de traduction) : Il y a un manque de compréhension parmi le personnel médical junior local concernant l'administration de produits de contraste iodés aux patients ayant des antécédents d'allergie aux produits iodées. Ces idées fausses peuvent potentialiser l'utilisation inutile de la prémédication et la demande d'examens sans injection de produit de contraste dans le cadre d'un examen améliorée de référence. Les résultats de cette étude suggèrent qu'il est nécessaire de déployer des efforts d'éducation futurs ciblés au stade de la formation de base spécialisée.

Actual guidelines on non-ST-elevation acute coronary syndrome: how do they help in the emergency department?.
Möckel M | Eur J Emerg Med. 2022 Feb 1;29(1):2-4
DOI: https://doi.org/10.1097/mej.0000000000000895
Keywords: Aucun

Perspective Article

Editorial : In 2020, the European Society of Cardiology (ESC) released new guidelines ‘for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation’.
In Emergency Medicine (EM), a primary challenge is to create a suspected diagnosis based on symptoms and a sometimes atypical presentation. Thus, in patients with chest pain, a large number of differential diagnoses from ACS and aortic dissection to mental health disorders and functional complaints occur. Especially regarding the management of suspected ACS, for use in EM, guidelines need to start with the primary presentation in the emergency department (ED) or even in the prehospital setting and management rules should address the uncer- tainty of the initial presentation.
With this in mind, three aspects of the actual ESC guideline will be critically appraised in the light of EM: initial diagnostic steps, initial therapeutic considerations and management rules related to the indication and timing of invasive coronary angiography.

Conclusion : Therefore, it is suggested that future guidelines, which focus on patients who typically present to the ED, EM specialists in addition to cardiologists should be primarily involved to further optimize the ESC guidelines.
Meanwhile, for the use in the ED, an operationalized flowchart for the management of patients with suspected NSTEMI is proposed (Fig. 1). Here, the area of uncer- tainty and the communication about patients is addressed from an EM perspective, but it also considers the view of an interventional cardiologist.

Conclusion (proposition de traduction) : Il est suggéré que pour les futures directives, qui se concentrent sur les patients qui se présentent généralement aux urgences, les urgentistes soient principalement impliqués à côté des cardiologues pour optimiser davantage les directives de l'ESC.
En attendant, pour l'utilisation aux urgences, un organigramme opérationnel pour la prise en charge des patients suspects de NSTEMI est proposé (Figure ci-dessous). Ici, le domaine de l'incertitude et la communication sur les patients sont abordés du point de vue de la médecine d'urgence, mais aussi du point de vue d'un cardiologue interventionnel.

Commentaire : 
Un résumé sur la prise en charge d'un patient chez qui l'on soupçonne un NSTEMI selon les directives de l'ESC  , la littérature publiée et les expériences personnelles. ESC, Société européenne de cardiologie ; NSTEMI, infarctus du myocarde sans élévation du segment ST.

Assessing left ventricular systolic function by emergency physician using point of care echocardiography compared to expert: systematic review and meta-analysis.
Albaroudi B, Haddad M, Albaroudi O, Abdel-Rahman ME, Jarman R, Harris T. | Eur J Emerg Med. 2022 Feb 1;29(1):18-32
DOI: https://doi.org/10.1097/mej.0000000000000866  | Télécharger l'article au format  
Keywords: Aucun

REVIEW ARTICLE

Editorial : Assessing left ventricular systolic function (LVSF) by echocardiography assists in the diagnosis and management of a diverse range of patients presenting to the emergency department (ED). We evaluated the agreement between ED-based clinician sonographers and apriori-defined expert sonographers. We conducted a systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched Medline, EMBASE, Cochrane, ClinicalTrials.gov, TRIP and Google Scholar for eligible studies from inception to February 2021. Risk of bias was evaluated using Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The level of agreement between clinician and expert sonographers was measured using kappa, sensitivity, specificity, positive and negative likelihood ratio statistics using random-effects models. Twelve studies were included (1131 patients, 1229 scans and 159 clinician sonographers). Significant heterogeneity was identified in patient selection, methods of assessment of LVSF, reference standards and statistical methods for assessing agreement. The overall quality of studies was low, with most being small, single centre convenience samples. A meta-analysis including seven studies (786 scans) where visual estimation method was used by clinician sonographers demonstrated simple Kappa of 0.68 [95% confidence interval (CI), 0.57-0.79], and sensitivity, specificity, positive and negative likelihood ratio of 89% (95% CI, 80-94%), 85% (95% CI, 80-89%), 5.98 (95% CI, 4.13-8.68) and 0.13 (95% CI, 0.06-0.24), respectively, between clinician sonographer and expert sonographer for normal/abnormal LVSF. The weighted kappa for five studies (429 scans) was 0.70 (95% CI, 0.61-0.80) for normal/reduced/severely reduced LVSF. There is substantial agreement between ED-based clinician sonographers and expert sonographers for assessing LVSF using visual estimation and ranking it as normal/reduced, or normal/reduced/severely reduced,

Conclusion : Clinician sonographer (trainee or attending) had a substantial agreement with an expert sonographer for the POC echocardiography assessment of LVSF as ‘normal or abnormal’ and as ‘normal, reduced and severely reduced’ by visual estimation. Few studies assessed the agreement between clinician sonographer and expert sonographer for EPSS and VTI methods and meta-analysis was not possible. There is considerable heterogeneity among studies with limited generalisability. A standardised training curriculum for LVSF assessment is needed. The quality of the included studies was low. Further studies are

Conclusion (proposition de traduction) : Le clinicien échographiste (stagiaire ou titulaire) était souvent en accord avec l'expert pour l’évaluation par échographie au point d'intervention de la fraction d'éjection ventriculaire gauche comme étant « normale ou anormale » et « normale, réduite et gravement réduite » par une estimation visuelle. Peu d’études ont évalué la concordance entre l'échographiste clinicien et expert pour le « E point-septal separation » (EPSS) et l'intégrale temps-vitesse (ITV) sous-aortique et la méta-analyse n’a pas été possible. Il existe une hétérogénéité considérable entre les études dont la généralisation est limitée. Un programme de formation normalisé pour l’évaluation de la fraction d'éjection ventriculaire gauche est nécessaire. La qualité des études incluses était faible. D’autres études sont justifiées.

Commentaire : On distingue quatre situations :
• FEVG > 65 %, représentant un VG hyperkinétique comme vu dans les états vasoplégiques ou hypovolémiqes
• FEVG > 50 %, soit normale
• FEVG entre 35 et 50 %, soit diminuée
• FEVG < 35 % soit sévèrement diminuée
Ces seuils sont arbitraires mais sont les plus communément utilisés.

E point-septal separation (EPSS)
C'est la mesure de la distance entre le feuillet antérieur de la mitrale et le septum, visualisé en mode TM sur une coupe parasternale long axe. La ligne de coupe doit prendre la partie la plus distale du feuillet antérieur de la mitrale. Le point E correspond au remplissage rapide diastolique, le point A (pic suivant) au clic auriculaire (absent chez les deux derniers patients car en FA. Un EPSS > 7 mm a une sensibilité de 87 % et une spécificité de 75 % pour prédire une FEVG inférieure à 50 %. (Evaluation fonction systolique du VG  )

Flux d’éjection ventriculaire gauche (flux sous aortique intraventriculaire) et mesure du débit cardiaque
Ce flux est enregistré en coupe 5 cavités. Il fuit la sonde et est codé en bleu en Doppler couleur. Son orientation est parallèle au septum interventriculaire. La constatation d’un flux couleur bleu homogéne (absence d’aliasing) signe qu’il n’existe aucune accélération pathologique du flux (qui laisserait suspecter une cardiomyopathie obstructive ou une sténose aortique.). En positionnant la fenêtre de Doppler pulsé dans le ventricule gauche, juste sous la valve aortique, un spectre négatif est enregistré, permettant la mesure le l’intégrale temps – vitesse (ITV sous aortique, normale 14 à 20 cm). L’ITV sous aortique est un des déterminants majeurs du volume d’éjection systolique (VES). Le VES est le produit de l’ITV par la surface de la chambre de chasse du VG obtenue en mesurant le diamètre (D) de cette dernière en PSGA (la surface (S) est obtenue en appliquant la formule πD²/4) (Évaluation hémodynamique en médecine d’urgence : apport de l’échocardiographie  ).

Association of dispatcher-assisted cardiopulmonary resuscitation with initial shockable rhythm and survival after out-of-hospital cardiac arrest.
Goto Y, Funada A, Maeda T, Goto Y. | Eur J Emerg Med. 2022 Feb 1;29(1):42-48
DOI: https://doi.org/10.1097/mej.0000000000000861  | Télécharger l'article au format  
Keywords: Aucun

Original Article

Introduction : Bystander cardiopulmonary resuscitation (CPR) and initial shockable rhythm are crucial predictors of survival after out-of-hospital cardiac arrest (OHCA). However, the relationship between dispatcher-assisted CPR (DA-CPR) and initial shockable rhythm is not completely elucidated.
Objective: To examine the association of DA-CPR with initial shockable rhythm and outcomes.

Méthode : This nationwide population-based observational study conducted in Japan included 59 688 patients with witnessed OHCA of cardiac origin after excluding those without bystander CPR. Patients were divided into DA-CPR (n = 42 709) and CPR without dispatcher assistance (unassisted CPR, n = 16 979) groups.
Outcome measures and analysis: The primary outcome measure was initial shockable rhythm, and secondary outcome measures were 1-month survival and neurologically intact survival. A Cox proportional hazards model adjusted for collapse-to-first-rhythm-analysis time and multivariable logistic regression models were used after propensity score (PS) matching to compare the incidence of initial shockable rhythm and outcomes, respectively.

Résultats : Among all patients (mean age 76.7 years), the rates of initial shockable rhythm, 1-month survival and neurologically intact survival were 20.8, 10.7 and 7.0%, respectively. The incidence of initial shockable rhythm in the DA-CPR group (20.4%, 3462/16 979) was significantly higher than that in the unassisted CPR group (18.5%, 3133/16 979) after PS matching (P < 0.0001). However, no significant differences were found between the two groups with respect to the incidence of initial shockable rhythm in the Cox proportional hazards model [adjusted hazard ratio of DA-CPR for initial shockable rhythm compared with unassisted CPR, 0.99; 95% confidence interval (CI), 0.97-1.02, P = 0.56]. No significant differences were observed in the survival rates in the two groups after PS matching [10.8% (1833/16 979) vs. 10.3% (1752/16 979), P = 0.16] and neurologically intact survival rates [7.3% (1233/16 979) vs. 6.8% (1161/16 979), P = 0.13]. The multivariable logistic regression model showed no significant differences between the groups with regard to survival (adjusted odds ratio of DA-CPR compared with unassisted CPR: 1.00; 95% CI, 0.89-1.13, P = 0.97) and neurologically intact survival (adjusted odds ratio: 1.12; 95% CI, 0.98-1.29, P = 0.14).

Conclusion : DA-CPR after OHCA had the same independent association with the likelihood of initial shockable rhythm and 1-month meaningful outcome as unassisted CPR.

Conclusion (proposition de traduction) : La réanimation cardiopulmonaire assistée par un assistant de régulation après un arrêt cardiaque en dehors de l’hôpital avait la même association indépendante avec la probabilité d’un rythme initial choquant et d’un résultat significatif à 1 mois que la réanimation cardiopulmonaire non assistée.

Factors associated with delayed revascularization in patients with ischemic stroke: a prospective study in one French region.
Laurent E, Bonnaud I, Gaudron M, Lahondère A, Godillon L, Vannier S, Bouilleau G, De Toffol B, Cottier JP, Laribi S, Grammatico-Guillon L. | Eur J Emerg Med. 2022 Feb 1;29(1):56-62
DOI: https://doi.org/10.1097/mej.0000000000000875
Keywords: Aucun

Original article

Introduction : Optimizing the care pathway of stroke is crucial for the revascularization of ischemic stroke.
Objectives: to identify factors associated with (1) a time interval over 4 h between the symptom onset and cerebral imaging in suspected stroke patients and (2) the absence of revascularization in patients with ischemic stroke.

Méthode : Patients over 18 years old with a suspected stroke admitted in 22 emergency rooms or stroke units in one French region between 1 March 2019 and 30 April 2019 were prospectively included by filling a dedicated form.
Outcome measures and analysis: Factors associated with the previously mentioned outcome measures were identified using logistic regression models.

Résultats : In total 991 patients were included; 537 patients (64% of 845 with available time intervals) were admitted more than 4 h after symptom onset. Three predictors were identified: not calling emergency medical services (EMS) [odds-ratio (OR) 5.2; 95% confidence interval (3.4-8.1)], a preexisting autonomy loss [2.0 (1.3-2.9)] and atypical clinical presentation [2.0 (1.3-3.1)]. A total of 385 patients had an ischemic stroke of whom 93 underwent a revascularization procedure (24%). The same three predictors were associated with the absence of revascularization procedure, added to an initial admission in a hospital without stroke unit [3.1 (1.1-8.6)].

Conclusion : This study shows that efforts to organize the care chain for stroke need to be intensified in the region to reduce treatment time intervals, which could include information campaigns focused on the impact of EMS call and the clinical presentation recognition.

Conclusion (proposition de traduction) : Cette étude montre que les efforts d'organisation de la chaîne des soins pour les AVC doivent être intensifiés en région pour réduire les intervalles de temps de traitement, ce qui pourrait inclure des campagnes d'information axées sur l'impact de l'appel aux services médicaux d'urgence et l'identification de la présentation clinique.

Effect of adrenaline dose on neurological outcome in out-of-hospital cardiac arrest: a nationwide propensity score analysis.
Jaeger D, Baert V, Javaudin F, Debaty G, Duhem H, Koger J, Gueugniaud PY, Tazarourte K, El Khoury C, Hubert H, Chouihed T; GR-RéAC. | Eur J Emerg Med. 2022 Feb 1;29(1):63-69
DOI: https://doi.org/10.1097/mej.0000000000000891
Keywords: Aucun

Original article

Introduction : Adrenaline is recommended during cardio-pulmonary resuscitation. The optimal dose remains debated, and the effect of lower than recommended dose is unknown.
Objective

Méthode : Patients were included from the French National Cardiac Arrest Registry and were grouped based on the received dose of adrenaline: recommended, higher and lower dose.
Outcome measures and analysis: The primary endpoint was good neurologic outcome at 30 days post-OHCA, defined by a cerebral performance category (CPC) of less than 3. Secondary endpoints included return of spontaneous circulation and survival to hospital discharge. A multiple propensity score adjustment approach was performed.

Résultats : 27 309 patients included from July 1st 2011 to January 1st 2019 were analysed, mean age was 68 (57-78) years and 11.2% had ventricular fibrillation. 588 (2.2%) patients survived with a good CPC score. After adjustment, patients in the high dose group had a significant lower rate of good neurologic outcome (OR, 0.6; 95% CI, 0.5-0.7). There was no significant difference for the primary endpoint in the lower dose group (OR, 0.8; 95% CI, 0.7-1.1). There was a lower rate of survival to hospital discharge in the high-dose group vs. standard group (OR, 0.5; 95% CI, 0.5-0.6).

Conclusion : The use of lower doses of adrenaline was not associated with a significant difference on survival good neurologic outcomes at D30. But a higher dose of adrenaline was associated with a lower rate of survival with good neurological outcomes and poorer survival at D30.

Conclusion (proposition de traduction) : L'utilisation de doses plus faibles d'adrénaline n'a pas été associée à une différence significative sur la survie avec de bons résultats neurologiques à J30. Mais une dose plus élevée d'adrénaline était associée à un taux de survie plus faible avec de bons résultats neurologiques et une moins bonne survie à J30.

Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review.
Hawkridge K, Ahmed I, Ahmed Z. | Eur J Trauma Emerg Surg. 2022 Feb;48(1):647-657
DOI: https://doi.org/10.1007/s00068-020-01576-x  | Télécharger l'article au format  
Keywords: Acute treatment; Pre-hospital; Spinal collars; Spinal injuries; Trauma; Trauma management.

Article original

Introduction : Spinal collars were introduced in 1967 into the management of spinal trauma care as it was thought that this technique of immobilisation would prevent any further neurological or spinal damage in high-risk patients. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature.

Méthode : A systematic search of the literature was conducted between 1990 and 2020, screening PubMed, Medline, Science Direct and Google Scholar. The consequent findings were then qualitatively synthesised with the aim of effectively evaluating the evidence to resolve the discrepancy between current practice and literature.

Résultats : Of the nine eligible studies, six deemed that spinal collars should not be used in pre-hospital trauma patients with the remaining three reporting uncertainty if spinal collars were best practice. Our results suggest that there is a discrepancy between current guidance and practice in that although the guidelines recommend the use of spinal collars in the pre-hospital setting the majority of the studies were against the use of spinal collars. Importantly, none of the studies reported any benefits of spinal collars.

Conclusion : Our study shows a disparity between current guidelines and the published literature and warrants further direct research to obtain a more comprehensive view of the use of spinal collars in a pre-hospital setting.

Conclusion (proposition de traduction) : Notre étude montre une disparité entre les directives actuelles et la littérature publiée et justifie de nouvelles recherches directes pour obtenir une vue plus complète de l'utilisation des colliers cervicaux dans un cadre pré-hospitalier.

Body temperature and in-hospital mortality in trauma patients: analysis of a nationwide trauma database in Japan.
Okada A, Okada Y, Narumiya H, Ishii W, Kitamura T, Iiduka R. | Eur J Trauma Emerg Surg. 2022 Feb;48(1):163-171
DOI: https://doi.org/10.1007/s00068-020-01489-9
Keywords: Fever; Hyperthermia; Hypothermia; Seasons; Trauma.

Original Article

Introduction : Avoiding body temperature (BT) abnormalities has been emphasized in trauma care, and BT correction in the initial treatment period may improve patient outcome. However, the effect of hyperthermia at hospital arrival on mortality in trauma patients is unclear. This study aimed to identify the association between BT and in-hospital mortality among adult trauma patients.

Méthode : This was a retrospective analysis of a multi-centre prospective cohort study. Data were obtained from the Japan Trauma Data Bank (JTDB). Adult trauma patients who were transferred directly from the scene of injury to the hospital and registered in the JTDB between January 2004 and December 2017 were included. The primary outcome was the association between BT at hospital arrival and in-hospital mortality. BT at hospital arrival was classified by 1 °C strata. We conducted multivariable logistic regression analyses to calculate the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality for each BT group using 36.0-36.9 °C as a reference.

Résultats : Overall, 153,117 patients were included. The total mortality rate was 7% (n = 10,118). The adjusted OR for in-hospital mortality for < 35.0 °C was 1.65 (95% CI 1.51-1.79, p < 0.001), 35.0-35.9 °C was 1.33 (95% CI 1.25-1.41, p < 0.001), 37.0-37.9 °C was 0.99 (95% CI 0.91-1.07, p = 0.639), 38.0-38.9 °C was 1.30 (95% CI 1.08-1.56, p = 0.007) and > 39.0 °C was 1.62 (95% CI 1.18-2.22, p = 0.003) compared to that for normothermia.

Conclusion : Our results reveal that hypothermia and hyperthermia at hospital arrival are associated with increased in-hospital mortality in adult trauma patients.

Conclusion (proposition de traduction) : Nos résultats montrent que l'hypothermie (< 36.0° C) et l'hyperthermie (≥ 38.0° C) à l'arrivée à l'hôpital sont associées à une augmentation de la mortalité hospitalière chez les patients adultes traumatisés.

Commentaire :  L'hypothermie (< 36,0  C) et l'hyperthermie (≥ 38,0  C) sont associées à la mortalité hospitalière.

Current practice and evolving concepts in septic shock resuscitation.
Bakker J, Kattan E, Annane D, Castro R, Cecconi M, De Backer D, Dubin A, Evans L, Gong MN, Hamzaoui O, Ince C, Levy B, Monnet X, Tascón GAO, Ostermann M, Pinsky MR, Russell JA, Saugel B, Scheeren TWL, Teboul JL, Baron AV, Vincent JL, Zampieri FG, Hernandez G. | Intensive Care Med. 2022 Feb;48(2):148-163
DOI: https://doi.org/10.1007/s00134-021-06595-9
Keywords: Fluid resuscitation; Fluids; Intensive care; Sepsis; Treatment; Vasoactive drugs.

Narrative Review

Editorial : Clinical and pathophysiological understanding of septic shock has progressed exponentially in the previous decades, translating into a steady decrease in septic shock-related morbidity and mortality. Even though large randomized, controlled trials have addressed fundamental aspects of septic shock resuscitation, many questions still exist. In this review, we will describe the current standards of septic shock resuscitation, but the emphasis will be placed on evolving concepts in different domains such as clinical resuscitation targets, adequate use of fluids and vasoactive drugs, refractory shock, and the use of extracorporeal therapies. Multiple research opportunities remain open, and collaborative endeavors should be performed to fill in these gaps.

Conclusion : In this review, we have discussed current practice and evolving concepts in septic shock resuscitation. While the pillars of hemodynamic resuscitation have not changed in general, there is new information on how to optimize fluid administration and the use of vasoactive drugs. The lack of solid evidence in all fields is of growing concern, and this precludes to make strong recommendations for most interventions.
A broad research agenda focusing on individualization and phenotyping of septic shock patients using combined efforts of the different excellence groups is, therefore, imperative.

Conclusion (proposition de traduction) : Dans cette revue, nous avons discuté des pratiques actuelles et des concepts en évolution dans la réanimation par choc septique. Alors que les piliers de la réanimation hémodynamique n'ont pas changé en général, il existe de nouvelles informations sur la façon d'optimiser l'administration de liquides de remlissage et l'utilisation de médicaments vasopresseurs. Le manque de preuves solides dans tous les domaines est de plus en plus préoccupant, ce qui empêche de formuler des recommandations solides pour la plupart des interventions.
Un vaste programme de recherche axé sur l'individualisation et le phénotypage des patients en choc septique en utilisant les efforts combinés des différents groupes d'excellence est donc impératif.

Feasibility of conservative fluid administration and deresuscitation compared with usual care in critical illness: the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomised clinical trial.
Silversides JA, McMullan R, Emerson LM, Bradbury I, Bannard-Smith J, Szakmany T, Trinder J, Rostron AJ, Johnston P, Ferguson AJ, Boyle AJ, Blackwood B, Marshall JC, McAuley DF. | Intensive Care Med. 2022 Feb;48(2):190-200
DOI: https://doi.org/10.1007/s00134-021-06596-8
Keywords: Critical illness; Deresuscitation; Diuretics; Fluid therapy; Infusions; Intravenous; Oedema; Water–electrolyte balance.

Original

Introduction : Fluid overload is common in critical illness and is associated with mortality. This study investigated the feasibility of a randomised trial comparing conservative fluid administration and deresuscitation (active removal of accumulated fluid using diuretics or ultrafiltration) with usual care in critical illness.

Méthode : Open-label, parallel-group, allocation-concealed randomised clinical feasibility trial. Mechanically ventilated adult patients expected to require critical care beyond the next calendar day were enrolled between 24 and 48 h following admission to the intensive care unit (ICU). Patients were randomised to either a 2-stage fluid strategy comprising conservative fluid administration and, if fluid overload was present, active deresuscitation, or usual care. The primary endpoint was fluid balance in the 24 h up to the start of study day 3. Secondary endpoints included cumulative fluid balance, mortality, and duration of mechanical ventilation.

Résultats : One hundred and eighty patients were randomised. After withdrawal of 1 patient, 89 patients assigned to the intervention were compared with 90 patients assigned to the usual care group. The mean plus standard deviation (SD) 24-h fluid balance up to study day 3 was lower in the intervention group (- 840 ± 1746 mL) than the usual care group (+ 130 ± 1401 mL; P < 0.01). Cumulative fluid balance was lower in the intervention group at days 3 and 5. Overall, clinical outcomes did not differ significantly between the two groups, although the point estimate for 30-day mortality favoured the usual care group [intervention arm: 19 of 90 (21.6%) versus usual care: 14 of 89 (15.6%), P = 0.32]. Baseline imbalances between groups and lack of statistical power limit interpretation of clinical outcomes.

Conclusion : A strategy of conservative fluid administration and active deresuscitation is feasible, reduces fluid balance compared with usual care, and may cause benefit or harm. In view of wide variations in contemporary clinical practice, large, adequately powered trials investigating the clinical effectiveness of conservative fluid strategies in critically ill patients are warranted.

Conclusion (proposition de traduction) : Une stratégie d'administration conservatrice de fluides et de déréanimation active est réalisable, réduit l'équilibre hydrique par rapport aux soins habituels et peut être bénéfique ou néfaste. Compte tenu des grandes variations dans la pratique clinique contemporaine, des essais de grande envergure et de puissance adéquate étudiant l'efficacité clinique des stratégies liquidiennes conservatrices chez les patients gravement malades sont justifiés.

Emerging evidence for non-pharmacologic interventions in reducing the burden of respiratory illnesses.
Khanolkar RA, Trajkovski A, Agarwal A, Pauls MA, Lang ES. | Intern Emerg Med. 2022 Feb 4:1–6
DOI: https://doi.org/10.1007/s11739-022-02932-y  | Télécharger l'article au format  
Keywords: Asthma; COVID-19 pandemic; Chronic obstructive pulmonary disease (COPD); Hospitalizations; Influenza; Masking; Non-pharmacologic interventions (NPIs); Physical distancing; Pneumonia; Respiratory illness; Viral triggers.

IM - REVIEW

Editorial : The global pandemic caused by SARS-CoV-2 (COVID-19) has led to significant morbidity and mortality, and unprecedented economic and health system disruption. Non-pharmacologic interventions (NPIs) such as masking and physical distancing have formed the underpinnings of COVID-19 infection control strategies. Concomitantly, numerous jurisdictions have seen a decrease in hospitalizations for non-COVID-19 respiratory illnesses (NCRIs) such as asthma, community-acquired pneumonia, influenza, and chronic obstructive pulmonary disease relative to pre-pandemic levels. These associations give rise to a number of testable hypotheses regarding the efficacy of NPIs in reducing the substantial burden of NCRIs. Here, we review emerging perspectives on the role of NPIs in NCRI prevention with the ultimate goal of informing future research and public policy development as we move into what may be the endemic phase of the COVID-19 pandemic.

Conclusion : In this article, we have presented evidence that the measures instituted globally to control the spread of COVID-19 have unexpectedly contributed to marked and sustained reductions in hospitalizations for non-COVID-19 respiratory illnesses. Additionally, we have laid out next steps that could help us better understand which NPIs have played the most significant roles in the observed reduction of non-COVID-19 respiratory diseases. It remains unclear whether these benefits were achieved with masking interventions alone or are also reliant on more stringent physical distancing measures related to the closure of establishments and restrictions on social gatherings and travel. Evaluation of which specific measures carry the highest yield, under what conditions they are most effective, and their potential for collateral adverse effects, will be crucial in guiding policy development. Due to the limitations of the current evidence base, including the lack of studies evaluating the effect of NPIs on mortality-related outcomes, the consideration of patient preferences will also be important in implementation.
Given reasonable evidence from the COVID-19 pandemic, policy-makers should consider empiric public health measures for individuals at high-risk of contracting viral respiratory illnesses or suffering from adverse outcomes as a result. Such policies will likely face barriers to widespread adoption including hesitancy to embracing masking and other NPIs on a voluntary basis, the association of these measures with repressive lockdown policies, and skepticism regarding their efficacy. While the use of NPIs is now variable and may only transiently persist in the early post-pandemic period, it is also possible that people may continue to use them on a more routine basis as has been observed in many Asian countries.
Nonetheless, the recommendations highlighted in this analysis provide a basis for a research agenda which will aid in more conclusively determining the relative risk and benefits of selective NPI implementation on the burden of respiratory illnesses and their sequalae. We hope that relevant stakeholders will engage in elucidating the veracity and relevance of what may be the key learnings of the global COVID-19 pandemic.

Conclusion (proposition de traduction) : Dans cet article, nous avons présenté des preuves que les mesures instituées à l'échelle mondiale pour contrôler la propagation du COVID-19 ont contribué de manière inattendue à des réductions marquées et soutenues des hospitalisations pour des maladies respiratoires non liées au COVID-19. De plus, nous avons défini les prochaines étapes qui pourraient nous aider à mieux comprendre quels NPI ont joué les rôles les plus importants dans la réduction observée des maladies respiratoires non COVID-19. On ne sait toujours pas si ces avantages ont été obtenus uniquement avec des interventions de masquage ou s'ils dépendent également de mesures de distanciation physique plus strictes liées à la fermeture des établissements et aux restrictions sur les rassemblements sociaux et les déplacements. L'évaluation des mesures spécifiques qui ont le meilleur rendement, dans quelles conditions elles sont les plus efficaces et leur potentiel d'effets négatifs collatéraux sera cruciale pour guider l'élaboration des politiques. En raison des limites de la base de données actuelle, y compris le manque d'études évaluant l'effet des NPI sur les résultats liés à la mortalité, la prise en compte des préférences des patients sera également importante dans la mise en œuvre.
Compte tenu des preuves raisonnables de la pandémie de COVID-19, les décideurs politiques devraient envisager des mesures de santé publique empiriques pour les personnes à haut risque de contracter des maladies respiratoires virales ou de souffrir d'effets indésirables en conséquence. De telles politiques seront probablement confrontées à des obstacles à une adoption généralisée, notamment l'hésitation à adopter le masquage et d'autres NPI sur une base volontaire, l'association de ces mesures avec des politiques de verrouillage répressives et le scepticisme quant à leur efficacité. Alors que l'utilisation des NPI est désormais variable et ne peut persister que de manière transitoire au début de la période post-pandémique, il est également possible que les gens continuent à les utiliser de manière plus régulière, comme cela a été observé dans de nombreux pays asiatiques.
Néanmoins, les recommandations mises en évidence dans cette analyse fournissent une base pour un programme de recherche qui aidera à déterminer de manière plus concluante le risque relatif et les avantages de la mise en œuvre sélective des NPI sur le fardeau des maladies respiratoires et de leurs séquelles…

SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia.
Cosentini R, Groff P, Brambilla AM, Camajori Todeschini R, Gangitano G, Ingrassia S, Marino R, Nori F, Pagnozzi F, Panero F, Ferrari R; SIMEU NIV Group collaborators. | Intern Emerg Med. 2022 Feb 1:1–15
DOI: https://doi.org/10.1007/s11739-021-02906-6  | Télécharger l'article au format  
Keywords: COVID-19; CPAP; HFNCO; NIPPV; NIV; Non-invasive respiratory support.

EM - ORIGINAL

Editorial : The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience.

Conclusion : Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.

Conclusion (proposition de traduction) : La justification, la littérature, les trucs et astuces, les ressources, les risques et les résultats attendus, ainsi que l'interaction avec le patient seront discutés pour chacune des techniques respiratoires non invasives croissantes : oxygène standard, HFNCO, CPAP, NIPPV et auto-repositionnement éveillé. Le dernier chapitre décrit notre approche suggérée pour le patient défaillant.

Commentaire :  Non-invasive respiratory support escalation in COVID19 pneumonia

Performance of non-invasive respiratory function indices in predicting clinical outcomes in patients hospitalized for COVID-19 pneumonia in medical and sub-intensive wards: a retrospective cohort study.
Cattazzo F, Inglese F, Dalbeni A, Piano S, Pengo MF, Montagnana M, Dell'Atti D, Soliani F, Cascella A, Vicini S, Gambino C, Minuz P, Vettor R, Parati G, Angeli P, Fava C; COVID Internal Medicine Team. | Intern Emerg Med. 2022 Jan 28:1–10
DOI: https://doi.org/10.1007/s11739-021-02922-6  | Télécharger l'article au format  
Keywords: COVID-19 pneumonia; Clinical outcomes; Non-invasive respiratory function indices.

IM - ORIGINAL

Editorial : Coronavirus disease 2019 (COVID-19) is a newly recognized infectious disease which can lead to acute respiratory distress syndrome requiring ventilatory support and intensive care unit admission. The aim of our study is to evaluate the performance of two non-invasive respiratory function indices (the ROX index and the SatO2/FiO2 ratio), as compared to the traditional PaO2/FiO2 ratio, in predicting a clinically relevant composite outcome (death or intubation) in hospitalized patients for COVID-19 pneumonia. Four hospital centers in Northern Italy conducted an observational retrospective cohort study during the first wave of COVID-19 pandemic. Four hundred and fifty-six patients with COVID-19 pneumonia admitted to medical or sub-intensive wards were enrolled. Clinical, laboratory, and respiratory parameters, for the calculation of different indices, were measured at hospital admission. In medical wards (Verona and Padua) the PaO2/FiO2 ratio, ROX index and SatO2/FiO2 ratio were able to predict intubation or death with good accuracy (AUROC for the PaO2/FiO2 ratio, ROX index and SatO2/FiO2 ratio of 75%, 75% and 74%, respectively). Regarding sub-intensive wards (Milan and Mantua), none of the three respiratory function indices was significantly associated with the composite outcome.

Conclusion : In patients admitted to medical wards for COVID-19 pneumonia, the ROX index and the SatO₂/FiO₂ ratio demonstrated not only good performance in predicting intubation or death, but their accuracy was comparable to that of the PaO₂/FiO₂ ratio. In this setting, where repeated arterial blood gas tests are not always feasible, they could be considered a reliable alternative to the invasive PaO₂/FiO₂ ratio.

Conclusion (proposition de traduction) : Chez les patients admis dans les services médicaux pour une pneumonie à la COVID-19, l'indice ROX et le rapport SatO₂/FiO₂ ont démontré non seulement de bonnes performances pour prédire l'intubation ou le décès, mais leur précision était comparable à celle du rapport PaO₂/FiO₂. Dans ce contexte, où des tests répétés des gaz du sang artériel ne sont pas toujours réalisables, ils pourraient être considérés comme une alternative fiable au rapport invasif PaO2/FiO2.

Investigation of the optimal method of oxygen administration with simultaneous use of a surgical mask: a randomized control study.
Matsui Y, Takazawa T, Takemae A, Murooka Y, Kanamoto M, Saito S. | J Anesth. 2022 Feb;36(1):26-31
DOI: https://doi.org/10.1007/s00540-021-02998-6  | Télécharger l'article au format  
Keywords: COVID-19; Oxygen administration; Oxygen reserve index; Surgical mask.

Original Article

Introduction : From the perspective of infection prevention during the Coronavirus disease 2019 (COVID-19) pandemic, a recommendation was made to use surgical masks after extubation in patients in the operating room. For compliance with this recommendation, anesthesiologists need to administer oxygen to the patient with an oxygen mask over the surgical mask. However, no studies have investigated whether this method allows good maintenance of oxygenation in patients. This study aimed to investigate which method of oxygen administration lends itself best to use with a surgical mask in terms of oxygenation.

Méthode : We administered oxygen to the study subjects using all the following three methods in random order: an oxygen mask over or under a surgical mask and a nasal cannula under the surgical mask. Oxygenation was assessed using the oxygen reserve index (ORi) and end-tidal oxygen concentration (EtO₂).

Résultats : This study included 24 healthy volunteers. ORi values with administration of oxygen were higher in the order of a nasal cannula under the surgical mask, an oxygen mask under the surgical mask, and an oxygen mask over the surgical mask, with median values of 0.50, 0.48, and 0.43, respectively, and statistically significant differences between all groups (P < 0.001). EtO₂ values were in the same order as ORi, with median values of 33.0%, 31.0%, and 25%, respectively, and statistically significant differences between all groups (P < 0.001).

Conclusion : Wearing a surgical mask over the nasal cannula during oxygen administration is beneficial for oxygenation and might help prevent aerosol dispersal.

Conclusion (proposition de traduction) : Le port d'un masque chirurgical sur les lunettes nasales pendant la supplémentation en oxygène est bénéfique pour l'oxygénation et pourrait aider à prévenir la dispersion des aérosols.

Commentaire :  Les trois différentes méthodes de supplémentation en oxygène testées.
Image montrant le port d'un masque à oxygène sur (a) et sous (b) le masque chirurgical et le port d'une canule nasale sous le masque chirurgical (c). Le sujet tenait un tube de prélèvement de gaz dans sa bouche

Steroid treatment in patients with acute respiratory distress syndrome: a systematic review and network meta-analysis.
Yoshihiro S, Hongo T, Ohki S, Kaneko T, Ishikawa J, Ihara S, Taito S, Sakaguchi M, Yatabe T. | J Anesth. 2022 Feb;36(1):107-121
DOI: https://doi.org/10.1007/s00540-021-03016-5  | Télécharger l'article au format  
Keywords: Critical care; Network meta-analysis; Respiratory insufficiency; Steroids; Systematic review.

Original Article

Introduction : Although the most recent systematic review and meta-analyses on acute respiratory distress syndrome (ARDS) have shown that the use of steroids decreases mortality in adult patients, its benefits and risks may differ depending on the type and dosage of the steroid. Therefore, we conducted a network meta-analysis (NMA) to compare the differences in the efficacy among different doses and types of steroids.

Méthode : We searched MEDLINE, CENTRAL, ICHUSHI, ClinicalTrials.gov, and WHO ICTRP databases from the earliest records to March 2021 for randomized control trials, which compared steroids with placebo or conventional therapy for ARDS. Using the random-effects model, we compared various categories of steroids (high-dose methylprednisolone, low-dose methylprednisolone, hydrocortisone, dexamethasone, and no steroid) concerning hospital mortality, incidence of infection, and ventilator-free days (VFD).

Résultats : We analyzed nine studies involving adult patients (n = 1212). Although there were no significant differences between the groups in terms of the mortality and incidence of infection, the number of VFD were greater when using low-dose methylprednisolone than when not using any steroids (Mean difference: 6.06; 95% confidence intervals: [2.5, 10.5]). Moreover, the rank probability showed that low-dose methylprednisolone might be the optimal treatment, whereas using no steroid or high-dose methylprednisolone may be inferior to other treatments in terms of mortality, infection, and VFD.

Conclusion : This NMA suggested that the effect of steroids on the outcome in patients with ARDS might depend on the type of the steroid drug administered. Moreover, further studies are needed to identify the optimal type and dosage.

Conclusion (proposition de traduction) : Cette méta-analyse en réseau a suggéré que l'effet des corticoïdes sur les résultats chez les patients atteints de SDRA pourrait dépendre du type de corticoïde administré. De plus, d'autres études sont nécessaires pour identifier le type et le dosage optimaux.

Higher PEEP versus lower PEEP strategies for patients in ICU without acute respiratory distress syndrome: A systematic review and meta-analysis.
Yi H, Li X, Mao Z, Liu C, Hu X, Song R, Qi S, Zhou F. | J Crit Care. 2022 Feb;67:72-78
DOI: https://doi.org/10.1016/j.jcrc.2021.09.026  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; Hypoxemia; Intensive care unit; Mechanical ventilation; Positive end-expiratory pressure.

COVID-19

Introduction : To evaluate the effects of high and low levels of PEEP on ICU patients without ARDS.

Méthode : We searched public databases (including PubMed, EMBASE, Cochrane Library and Clinicaltrial.gov). The Cochrane Risk of Bias Assessment tool was used to evaluate the quality of the included studies.

Résultats : We included 2307 patients from 24 trials. Although no significant difference was found between high and low PEEP applications in in-hospital mortality (risk ratio[RR] 0.98, 95% confidence interval[CI] [0.81, 1.19], P = 0.87), high PEEP indeed decreased the incidence of ARDS, hypoxemia, and increased the level of PaO₂/FIO₂. In addition, although the overall results did not reveal any advantages of high PEEP in terms of secondary outcomes regarding 28-day mortality, the duration of ventilation, atelectasis, pulmonary barotrauma, hypotension, and so forth, the subgroup analysis concerning the level of low PEEP (ZEEP or not) and patient type (postoperative or medical ones) yielded different results. The TSA results suggested that more RCTs are needed.

Conclusion : Although ventilation with high PEEP in ICU patients without ARDS may not reduce in-hospital mortality, the decreased incidences of ARDS and hypoxemia and the improvement in PaO₂/FIO₂ were found in the high PEEP arm.

Conclusion (proposition de traduction) : Bien que la ventilation avec une PEP élevée chez les patients en soins intensifs sans SDRA puisse ne pas réduire la mortalité hospitalière, la diminution de l'incidence du SDRA et de l'hypoxémie et l'amélioration de la PaO₂/FIO₂ ont été observées dans le bras PEP élevée.

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological statu.
Bedford JP, Johnson A, Redfern O, Gerry S, Doidge J, Harrison D, Rajappan K, Rowan K, Young JD, Mouncey P, Watkinson PJ. | J Crit Care. 2022 Feb;67:149-156
DOI: https://doi.org/10.1016/j.jcrc.2021.11.005  | Télécharger l'article au format  
Keywords: Arrhythmia; Atrial fibrillation; Critical illness; Intensive care; Management.

Circulation

Introduction : New-onset atrial fibrillation (NOAF) is common in patients on an intensive care unit (ICU). Evidence guiding treatments is limited, though recent reports suggest beta blocker (BB) therapy is associated with reduced mortality.

Méthode : We conducted a multicentre cohort study of adult patients admitted to 3 ICUs in the UK and 5 ICUs in the USA. We analysed the haemodynamic changes associated with NOAF. We analysed rate control, rhythm control, and hospital mortality associated with common NOAF treatments. We balanced admission and post-NOAF, pre-treatment covariates across treatment groups.

Résultats : NOAF was followed by a systolic blood pressure reduction of 5 mmHg (p < 0.001). After adjustment, digoxin therapy was associated with inferior rate control versus amiodarone (adjusted hazard ratio (aHR) 0.56, [95% CI 0.34-0.92]). Calcium channel blocker (CCB) therapy was associated with inferior rhythm control versus amiodarone (aHR 0.59 (0.37-0.92). No difference was detected between BBs and amiodarone in rate control (aHR 1.15 [0.91-1.46]), rhythm control (aHR 0.85, [0.69-1.05]), or hospital mortality (aHR 1.03 [0.53-2.03]).

Conclusion : NOAF in ICU patients is followed by decreases in blood pressure. BBs and amiodarone are associated with similar cardiovascular control and appear superior to digoxin and CCBs. Accounting for key confounders removes previously reported mortality benefits associated with BB treatment.

Conclusion (proposition de traduction) : La fibrillation auriculaire d'apparition récente chez les patients en soins intensifs est suivie d'une diminution de la pression artérielle. Les bêta-bloquants et l'amiodarone sont associés à un contrôle cardiovasculaire similaire et semblent supérieurs à la digoxine et aux inhibiteurs calciques. La prise en compte des principaux facteurs de confusion supprime les avantages de mortalité précédemment signalés associés au traitement par bêta-bloquant.

Superficial placement of endotracheal tubes associated with unplanned extubation: A case-control study.
Ju TR, Wang E, Castaneda C, Rathod A, Abe O. | J Crit Care. 2022 Feb;67:39-43
DOI: https://doi.org/10.1016/j.jcrc.2021.09.010  | Télécharger l'article au format  
Keywords: Airway extubation; Airway management; Complications; Extubation; Tracheal extubation.

Lung

Introduction : Unplanned extubations (UEs) refer to the inadvertent removal of endotracheal tubes (ETTs). Superficially placed ETTs anecdotally increases the risk of UEs. This study aims to assess the impact of ETT position as well as other factors that could be associated with risk of UEs.

Méthode : A retrospective case-control study was conducted at NewYork-Presbyterian Queens Hospital from January 2017 to February 2020. All adults admitted to intensive care units (ICUs) who received mechanical ventilation (MV) through ETTs were screened to identify UEs. For each case with UE, two controls with planned extubation were identified. A multivariate logistic regression was conducted to identify risk factors associated with UEs.

Résultats : 1100 patients received MV through ETTs during the time period. The incidence of UE was 4.9%. 53 patients with UEs and 106 patients with planned extubation were included for statistical analysis. Overall, patients with UE had higher in-hospital mortality rates (26.4% versus 11.3%, P = 0.02) and reintubation rates (28.3% versus 6.6%, P < 0.001). Within the UE group, patients who required reintubation had significantly higher in-hospital mortality rates than those who did not require reintubation (53.3% versus 15.8%, P = 0.005). Multivariate logistic regression showed higher APACHE II scores (Odds ratios (OR) 1.07; 95% Confidence interval (CI), 1 to 1.13), distance of ETT tips to carina ≥6 cm (OR 6.41; 95% CI, 1.1 to 37.3), physical restraint use (OR 2.98; 95% CI, 1.28 to 6.95) and continuous infusions of sedatives and/or analgesics (OR 10.72, 95% CI, 4.19 to 27.43) were associated with UE.

Conclusion : UE and the need for reintubation is associated with worse outcomes. Distance of ETT tips to carina ≥6 cm may be associated with higher risks of UE. Further prospective studies are needed to establish the optimal position of ETT to prevent UE.

Conclusion (proposition de traduction) : L'extubation accidentelle et la nécessité d'une réintubation sont associées à de moins bons résultats. La distance entre les extrémités des sondes endotrachéales et la carène ≥ 6 cm peut être associée à des risques plus élevés d'extubation non planifiée. D'autres études prospectives sont nécessaires pour établir la position optimale du tube endotrachéal afin d'éviter une extubation accidentelle.

Efficacy of combination triple therapy with vasopressin, steroid, and epinephrine in cardiac arrest: a systematic review and meta-analysis of randomized-controlled trials.
Saghafi F, Bagheri N, Salehi-Abargouei A, Sahebnasagh A. | J Intensive Care. 2022 Feb 2;10(1):5
DOI: https://doi.org/10.1186/s40560-022-00597-5  | Télécharger l'article au format  
Keywords: Cardiac arrest; Corticosteroid; Epinephrine; In-hospital cardiac arrest; Meta-analysis; Return of spontaneous circulation; Survival; Systematic review; Triple therapy; Vasopressin.

Research

Introduction : This study investigated whether combination therapy with vasopressin, steroid, and epinephrine (VSE) improves in-hospital survival and return of spontaneous circulation (ROSC) during and after resuscitation in-hospital cardiac arrest (CA).

Méthode : Various databases were explored from inception until October 2021 for relevant published clinical trials and cohort studies.

Résultats : Three clinical trials were included. Pooled analysis suggested that VSE was significantly associated with increased ROSC in patients with in-hospital CA (IHCA) (odds ratio (OR): 2.281, 95% confidence interval (CI): 1.304-3.989, P value = 0.004). Meta-analysis of two studies (368 patients) demonstrated a significant difference in the reduction of mean arterial pressure (MAP) during and 15-20 min after cardiopulmonary resuscitation (standardized mean difference (SMD): 1.069, 95% CI: 0.851-1.288, P value < 0.001), renal failure free days (SMD = 0.590; 95% CI: 0.312-0.869 days; P value < 0.001), and coagulation failure free days (SMD = 0.403; 95% CI: 0.128-0.679, P value = 0.004). However, no significant difference was observed for survival-to-discharge ratio (OR: 2.082, 95% CI: 0.638-6.796, P value = 0.225) and ventilator free days (SMD = 0.201, 95% CI: - 0.677, 1.079 days; P value = 0.838).

Conclusion : VSE combination therapy during and after IHCA may have beneficial effects in terms of the ROSC, renal and circulatory failure free days, and MAP.

Conclusion (proposition de traduction) : L'association de vasopressine, de stéroïdes et d'épinéphrine pendant et après un arrêt cardiaque à l'hôpital peut avoir des effets bénéfiques en termes de retour à une activité circulatoire spontanée, de jours sans insuffisance rénale et circulatoire et de la pression artérielle moyenne.

Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19: The RECOVERY-RS Randomized Clinical Trial.
Perkins GD, Ji C, Connolly BA, Couper K, Lall R, Baillie JK, Bradley JM, Dark P, Dave C, De Soyza A, Dennis AV, Devrell A, Fairbairn S, Ghani H, Gorman EA, Green CA, Hart N, Hee SW, Kimbley Z, Madathil S, McGowan N, Messer B, Naisbitt J, Norman C, Parekh D, Parkin EM, Patel J, Regan SE, Ross C, Rostron AJ, Saim M, Simonds AK, Skilton E, Stallard N, Steiner M, Vancheeswaran R, Yeung J, McAuley DF; RECOVERY-RS Collaborators. | JAMA. 2022 Feb 8;327(6):546-558
DOI: https://doi.org/10.1001/jama.2022.0028
Keywords: Aucun

Original Investigation

Introduction : Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies.
Objective: To determine whether either CPAP or HFNO, compared with conventional oxygen therapy, improves clinical outcomes in hospitalized patients with COVID-19-related acute hypoxemic respiratory failure.

Méthode : A parallel group, adaptive, randomized clinical trial of 1273 hospitalized adults with COVID-19-related acute hypoxemic respiratory failure. The trial was conducted between April 6, 2020, and May 3, 2021, across 48 acute care hospitals in the UK and Jersey. Final follow-up occurred on June 20, 2021.
Interventions: Adult patients were randomized to receive CPAP (n = 380), HFNO (n = 418), or conventional oxygen therapy (n = 475).
Main outcomes and measures: The primary outcome was a composite of tracheal intubation or mortality within 30 days.

Résultats : The trial was stopped prematurely due to declining COVID-19 case numbers in the UK and the end of the funded recruitment period. Of the 1273 randomized patients (mean age, 57.4 [95% CI, 56.7 to 58.1] years; 66% male; 65% White race), primary outcome data were available for 1260. Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group, 11.5% in the HFNO group, and 23.6% in the conventional oxygen therapy group). The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, -8% [95% CI, -15% to -1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, -1% [95% CI, -8% to 6%], P = .83). Adverse events occurred in 34.2% (130/380) of participants in the CPAP group, 20.6% (86/418) in the HFNO group, and 13.9% (66/475) in the conventional oxygen therapy group.

Conclusion : Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy, and early study termination and crossover among the groups should be considered when interpreting the findings.

Conclusion (proposition de traduction) : Chez les patients présentant une insuffisance respiratoire hypoxémique aiguë due à la COVID-19, une stratégie initiale de CPAP a significativement réduit le risque d'intubation trachéale ou de mortalité par rapport à l'oxygénothérapie conventionnelle, mais il n'y avait pas de différence significative entre une stratégie initiale de HFNO par rapport à l'oxygénothérapie conventionnelle. L'étude peut avoir été sous-alimentée pour la comparaison de l'HFN par rapport à l'oxygénothérapie conventionnelle, et l'arrêt précoce de l'étude et le croisement entre les groupes doivent être pris en compte lors de l'interprétation des résultats.

Diagnosis and Treatment of Acute Coronary Syndromes: A Review.
Bhatt DL, Lopes RD, Harrington RA. | JAMA. 2022 Feb 15;327(7):662-675
DOI: https://doi.org/10.1001/jama.2022.0358
Keywords: Aucun

Review

Introduction : Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with ACS, including more than 1 million patients hospitalized in the US.

Discussion : Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS, although approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or, more commonly, in combination with chest pain. For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS). STEMI is caused by complete coronary artery occlusion and accounts for approximately 30% of ACS. ACS without significant ST-segment elevation on electrocardiography, termed NSTE-ACS, account for approximately 70% of ACS, are caused by partial or intermittent occlusion of the artery and are associated with ST-segment depressions (approximately 31%), T-wave inversions (approximately 12%), ST-segment depressions combined with T-wave inversions (16%), or neither (approximately 41%). When electrocardiography suggests STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7%. If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration), followed b

Conclusion : Each year, an estimated more than 7 million people are diagnosed with ACS worldwide. For patients with STEMI, coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI. For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death.

Conclusion (proposition de traduction) : Chaque année, on estime que plus de 7 millions de personnes sont diagnostiquées avec un syndrome coronarien aigu dans le monde. Pour les patients présentant un infarctus du myocarde avec élévation du segment ST, le cathétérisme coronarien et l'intervention coronarienne percutanée dans les 2 heures suivant la présentation réduisent la mortalité, le traitement fibrinolytique étant réservé aux patients n'ayant pas accès à une intervention coronarienne percutanée immédiate. Pour les patients à haut risque présentant des syndromes coronariens aigus sans élévation du segment ST sans contre-indications, une coronarographie invasive rapide suivie d'une revascularisation percutanée ou chirurgicale est associée à des taux de mortalité plus faibles.

Commentaire :  Diagnostic initial et prise en charge des syndromes coronariens aigus

Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase.
Kam W, Holmes DN, Hernandez AF, Saver JL, Fonarow GC, Smith EE, Bhatt DL, Schwamm LH, Reeves MJ, Matsouaka RA, Khan YM, Unverdorben M, Birmingham MC, Lyden PD, Asimos AW, Altschul D, Schoonover TL, Jumaa MA, Nomura JT, Suri MFK, Moore SA, Lafranchise EF, Olson D, Peterson ED, Xian Y. | JAMA. 2022 Feb 22;327(8):760-771
DOI: https://doi.org/10.1001/jama.2022.0948
Keywords: Aucun

Original Investigation

Introduction : Current guidelines recommend against use of intravenous alteplase in patients with acute ischemic stroke who are taking non-vitamin K antagonist oral anticoagulants (NOACs).
Objective: To evaluate the safety and functional outcomes of intravenous alteplase among patients who were taking NOACs prior to stroke and compare outcomes with patients who were not taking long-term anticoagulants.

Méthode : A retrospective cohort study of 163 038 patients with acute ischemic stroke either taking NOACs or not taking anticoagulants prior to stroke and treated with intravenous alteplase within 4.5 hours of symptom onset at 1752 US hospitals participating in the Get With The Guidelines-Stroke program between April 2015 and March 2020, with complementary data from the Addressing Real-world Anticoagulant Management Issues in Stroke registry.
Exposures: Prestroke treatment with NOACs within 7 days prior to alteplase treatment.
Main outcomes and measures: The primary outcome was symptomatic intracranial hemorrhage occurring within 36 hours after intravenous alteplase administration. There were 4 secondary safety outcomes, including inpatient mortality, and 7 secondary functional outcomes assessed at hospital discharge, including the proportion of patients discharged home.

Résultats : Of 163 038 patients treated with intravenous alteplase (median age, 70 [IQR, 59 to 81] years; 49.1% women), 2207 (1.4%) were taking NOACs and 160 831 (98.6%) were not taking anticoagulants prior to their stroke. Patients taking NOACs were older (median age, 75 [IQR, 64 to 82] years vs 70 [IQR, 58 to 81] years for those not taking anticoagulants), had a higher prevalence of cardiovascular comorbidities, and experienced more severe strokes (median National Institutes of Health Stroke Scale score, 10 [IQR, 5 to 17] vs 7 [IQR, 4 to 14]) (all standardized differences >10). The unadjusted rate of symptomatic intracranial hemorrhage was 3.7% (95% CI, 2.9% to 4.5%) for patients taking NOACs vs 3.2% (95% CI, 3.1% to 3.3%) for patients not taking anticoagulants. After adjusting for baseline clinical factors, the risk of symptomatic intracranial hemorrhage was not significantly different between groups (adjusted odds ratio [OR], 0.88 [95% CI, 0.70 to 1.10]; adjusted risk difference [RD], -0.51% [95% CI, -1.36% to 0.34%]). There were no significant differences in the secondary safety outcomes, including inpatient mortality (6.3% for patients taking NOACs vs 4.9% for patients not taking anticoagulants; adjusted OR, 0.84 [95% CI, 0.69 to 1.01]; adjusted RD, -1.20% [95% CI, -2.39% to -0%]). Of the secondary functional outcomes, 4 of 7 showed significant differences in favor of the NOAC group after adjustment, including the proportion of patients discharged home (45.9% vs 53.6% for patients not taking anticoagulants; adjusted OR, 1.17 [95% CI, 1.06 to 1.29]; adjusted RD, 3.84% [95% CI, 1.46% to 6.22%]).

Conclusion : Among patients with acute ischemic stroke treated with intravenous alteplase, use of NOACs within the preceding 7 days, compared with no use of anticoagulants, was not associated with a significantly increased risk of intracranial hemorrhage.

Conclusion (proposition de traduction) : Parmi les patients ayant subi un AVC ischémique aigu traités par alteplase intraveineux, l'utilisation d'un AOD au cours des 7 jours précédents, par rapport à l'absence d'utilisation d'anticoagulants, n'a pas été associée à un risque significativement accru d'hémorragie intracrânienne.

Clinical Outcomes in Patients With Delayed Hospitalization for Non–ST-Segment Elevation Myocardial Infarction.
Cha JJ, Bae S, Park DW, Park JH, Hong SJ, Park SM, Yu CW, Rha SW, Lim DS, Suh SY, Han SH, Woo SI, Lee NH, Choi D, Chae IH, Kim HS, Hong YJ, Ahn Y, Jeong MH, Ahn TH. | J Am Coll Cardiol. 2022 Feb 1;79(4):311-323
DOI: https://doi.org/10.1016/j.jacc.2021.11.019
Keywords: NSTEMI; all-cause mortality; door-to-catheter time; prehospital delay; symptom-to-door time.

ORIGINAL INVESTIGATION

Introduction : Recently, the number of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) has reduced, whereas increased mortality was reported. A plausible explanation for increased mortality was prehospital delay because of patients' reticence of their symptoms.

Méthode : The purpose of this study was to investigate the association between prehospital delay and clinical outcomes in patients with NSTEMI METHODS: Among 13,104 patients from the Korea-Acute-Myocardial-Infarction-Registry-National Institutes of Health, the authors evaluated 6,544 patients with NSTEMI. Study patients were categorized into 2 groups according to symptom-to-door (StD) time (<24 or ≥24 hours). The primary outcome was 3-year all-cause mortality, and the secondary outcome was 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure.

Résultats : Overall, 1,827 (27.9%) patients were classified into the StD time ≥24 hours group. The StD time ≥24 hours group had higher all-cause mortality (17.0% vs 10.5%; P < 0.001) and incidence of secondary outcomes (23.3% vs 15.7%; P < 0.001) than the StD time <24 hours group. The higher all-cause mortality in the StD time ≥24 hours group was observed consistently in the subgroup analysis regarding age, sex, atypical chest pain, dyspnea, Q-wave in electrocardiogram, use of emergency medical services, hypertension, diabetes mellitus, chronic kidney disease, left ventricle dysfunction, TIMI (Thrombolysis In Myocardial Infarction) flow, and the GRACE risk score. In the multivariable analysis, independent predictors of prehospital delay were the elderly, women, nonspecific symptoms such as atypical chest pain or dyspnea, diabetes, and no use of emergency medical services.

Conclusion : Prehospital delay is associated with an increased risk of 3-year all-cause mortality in patients with NSTEMI.

Conclusion (proposition de traduction) : Le délai préhospitalier est associé à un risque accru de mortalité toutes causes confondues à 3 ans chez les patients présentant un infarctus du myocarde sans élévation du segment ST.

Commentaire : • Cerrato E, Forno D, Ferro S, Chinaglia A. Characteristics, in-hospital management and outcome of late acute ST-elevation myocardial infarction presenters. J Cardiovasc Med (Hagerstown). 2017 Aug;18(8):567-571  .

Pour mémoire :
• Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM; ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42(14):1289-1367  .
• Jneid H, Addison D, Bhatt DL, Fonarow GC, Gokak S, Grady KL, Green LA, Heidenreich PA, Ho PM, Jurgens CY, King ML, Kumbhani DJ, Pancholy S. 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2017 Oct 17;70(16):2048-2090  .

Ferreira D, Grelet T, Besch G. | Le Prat en Anesthésie Réanimation [Internet]. 2022;26(1):11–9
DOI: https://www.sciencedirect.com/science/article/pii/S1279796022000055
Keywords: Lung ultrasound; Intensive care unit; Acute respiratory failure; Diagnosis

Mise au point

Editorial : Depuis une vingtaine d’années, la simplicité d’utilisation et la disponibilité des échographes dans les services de réanimation, ont permis l’essor de l’échographie pleuro-pulmonaire (EPP). La sémiologie échographique basée sur l’analyse d‘artefacts pleuraux permet non seulement d’identifier un poumon normal mais aussi de diagnostiquer des pathologies pleurales (pneumothorax et épanchement pleural) et des atteintes du parenchyme pulmonaire (syndrome interstitiel, consolidation alvéolaire). L’exploration systématique des deux hémi-thorax par EPP permet de quantifier la sévérité de l’atteinte pleuro-pulmonaire. L’EPP a été intégrée dans des algorithmes diagnostiques de prise en charge de l’insuffisance respiratoire aiguë et de l’insuffisance circulatoire aiguë. L’impact de l’utilisation de l’EPP sur le pronostic des patients admis en réanimation reste cependant à déterminer.

Conclusion (proposition de traduction) : L’échographie pleuro-pulmonaire est un outil diagnostic simple, non invasif et rapide, parfaitement adapté à l’environnement des soins intensifs et de la réanimation. L’analyse dynamique des artefacts générés par le poumon sain et pathologique est simple et peut être rapidement maitrisée après une formation courte des équipes médicales. L’exploration systématique de la plèvre et du poumon lors de l’application d’arbres décisionnels spécifiques, permet d’établir un diagnostic étiologique et une prise en charge thérapeutique adaptées aux situations d’urgence vitales respiratoires et hémodynamiques rencontrées en soins intensifs et en réanimation. L’impact de l’utilisation de l’échographie pleuro-pulmonaire sur le pronostic des patients admis en soins intensifs et en réanimation reste cependant à déterminer.

Bruyère M | Le Prat en Anesthésie Réanimation [Internet]. 2022;26(1):28–35
DOI: https://www.sciencedirect.com/science/article/pii/S1279796022000018
Keywords: Obstetrics; Collapse; Cardiac arrest; ECMO; D-Dimers

Mise au point

Editorial : En obstétrique, les causes d’un état de choc sont les mêmes que celles des décès maternels : cardiopathie, embolies amniotique et pulmonaire, hémorragie du post-partum, sepsis (pour les plus fréquentes). La survie fœtale est directement dépendante de la qualité de la réanimation maternelle. L’appel à l’aide de l’ensemble de l’équipe d’obstétrique et de l’équipe d’assistance circulatoire doit être immédiat. Il est important de ne pas modifier la prise en charge d’un choc en raison de l’état de grossesse, et en dehors de certaines spécificités (extraction fœtale utile des que la taille de l’utérus atteint l’ombilic pour améliorer la réanimation maternelle en cas d’arrêt cardiaque, ECMO précoce surtout en cas d’embolie amniotique). Tous les traitements d’urgence et les algorithmes de réanimation appliqués en population générale sont utilisables dans la circonstance. Une des difficultés est de reconnaître la gravité de l’état chez des patientes jeunes dont la tolérance hémodynamique est prolongée. Les aides cognitives de la SFAR et les scores de gravité, comme le shock index, doivent être connus et utilisés. La communication et le travail d’équipe sont essentiels à la bonne conduite de la prise en charge, surtout en situation critique ou le stress dégrade les interactions entre les soignants.

Conclusion (proposition de traduction) : Il est important de ne pas modifier la prise en charge d’un choc en raison de l’état de grossesse, et en dehors de certaines spécificités (extraction fœtale pour améliorer la réanimation maternelle en cas d’AC, ECMO précoce sur- tout en cas d’embolie amniotique), tous les traitements d’urgence et les algorithmes de réanimation en population générale sont utilisables. La survie fœtale dépend de la réanimation maternelle. Une des difficultés est de recon- naître l’état de gravité chez des patientes jeunes avec une tolérance hémodynamique prolongée. Les aides cognitives de la SFAR, le shock index, les indications d’ECMO doivent être connus et utilisés. Enfin, se rappeler que la communica- tion et le travail d’équipe doivent être optimisés, surtout en situation critique ou le stress dégrade les interactions entre les soignants.

Touzani S, Houari N, El Bouazzaoui A, Boukatta B, Kanjaa N. | Le Prat en Anesthésie Réanimation [Internet]. 2022;26(1):36–45
DOI: https://www.sciencedirect.com/science/article/pii/S1279796021001601
Keywords: Severity; Acute cholangitis; ICU; Management

Mise au point

Editorial : La gravité de l’angiocholite aiguë est liée à la dissémination de l’infection avec risque de choc et de défaillances d’organes. À l’instar de la « Surviving Sepsis Campaign », des recommandations régulièrement mises à jour émanent du « Tokyo Guidelines Working Group ». Une approche interventionnelle précoce et multidisciplinaire est absolument essentielle à la survie. Les éléments clés sont une identification rapide des formes potentiellement graves, une thérapie antimicrobienne et une réanimation adéquates pour anticiper et/ou gérer les complications septiques, couplées à une décompression urgente pour rétablir le drainage biliaire. Cette mise au point physiopathologique et thérapeutique a pour objectifs d’améliorer le raisonnement clinique et de réduire la marge d’incertitude du praticien en proposant un protocole actualisé, contextualisé et personnalisable.

Conclusion (proposition de traduction) : L’angiocholite aigüe grave, en véritable urgence médico-chirurgicale, nécessite une collaboration étroite entre endoscopistes hépatobiliaires, radiologues, chirurgiens, microbiologistes et anesthésistes-réanimateurs. Le défi de tout clinicien est d’identifier les formes potentiellement graves afin d’initier dans les plus brefs délais une prise en charge thérapeutique adaptée. Le diagnostic précoce, les antibiotiques, la réanimation et le drainage biliaire mini-invasif ont amélioré les résultats pour les patients bien qu’il y ait encore des progrès à faire.

de Saint-Affrique D. | Med Droit. 2022 February;172:5)7
DOI: https://www.sciencedirect.com/science/article/pii/S1246739121000981
Keywords: Artificial intelligencePredictive medicineAlgorithmEthicsLawDiagnostic improvement

Droit civil – Exercice professionnel

Editorial : Conjuguer IA et médecine c’est parler de médecine du futur mais davantage encore d’amélioration de la qualité des soins. À ses champs d’applications: médecine prédictive, de précision, aide à la décision, prévention, chirurgie assistée par ordinateur, accompagnement robotisé des personnes âgées. répondent des préoccupations liées: la possibilité de conserver un contact humain pour le patient, l’explicabilité de l’algorithme, la collecte des données de santé, l’amélioration du système de soins. Les applications de l’IA permettant déjà d’améliorer la qualité des soins. Son déploiement au cœur de la médecine du futur est en évolution constante. Pour être acceptables et légitimes, les décisions de tout algorithme doivent pouvoir être comprises et donc expliquées. Seule une bonne compréhension des diagnostics et thérapies proposés par l’application de l’IA pourra en effet permettre aux médecins de discuter avec leurs patients et de leur exposer les alternatives possibles. Dans le cas inverse, le médecin risque d’écarter l’utilisation des algorithmes car il ne pourra pas justifier les décisions ce qui posera des problèmes en terme notamment de recherche de responsabilité.

Conclusion (proposition de traduction) : L’enjeu du futur sera certainement la maîtrise des développements de l’IA par les humains, ce que de docteur D. Gruzon appelle : « la garantie humaine ». Il s’agit ici de garantir une supervision humaine de toute utilisation du numérique en santé et de donner la possibilité à toute personne d’avoir une relation avec un soignant susceptible de lui transmettre l’ensemble des informations la concernant dans le cadre de son parcours de soins.
Cette supervision s’exprime à travers la nécessité de préserver la maîtrise finale du professionnel de santé, en interaction avec le patient, pour prendre des décisions appropriées en fonction de chaque situation spécifique, notamment pour permettre un deuxième avis médical en cas de doute sur la recommandation thérapeutique de l’algorithme.

The Safety of High-Dose Intranasal Fentanyl in the Pediatric Emergency Department.
Anderson T, Harrell C, Snider M, Kink R. | Pediatr Emerg Care. 2022 Feb 1;38(2):e447-e450
DOI: https://doi.org/10.1097/pec.0000000000002627
Keywords: Aucun

Original article

Introduction : This study aimed to determine if the use of intranasal (IN) fentanyl in the pediatric emergency department of 2 to 5 μg/kg at doses greater than 100 μg is associated with adverse events in pediatric patients.

Méthode : We performed a retrospective chart review of patients receiving IN fentanyl at an urban, tertiary care emergency department in Memphis, TN, from January 1, 2011, to December 31, 2017. All adverse events documented through the hospital's voluntary safety reporting system involving IN fentanyl were reviewed to determine patient outcomes.

Résultats : A total of 3205 patients received greater than 100 μg of IN fentanyl during the study period from 2011 to 2017. The average (SD) patient age was 13.7 (2.65) years, ranging from 5 to 18 years. The mean (SD) initial dose was 162 (30) μg ranging from 102 to 265 μg (2 doses were given greater than 200 μg in the study period). Initial average (SD) dose for weight was 2.62 (0.5) μg/kg. A total of 13 adverse events were documented, with only 3 occurring at doses greater than 100 μg. No patients required the reversal agent naloxone or invasive respiratory support.

Conclusion : To our knowledge, this is the first study using doses greater than 100 μg of IN fentanyl in a pediatric population. Our results indicate that fentanyl can be safely administered at doses of greater than 100 μg without any clinically significant adverse outcomes observed for 7 years of use. It is our hope that this information will increase utilization of IN fentanyl for treatment of acute pain in emergency departments and in the prehospital setting.

Conclusion (proposition de traduction) : À notre connaissance, il s'agit de la première étude utilisant des doses supérieures à 100 μg de fentanyl intranasal dans une population pédiatrique. Nos résultats indiquent que le fentanyl peut être administré en toute sécurité à des doses supérieures à 100 μg sans aucun effet indésirable cliniquement significatif observé après 7 ans d'utilisation. Nous espérons que ces informations permettront augmenter l'utilisation du fentanyl intranasal pour le traitement de la douleur aiguë dans les services d'urgence et en milieu préhospitalier.

Improving CPR Quality by Using a Real-Time Feedback Defibrillator During Pediatric Simulation Training.
Frazier M, Dewan M, Keller-Smith R, Shoemaker J, Stewart C, Tegtmeyer K. | Pediatr Emerg Care. 2022 Feb 1;38(2):e993-e996
DOI: https://doi.org/10.1097/pec.0000000000002370
Keywords: Aucun

Original article

Introduction : The aim of this study was to assess the effectiveness of a defibrillator with real-time feedback during code team training to improve adherence to the American Heart Association (AHA) resuscitation guidelines.

Méthode : This is a retrospective cohort study designed to compare pediatric resident adherence to the AHA cardiopulmonary resuscitation guidelines before and after use of real-time feedback defibrillator during code team training simulation. After institution of a real-time feedback defibrillator, first-year resident's adherence to the AHA guidelines for chest compression rate (CCR), fraction, and depth during code team training from January 2017 to December 2018 was analyzed. It was then compared with results of a previously published study from our institution that analyzed the CCR and fraction from January 2015 to January 2016, before the implementation of a defibrillator with real-time feedback.

Résultats : We compared 19 eligible session preintervention and 36 postintervention sessions. Chest compression rate and chest compression fraction (CCF) were assessed preintervention and postintervention. The depth of compression was only available postintervention. There was improvement in the proportion of code team training sessions with mean compression rate (74% preintervention vs 100% postintervention, P = 0.003) and mean CCF (79% vs 97%, P = 0.04) in adherence with the AHA guideline.

Conclusion : The use of real-time feedback defibrillators improved the adherence to the AHA cardiopulmonary resuscitation guidelines for CCF and CCR during pediatric resident simulation.

Conclusion (proposition de traduction) : L'utilisation de défibrillateurs avec rétroaction en temps réel a amélioré le respect des directives de réanimation cardiorespiratoire de l'AHA pour la fraction de compression thoracique et le taux de compression thoracique pendant la simulation des résidents pédiatriques.

Multisystem Inflammatory Syndrome in Children: Examining Emerging Data and Identifying Key Knowledge Gaps.
Sartori LF, Balamuth F.. | Pediatr Emerg Care. 2022 Feb 1;38(2):83-91
DOI: https://doi.org/10.1097/pec.0000000000002633
Keywords: MIS-C, COVID-19, Kawasaki Disease

CME Review Article

Editorial : Multisystem inflammatory syndrome in children (MIS-C) is a syndrome of abnormal immune response after severe acute respiratory syndrome coronavirus 2 infection that can result in organ dysfunction including severe cardiovascular compromise in children. Increased evidence supports a clinical and laboratory profile in MIS-C distinct from Kawasaki disease, with MIS-C typically occurring in older children and with more prominent gastrointestinal and neurologic symptoms, as well as increased inflammation, lymphopenia, and cardiac injury on laboratory testing. However, high-level evidence regarding best practices for treatment and long-term outcomes in MIS-C is limited.

Conclusion : Knowledge about MIS-C has increased exponentially since it first emerged on the scene in spring 2020 through twitter alerts and case reports, but key knowledge gaps still exist. Current evidence supports the hypothesis that MIS-C is a disease process similar to, yet distinct from, KD in its epidemiology, clinical presentation, and laboratory findings. Guideline-based protocols for diagnosis and treatment of MIS-C have been implemented, but better assessment of treatment protocols, particularly for refractory cases, warrant attention. Similarly, future research should seek to better understand underlying disease mechanisms, racial disparities in incidence and outcome, and long-term outcomes and best practices for survivors.

Conclusion (proposition de traduction) : Les connaissances sur le PIMS ont augmenté de façon exponentielle depuis sa première apparition sur la scène au printemps 2020 par le biais d'alertes Twitter et de rapports de cas, mais il existe toujours des lacunes dans les connaissances. Les preuves actuelles appuient l'hypothèse selon laquelle le PIMS est un processus pathologique similaire, mais distinct de la maladie de Kawasaki dans son épidémiologie, sa présentation clinique et ses résultats de laboratoire. Des protocoles basés sur des lignes directrices pour le diagnostic et le traitement du PIMS ont été mis en œuvre, mais une meilleure évaluation des protocoles de traitement, en particulier pour les cas réfractaires, mérite une attention particulière. De même, les recherches futures devraient chercher à mieux comprendre les mécanismes sous-jacents de la maladie, les disparités raciales dans l'incidence et les résultats, ainsi que les résultats à long terme et les meilleures pratiques pour les survivants.

Commentaire : Réponse rapide dans le cadre de la COVID-19 : Repérage et prise en charge du syndrome inflammatoire multi-systémique pédiatrique (PIMS) post-infectieux. Mise à jour le 1er février 2022. HAS  .

Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department.
Kovacich NJ, Nelson AC, McCormick T, Kaucher KA. | Pediatr Emerg Care. 2022 Feb 1;38(2):e540-e543
DOI: https://doi.org/10.1097/pec.0000000000002382
Keywords: Aucun

Original Research Article

Introduction : Bradycardia during rapid sequence intubation (RSI) is an uncommon but serious adverse effect encountered in pediatric intubations. Atropine has historically been used in the pediatric population as RSI premedication to prevent bradycardia, especially when using succinylcholine as an induction agent. The objective of this analysis was to identify the incidence of bradycardia with or without atropine use.

Méthode : This single-center, retrospective, observational case series reviewed pediatric patients up to 18 years old requiring intubation from January 1, 2015, to December 31, 2018. Bradycardia was determined by analyzing heart rates associated with time during and up to 5 minutes after intubation.

Résultats : A total of 62 patients were included. Three (4.8%) patients experienced a bradycardic event during intubation. A total of 15 (24.2%) patients received atropine for pretreatment of RSI. Incidence of bradycardia was similar between those who received atropine and those who did not. An increasing trend in atropine use was shown throughout the assessment period, yet only 18 (29%) patients met criteria for atropine pretreatment based on the 2015 Pediatric Advanced Life Support guideline recommendations for RSI.

Conclusion : Bradycardia incidence was low in pediatric patients undergoing RSI in our emergency department. Use of atropine or succinylcholine did not affect the incidence of bradycardia during pediatric intubation over this study period. Our results show a low incidence of bradycardia and support the 2015 Pediatric Advanced Life Support Guideline recommendation of limiting the use of atropine premedication in pediatric intubations.

Conclusion (proposition de traduction) : L'incidence de la bradycardie était faible chez les patients pédiatriques bénéficiant d'une intubation à séquence rapide dans notre service des urgences. L'utilisation d'atropine ou de succinylcholine n'a pas affecté l'incidence de la bradycardie pendant l'intubation pédiatrique au cours de cette période d'étude. Nos résultats montrent une faible incidence de bradycardie et soutiennent la recommandation 2015 « Pediatric Advanced Life Support Guideline » de limiter l'utilisation de la prémédication par l'atropine dans les intubations pédiatriques.

Commentaire : La recommandations Formalisées d’Experts (RFE commune SFAR- SRLF 2016) intitulée Intubation et exhumation du patient de réanimation propose : R4.1 (pédiatrie) - Il faut probablement administrer de l'atropine avant l'intubation lors de l'induction en réanimation des enfants âgés de 28 jours à 8 ans pour réduire le risque de bradycardie, notamment dans les situations de choc septique, de choc hypovolémique ou lors de l'utilisation de Suxaméthonium.

La posologie conseillée de l'atropine (tenir à disposition) est 20 µg/kg d’atropine par voie intraveineuse (éventuellement à répéter).

Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department.
Funakoshi H, Kunitani Y, Goto T, Okamoto H, Hagiwara Y, Watase H, Hasegawa K; Japanese Emergency Medicine Network Investigators. | Pediatr Emerg Care. 2022 Feb 1;38(2):e563-e568
DOI: https://doi.org/10.1097/pec.0000000000002356
Keywords: Aucun

Original Research Article

Introduction : Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED).

Méthode : This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation.

Résultats : A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05).

Conclusion : In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.

Conclusion (proposition de traduction) : Dans cette analyse d'importantes données multicentriques prospectives, plusieurs tentatives d'intubation étaient associées à un taux significativement plus élevé d'événements indésirables liés à l'intubation chez les enfants aux urgences.

"Elbow-Lock" Chest Compression Method in the Setting of Single Rescuer Pediatric Cardiopulmonary Resuscitation: A Crossover Simulation Study.
Kang JH, Jang YD, Han K, Jung EK, Yu JK, Ji JG, Lee SW, Yoon YS, Kim YW. | Pediatr Emerg Care. 2022 Feb 1;38(2):e583-e587
DOI: https://doi.org/10.1097/pec.0000000000002418
Keywords: Aucun

Original Research Article

Introduction : We designed a new 1-handed chest compression method, the "elbow-lock" chest compression (ELCC), for a single rescuer in pediatric cardiopulmonary resuscitation (CPR). Then, we compared the effectiveness between the ELCC and standard chest compression (SCC) method.

Méthode : This prospective, randomized controlled, crossover simulation trial studied 34 emergency medical professionals, including physicians, nurses, and EMTs. We compare the quality of chest compression and fatigue point time between the ELCC and the SCC.

Résultats : Participants who performed the ELCC method maintained a proper depth of compression compared with SCC method (50.0 ± 0.3 mm vs 40.5 ± 0.4 mm, P < 0.001). However, the 2 methods did not differ in terms of compression velocity since neither reached the standard velocity (96.7 ± 7.1/minutes vs 91.7 ± 7.0/minutes, P < 0.016). With respect to the overall score, ELCC was more effective than the SCC (91.6 ± 3.7% vs 85.3 ± 8.8%, P = 0.002). In addition, the fatigue point time was slower in the ELCC group than the SCC group (7.3 ± 0.3/minutes vs 6.1 ± 0.4/minutes, P < 0.001).

Conclusion : The single rescuer ELCC method is an effective alternative to the SCC method for pediatric CPR because the ELCC method can prevent elbow flexion.Trial registration: Our research is simulation manikin study. So we do not need to "trial registration".

Conclusion (proposition de traduction) : La méthode de compression thoracique "coude-verrouillé" à un sauveteur est une alternative efficace à la méthode de compression thoracique standard pour la RCP pédiatrique, car la méthode de compression thoracique "coude-verrouillé" peut empêcher la flexion du coude. Enregistrement d'essai : notre recherche est une étude de simulation sur mannequin. Nous n'avons donc pas besoin de "l'enregistrement d'essai".

Commentaire :  FIGURE 1. Méthode SCC. A, Vue de face. B, vue latérale. C, position des mains de la méthode de compression thoracique standard.

FIGURE 2. Méthode ELCC. A, Vue de face. B, vue latérale. C, position de la main de la méthode de compression thoracique "coude verrouillé".

Evaluating Adolescent Substance Use and Suicide in the Pediatric Emergency Department.
Quimby EG, Brogan L, Atte T, Diamond G, Fein JA. | Pediatr Emerg Care. 2022 Feb 1;38(2):e595-e599
DOI: https://doi.org/10.1097/pec.0000000000002453
Keywords: Aucun

Original Research Article

Introduction : This study evaluates the relationship between substance use and impairment and current suicidal thoughts or behaviors in adolescent patients screened in a pediatric emergency department (ED).

Méthode : Data were collected between June 2013 and February 2018 from adolescent patients who presented to a single, urban, pediatric ED. Adolescents completed a computerized, self-administered assessment that evaluates depression, suicide, posttraumatic stress, violence, traumatic exposure, bullying, and substance use. Assessments are administered as standard care to all ED patients aged 14 to 18 years. We used binary logistic regression to estimate the odds of reporting current suicidal thoughts or behaviors associated with patient demographics (ie, age, sex, and race), substance use in the past month, and substance-related impairment.

Résultats : A total of 11,623 adolescent patients (65.4% female and 52.9% African American) completed the assessment. Participants were, on average, 15.7 years old (SD = 1.27). Younger age (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.74-0.84) and substance use impairment (OR, 0.44; 95% CI, 0.33-0.58) decreased the odds of reporting current suicidal thoughts or behaviors, whereas male sex (OR, 1.51; 95% CI, 1.28-1.79) and those with past-month substance use (OR, 1.85; 95% CI, 1.51-2.26) increased the odds.

Conclusion : Recent substance use and male sex are associated with a higher likelihood of adolescents reporting current suicidal thoughts or behaviors during an ED visit. Standardized screening during pediatric ED visits may allow for more efficient evaluation of patients in higher-risk groups.

Conclusion (proposition de traduction) : La consommation récente de substances et le sexe masculin sont associés à une probabilité plus élevée que les adolescents signalent des idées ou des comportements suicidaires au moment de la prise en charge lors d'une consultation aux urgences. Le dépistage standardisé lors des consultations pédiatriques aux urgences peut permettre une évaluation plus efficace des patients dans ces groupes à risque élevé.

Trampoline Injuries in Children and Adolescents: A Jumping Threat.
Hussein MH, Toreih AA, Attia AS, Alrowaili M, Fawzy MS, Tatum D, Toraih EA, Kandil E, Duchesne J, Taghavi S. | Pediatr Emerg Care. 2022 Feb 1;38(2):e894-e899
DOI: https://doi.org/10.1097/pec.0000000000002457
Keywords: Aucun

Original Research Article

Introduction : As trampoline use grows more popular in the United States, the frequency of injuries continues to climb. We hypothesized that toddlers would be at the highest risk for trampoline injuries requiring hospitalization.

Méthode : The National Electronic Injury Surveillance System database was examined for trampoline injuries from 2009 to 2018. Patients were categorized into 3 main age groups: toddlers (<2 years), children (2-12 years), and adolescents (13-18 years). Regression models were used to identify patients at high risk for injury or hospitalization.

Résultats : There was a total of 800,969 meeting inclusion criteria, with 433,827 (54.2%) occurring at their own homes and 86,372 (18.1%) at the sporting venue. Of the total, 36,789 (4.6%) were admitted to a hospital. Fractures (N = 270,884, 34%), strain/sprain injuries (N = 264,990, 33%), followed by skin contusions/abrasions (N = 115,708, 14%) were the most common diagnoses. The most frequent injury sites were lower and upper extremities accounting for 329,219 (41.1%) and 244,032 (30.5%), whereas 175,645 (21.9%) had head and neck injuries. Musculoskeletal injuries (74%) and concussions (2.6%) were more frequent in adolescents than children (67.6% and 1.6%) and toddlers (56.3% and 1.3%). Internal organ and soft tissue injuries were frequent in toddlers. There were no fatalities reported in the injured patients. Multivariate analysis showed adolescents, female sex, extremity injuries, and musculoskeletal injuries were associated with hospitalization. Injury at a sporting venue was not associated with hospitalization.

Conclusion : Adolescents and girls are at increased risk of trampoline injury, warranting hospitalization. Safety standards may help prevent extremity and musculoskeletal injuries in the pediatric population. Finally, use of trampolines at sporting venues does not appear to be particularly dangerous.

Conclusion (proposition de traduction) : Les adolescentes et les filles courent un risque accru de blessure au trampoline, justifiant une hospitalisation. Les normes de sécurité peuvent aider à prévenir les blessures aux extrémités et musculosquelettiques dans la population pédiatrique. Enfin, l'utilisation des trampolines sur les sites sportifs ne semble pas particulièrement dangereuse.

Pediatric Foreign Body Aspiration: Time of Occurrence and Factors Affecting Outcomes.
Paap MK, Leuin S, Carvalho D. | Pediatr Emerg Care. 2022 Feb 1;38(2):e958-e960
DOI: https://doi.org/10.1097/pec.0000000000002503
Keywords: Aucun

Original Research Article

Introduction : The goal of this study was to assess which factors could affect outcomes in pediatric patients undergoing bronchoscopy for foreign body aspiration (FBA).

Méthode : This is a retrospective case series study evaluating patients who underwent bronchoscopies because of FBA at a tertiary pediatric hospital between January 1, 2010, and December 6. 2018. Data collected included demographic information, time of the aspiration event, history of developmental delay, time of the procedure, duration of the procedure, and outcome (discharged, admission to the hospital or pediatric intensive care unit [PICU], or deceased). Statistical analysis was performed using standard regression analysis and analysis of variance.

Résultats : There were a total of 114 patients who underwent bronchoscopy for FBA (61% male and 39% female). The mean ± SD age was 2.8 ± 3.4 years, and 16% had developmental delay. The mean age for patients with developmental delay was 3.43 years, compared with 1.69 years for patients without developmental delay. The age difference between these 2 groups was statistically significant (P = 0.0047). The most commonly aspirated object was food (57%), and patients were usually with their parents at the time of aspiration (78%). Most aspiration events (57%) happened between 4 pm to 4 am. The mean ± SD time of procedure was 38 ± 28 minutes. The probability of admission to the hospital, PICU, and death increased with the duration of the procedure (P < 0.001). Patients with procedures longer than 60 minutes had a 40% probability of admission to the PICU, and patients with cases longer than 120 minutes had 13% probability of mortality.

Conclusion : Most FBA s occurred in the evening while the children were with their parents. Education of families regarding the risk of aspiration is crucial, so they are always attentive to this issue. Although the focus on prevention tends to be with younger patients, it is essential to emphasize the risk of FBA in older patients with developmental delay. Because most episodes of aspiration occur later in the day, it is imperative that tertiary pediatric centers ensure that the evening staff is trained and have the available equipment for these complex cases.

Conclusion (proposition de traduction) : La plupart des inhalation de corps étrangers se produisaient le soir alors que les enfants étaient avec leurs parents. L'éducation des familles concernant le risque d'inhalation est cruciale, elles sont donc toujours attentives à cette question. Bien que l'accent soit mis sur la prévention chez les patients plus jeunes, il est essentiel de souligner le risque d'inhalation de corps étranger chez les enfants plus âgés présentant un retard de développement. Comme la plupart des épisodes d'inhalation surviennent plus tard dans la journée, il est impératif que les service pédiatriques tertiaires s'assurent que le personnel de soir soit formé et dispose de l'équipement nécessaire pour ces cas complexes.

Infant Cardiopulmonary Resuscitation Quality While Walking Fast: A Simulation Study.
Santos-Folgar M, Fernández-Méndez F, Otero-Agra M, Abelairas-Gómez C, Murciano M, Rodríguez-Núñez A, Barcala-Furelos R. | Pediatr Emerg Care. 2022 Feb 1;38(2):e973-e977
DOI: https://doi.org/10.1097/pec.0000000000002505
Keywords: Aucun

Original Research Article

Introduction : This study focuses on the characteristics (feasibility, resuscitation quality, and physical demands) of infant cardiopulmonary resuscitation (CPR) on the forearm during fast walking, performed by a trained lay rescuer.

Méthode : Twenty-one university students from the infant education degree participated in a randomized crossover simulation study to compare a standard pediatric CPR versus a walking pediatric CPR with a manikin on the rescue forearm. Each rescuer performed 2 resuscitation tests of 2 minutes on the infant manikin. Cardiopulmonary resuscitation, physiological, and perceived effort variables were measured.

Résultats : The quality of chest compressions was higher in standard pediatric CPR than in walking pediatric CPR (72% vs 51%; P < 0.001) and overall CPR quality (59% vs 49%; P = 0.02). There were no differences between ventilation quality (47% vs 46%). Walking pediatric CPR presented a higher percentage of maximum heart rate (52% vs 69%; P < 0.001) and perceived exertion rate (2 vs 5; P < 0.001). Participants walked an average of 197 m during the test.

Conclusion : In conclusion, pediatric walking CPR is feasible although it represents a slight quality decrease in a simulation infant CPR setting. The option "CPR while walking fast to a safe place" seems to be suitable in terms of safety both for the victim and the rescuer, as well as CPR quality in special circumstances.

Conclusion (proposition de traduction) : En conclusion, la RCP pédiatrique en marchant à pied est faisable bien qu'elle représente une légère diminution de la qualité dans le cadre de le simulation de le RCP du nourrissons. L'option « RCP en marchant rapidement vers un lieu sûr » semble adaptée en termes de sécurité tant pour la victime que pour le secouriste, ainsi qu'en termes de qualité de la RCP dans des circonstances particulières.

Commentaire : 

Comparison of Standard Technique, Ultrasonography, and Near-Infrared Light in Difficult Peripheral Vascular Access: A Randomized Controlled Trial.
Yalçınlı S, Karbek Akarca F, Can Ö, Uz İ, Konakçı G. | Prehosp Disaster Med.. 2022 Feb;37(1):65-70
DOI: https://doi.org/10.1017/s1049023x21001217  | Télécharger l'article au format  
Keywords: catheterization; emergency medicine; emergency nursing; interventional; near-infrared; peripheral; spectroscopy; ultrasonography.

Original Research

Introduction : Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA.

Méthode : This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims.

Résultats : This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods.

Conclusion : It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.

Conclusion (proposition de traduction) : Il a été constaté que l'échographie augmente le succès de la première tentative par rapport à la méthode standard et à la lumière proche infrarouge chez les patients ayant un abord veineux difficile.

Impact of Specific Emergency Measures on Survival in Out-of-Hospital Traumatic Cardiac Arrest.
Savary D, Morin F, Douillet D, Drouet A, Ageron FX, Charvet R, Carneiro B, Metton P, Fadel M, Descatha A. | Prehosp Disaster Med. 2022 Feb;37(1):51-56
DOI: https://doi.org/10.1017/s1049023x21001308
Keywords: Advanced Life Support; cardiac arrest; trauma.

Original Research

Introduction : The management of out-of-hospital traumatic cardiac arrest (TCA) for professional rescuers entails Advanced Life Support (ALS) with specific actions to treat the potential reversible causes of the arrest: hypovolemia, hypoxemia, tension pneumothorax (TPx), and tamponade. The aim of this study was to assess the impact of specifi

Méthode : This retrospective study concerns all TCA patients treated in two emergency medical units, which are part of the Northern French Alps Emergency Network (RENAU), from January 2004 through December 2017. Utstein variables and specific rescue measures in TCA were compiled: fluid expansion, pelvic stabilization, tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at Day 30 with good neurological status (Cerebral Performance Category [CPC] score CPC 1 and CPC 2).

Résultats : In total, 287 resuscitation attempts in TCA were included and 279 specific interventions were identified: 262 fluid expansions, 41 pelvic stabilizations, five tourniquets, and 175 bilateral thoracostomies (including 44 with TPx).

Conclusion : Among the standard resuscitation measures to treat the reversible causes of cardiac arrest, this study found that bilateral thoracostomy and tourniquet application on a limb hemorrhage improve survival in TCA. A larger sample for pelvic stabilization is needed.

Conclusion (proposition de traduction) : Parmi les mesures de réanimation standard pour traiter les causes réversibles de l'arrêt cardiaque, cette étude a révélé que la thoracostomie bilatérale et l'application d'un garrot sur une hémorragie d'un membre améliorent la survie en cas d'arrêt cardiaque traumatique. Un échantillon plus important pour la stabilisation pelvienne est nécessaire.

Point-of-Care Ultrasound Use by EMS Providers in Out-of-Hospital Cardiac Arrest.
Kreiser MA, Hill B, Karki D, Wood E, Shelton R, Peterson J, Riccio J, Zapata I, Khalil PA, Gubler D, LaPorta AJ, Roosevelt GE, Toney AG. | Prehosp Disaster Med. 2022 Feb;37(1):39-44
DOI: https://doi.org/10.1017/s1049023x21001357
Keywords: Aucun

Original Research

Introduction : Paramedics received training in point-of-care ultrasound (POCUS) to assess for cardiac contractility during management of medical out-of-hospital cardiac arrest (OHCA). The primary outcome was the percentage of adequate POCUS video acquisition and accurate video interpretation during OHCA resuscitations. Secondary outcomes included POCUS impact on patient management and resuscitation protocol adherence.

Méthode : A prospective, observational cohort study of paramedics was performed following a four-hour training session, which included a didactic lecture and hands-on POCUS instruction. The Prehospital Echocardiogram in Cardiac Arrest (PECA) protocol was developed and integrated into the resuscitation algorithm for medical non-shockable OHCA. The ultrasound (US) images were reviewed by a single POCUS expert investigator to determine the adequacy of the POCUS video acquisition and accuracy of the video interpretation. Change in patient management and resuscitation protocol adherence data, including end-tidal carbon dioxide (EtCO2) monitoring following advanced airway placement, adrenaline administration, and compression pauses under ten seconds, were queried from the prehospital electronic health record (EHR).

Résultats : Captured images were deemed adequate in 42/49 (85.7%) scans and paramedic interpretation of sonography was accurate in 43/49 (87.7%) scans. The POCUS results altered patient management in 14/49 (28.6%) cases. Paramedics adhered to EtCO2 monitoring in 36/36 (100.0%) patients with an advanced airway, adrenaline administration for 38/38 (100.0%) patients, and compression pauses under ten seconds for 36/38 (94.7%) patients.

Conclusion : Paramedics were able to accurately obtain and interpret cardiac POCUS videos during medical OHCA while adhering to a resuscitation protocol. These findings suggest that POCUS can be effectively integrated into paramedic protocols for medical OHCA.

Conclusion (proposition de traduction) : Les intervenants paramédicaux ont été en mesure d'obtenir et d'interpréter avec précision des vidéos d'échographie cardiaque au point d'intervention lors d'un arrêt cardiaque médical extrahospitalier tout en respectant un protocole de réanimation. Ces résultats suggèrent que l'échographie au point d'intervention peut être intégrée efficacement dans les protocoles paramédicaux pour les arrêts cardiaques extrahospitaliers médicaux.

Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest.
Abramson TM, Bosson N, Loza-Gomez A, Eckstein M, Gausche-Hill M. | Prehosp Emerg Care. 2022 Mar-Apr;26(2):173-178
DOI: https://doi.org/10.1080/10903127.2020.1869873
Keywords: dextrose; glucagon; hypoglycemia; out of hospital cardiac arrest; point of care testing.

Focus on Cardiac Arrest

Introduction : Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes.

Méthode : This was a retrospective analysis of OHCA in a large, regional EMS system from 2011 to 2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome.

Résultats : There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. Of the 32,780 patients with a documented POC glucose result who were identified as hypoglycemic, only 27 (0.08%) received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference -2.0% (95%CI -4.4%, 0.4%), p = 0.1.

Conclusion : In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.

Conclusion (proposition de traduction) : Dans ce système de services médicaux d'urgence, les tests glycémie au point d'intervention étaient courants chez les adultes victimes d'arrêts cardiaques en dehors de l'hôpital, mais la survie jusqu'à la sortie de l'hôpital avec de bons résultats neurologiques ne différait pas entre les patients traités et non traités pour hypoglycémie. Ces résultats remettent en question la pratique courante de mesure et de traitement de l'hypoglycémie chez les patients extrahospitaliers en arrêt cardiaque.

How Does Rescuer Fitness Affect the Quality of Prolonged Cardiopulmonary Resuscitation? .
Lancaster GD, Stilley JD, Franke WD. | Prehosp Emerg Care. 2022 Mar-Apr;26(2):195-203
DOI: https://doi.org/10.1080/10903127.2021.1894275
Keywords: cardiopulmonary resuscitation; emergency medical services; muscle power; muscle strength; out of hospital cardiac arrest.

Focus on Cardiac Arrest

Introduction : High quality cardiopulmonary resuscitation (CPR) is crucial for patients experiencing cardiac arrest. CPR quality declines within the first few minutes of CPR performance. Being more fit is associated with higher CPR quality, yet the fitness parameters needed remain uncertain. It is also unknown how CPR quality is affected during a protocol of realistic CPR when rescuers switch compressors every two minutes, as recommended by the American Heart Association (AHA), and extended duration, as might be encountered with an out-of-hospital cardiac arrest. The purpose of the present study is to determine the extent to which different measures of physical fitness predict high quality CPR performance when rescuers follow current CPR guidelines.

Méthode : Subjects underwent a fitness assessment evaluating lower back muscular endurance, abdominal muscular endurance, upper body muscular strength, and upper body anaerobic power. At least 48 hours later, subjects returned to the laboratory for CPR testing. CPR quality was determined by compression rate (>100/minute), compression depth (>2 inches, or 50 mm), and adequate (full) chest recoil between compressions, based on American Heart Association guidelines. A CPR Quality Score, designed to represent cardiac output, was calculated as the product of compression rate and depth.

Résultats : Thirty-three of 42 subjects were able to achieve a CPR Quality Score greater than 5000, the minimum needed to meet AHA recommendations. Higher anaerobic power and bench press scores were predictive of both high CPR Quality Scores (R²=0.47) and compression depth (R²=0.47). Sex (female) was predictive of better chest compression recoil percentages (R²=0.15).

Conclusion : Most rescuers can maintain high quality CPR if given two minute breaks between cycles. Rescuers with high anaerobic fitness and muscular strength may be able to provide higher quality CPR.

Conclusion (proposition de traduction) : La plupart des secouristes peuvent maintenir une RCP de haute qualité s'ils bénéficient de deux minutes de pause entre les cycles. Les secouristes ayant une capacité anaérobie et une force musculaire élevées peuvent être en mesure de fournir une RCP de meilleure qualité.

Incidence, Complications, and Factors Associated with Out-of-Hospital First Attempt Intubation Failure in Adult Patients: A Secondary Analysis of the CURASMUR Trial Data.
Nicol T, Gil-Jardiné C, Jabre P, Adnet F, Ecollan P, Guihard B, Ferdynus C, Combes X. | Prehosp Emerg Care. 2022 Mar-Apr;26(2):280-285
DOI: https://doi.org/10.1080/10903127.2021.1891357
Keywords: emergency; intubation; intubation related complications; prehospital.

Original contribution

Introduction : The objectives of this study were to evaluate first attempt intubation failure rate, its associated factors, and its related complications in out-of-hospital emergency setting, when emergency physicians perform standardized airway management using rapid sequence intubation in adult patients.

Méthode : The present study was a substudy of the Succinylcholine versus Rocuronium for out-of-hospital Emergency Intubation (CURASMUR) Trial, which compared Succinylcholine and Rocuronium used for Rapid sequence intubation. First attempt Intubation failure rate and early intubation related complications were recorded. We used multivariable logistic regression analysis to determine first intubation failure associated factors.

Résultats : A total of 1230 patients were included with mean age of 55.9 +/- 19 years. First attempt intubation failure was recorded in 285 (23.2%) patients. The occurrence of a first attempt intubation failure was independently associated with history of ear, nose, and throat neoplasia (OR 2.20, CI 95% 1.06-4.60). Early intubation related complications were more frequent in case of first attempt intubation failure: 80 of 285 (28.4%) in patients with first attempt intubation failure and 185 of 945 (19.6%) in patients with successful first attempt intubation [OR 1.44; CI 95%, 1.11-1.87].

Conclusion : Based on a large multicenter study on out-of-hospital tracheal intubation of adult patients, we found that first attempt intubation failure rate was high and that history of ear, nose, and throat (ENT) neoplasia was an independent associated factor. Failure in first intubation attempt was associated with significantly more intubation related complications.

Conclusion (proposition de traduction) : Sur la base d'une vaste étude multicentrique sur l'intubation trachéale extra-hospitalière de patients adultes, nous avons constaté que le taux d'échec de la première tentative d'intubation était élevé et que les antécédents de néoplasie ORL étaient un facteur associé indépendant. L'échec de la première tentative d'intubation était associé à beaucoup plus de complications liées à l'intubation.

Characteristics and Outcomes of Prehospital Tourniquet Use for Trauma in the United States.
Hashmi ZG, Hu PJ, Jansen JO, Butler FK, Kerby JD, Holcomb JB. | Prehosp Emerg Care. 2022 Feb 3:1-7
DOI: https://doi.org/10.1080/10903127.2021.2025283
Keywords: Aucun

Article

Introduction : The use of the extremity tourniquet in military environments has reduced preventable deaths due to exsanguinating hemorrhage, leading to increased use in civilian settings. However, the outcomes of contemporary prehospital tourniquet use in civilian settings are not well-described nationally. The objective of this study was to describe the characteristics and outcomes following prehospital tourniquet use by emergency medical services (EMS) in the United States.

Méthode : All trauma activations reported to the National EMS Information System 2019 (NEMSIS) were included. Patients who had ≥1 tourniquet applied were identified. Descriptive analyses were used to compare characteristics between tourniquet and no-tourniquet cohorts. Coarsened exact matching was performed to generate a k2k match (on age, sex, lowest-systolic blood pressure, initial patient acuity, provider's initial impression, injury mechanism, and presence of upper/lower extremity injuries) and used to compare outcomes. Trauma patients who may have potentially benefited from tourniquet application (extremity injury, shock index ≥1 and no documented tourniquet application) were identified.

Résultats : A total of 7,161 tourniquets were applied among 4,571,379 trauma activations (1.6/1000 activations). Patients in the tourniquet cohort were younger (40 ± 18 vs 52 ± 26 mean ± SD years), more hypotensive (16.1% vs. 2.5%) and had higher initial acuity (65.0% critical/emergent vs. 20.6%) [p < 0.01 for all]. A total of 7,074 patients in the tourniquet cohort were matched with 7,074 patients in the non-tourniquet cohort. Post-match analysis revealed that the patients in tourniquet cohort had a higher final acuity (80.8% vs. 75.0%, p < 0.01), lower scene-time (15.4 ± 13.6 vs. 17.0 ± 14.2 mean ± SD minutes, p < 0.01), and higher survival-to-hospital (83.6% vs. 75.1%, p < 0.01). A total of 141,471 trauma patients who may have potentially benefited from tourniquet application were identified.

Conclusion : Prehospital tourniquet use by EMS in the United States is associated with lower scene-time and improved survivability to hospital. Results indicate that patients might benefit from wider tourniquet use in the civilian prehospital setting.

Conclusion (proposition de traduction) : L'utilisation de garrots préhospitaliers par par les services médicaux d'urgence aux États-Unis est associée à un temps sur les lieux d'intervention réduit et à une meilleure capacité de survie à l'hôpital. Les résultats indiquent que les patients pourraient bénéficier d'une utilisation plus large du garrot dans le cadre préhospitalier civil.

Long-term outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis.
Chin YH, Yaow CYL, Teoh SE, Foo MZQ, Luo N, Graves N, Ong MEH, Ho AFW. | Resuscitation. 2022 Feb;171:15-29
DOI: https://doi.org/10.1016/j.resuscitation.2021.12.026
Keywords: Cardiac; Cardiac arrest; Long-term outcomes; OHCA; Out of hospital; Out-of-hospital cardiac arrest; Sudden cardiac arrest; Survival.

Review

Introduction : Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge).

Méthode : Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model.

Résultats : 67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI = 71.2-82.4), 69.6% (CI = 54.5-70.3), 62.7% (CI = 54.5-70.3), 46.5% (CI = 32.0-61.6), and 20.8% (CI = 7.8-44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR = 2.1, CI = 1.8-2.3), North America (RR = 2.0, CI = 1.7-2.2) and Oceania (RR = 1.9, CI = 1.6-2.1). Males had a higher 1-year survival (RR:1.41, CI = 1.25-1.59), and patients with initial shockable rhythm had improved 1-year (RR = 3.07, CI = 1.78-5.30) and 3-year survival (RR = 1.45, CI = 1.19-1.77). OHCA occurring in residential locations had worse 1-year survival (RR = 0.42, CI = 0.25-0.73).

Conclusion : Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.

Conclusion (proposition de traduction) : Notre étude a révélé que jusqu'à 20,8 % des patients en arrêt cardiaque extra-hospitalier ont survécu jusqu'à 15 ans, et la survie était plus faible en Asie par rapport aux autres régions. Une analyse plus approfondie des différences de survie entre les régions est nécessaire pour orienter le futur traitement à long terme des patients en arrêt cardiaque extra-hospitalier.

Vasopressin and glucocorticoids for in-hospital cardiac arrest: A systematic review and meta-analysis of individual participant data.
Holmberg MJ, Granfeldt A, Mentzelopoulos SD, Andersen LW. | Resuscitation. 2022 Feb;171:48-56
DOI: https://doi.org/10.1016/j.resuscitation.2021.12.030
Keywords: Cardiac arrest; Glucocorticoids; Individual participant data; Meta-analysis; Steroids; Vasopressin.

Review

Introduction : To perform a systematic review and individual participant data meta-analysis of vasopressin and glucocorticoids for the treatment of cardiac arrest.

Méthode : The PRISMA-IPD guidelines were followed. We searched Medline, Embase, and the Cochrane Library for randomized trials comparing vasopressin and glucocorticoids to placebo during cardiac arrest. The population included adults with cardiac arrest in any setting. Pairs of investigators reviewed studies for relevance, extracted data, and assessed risk of bias. Meta-analyses were conducted using individual participant data. A Bayesian framework was used to estimate posterior treatment effects assuming various prior beliefs. The certainty of evidence was evaluated using GRADE.

Résultats : Three trials were identified including adult in-hospital cardiac arrests only. Individual participant data were obtained from all trials yielding a total of 869 patients. There was some heterogeneity in post-cardiac arrest interventions between the trials. The results favored vasopressin and glucocorticoids for return of spontaneous circulation (odds ratio: 2.09, 95%CI: 1.54 to 2.84, moderate certainty). Estimates for survival at discharge (odds ratio: 1.39, 95%CI: 0.90 to 2.14, low certainty) and favorable neurological outcome (odds ratio: 1.64, 95%CI, 0.99 to 2.72, low certainty) were more uncertain. The Bayesian estimates for return of spontaneous circulation were consistent with the primary analyses, whereas the estimates for survival at discharge and favorable neurological outcome were more dependent on the prior belief.

Conclusion : Among adults with in-hospital cardiac arrest, vasopressin and glucocorticoids compared to placebo, improved return of spontaneous circulation. Larger trials are needed to determine whether there is an effect on longer-term outcomes.

Conclusion (proposition de traduction) : Chez les adultes ayant subi un arrêt cardiaque à l'hôpital, la vasopressine et les glucocorticoïdes par rapport au placebo ont amélioré la reprise d'activité circulatoire spontanée. Des essais plus importants sont nécessaires pour déterminer s'il y a un effet sur les résultats à plus long terme.

Hyperoxia after pediatric cardiac arrest: Association with survival and neurological outcomes.
Barreto JA, Weiss NS, Nielsen KR, Farris R, Roberts JS. | Resuscitation. 2022 Feb;171:8-14
DOI: https://doi.org/10.1016/j.resuscitation.2021.12.003
Keywords: Children; Hyperoxia; Post-arrest care; Resuscitation.

Clinical Paper

Introduction : To evaluate the association between hyperoxia in the first 24 hours after in-hospital pediatric cardiac arrest and mortality and poor neurological outcome.

Méthode : This is a retrospective cohort study of inpatients in a freestanding children's hospital. We included all patients younger than 18 years of age with in-hospital cardiac arrest between December 2012 and December 2019, who achieved return of circulation (ROC) for longer than 20 minutes, survived at least 24 hours after cardiac arrest, and had documented PaO2 or SpO2 during the first 24 hours after ROC. Hyperoxia was defined as having at least one level of PaO2 above 200 mmHg in the first 24 hours after cardiac arrest.

Résultats : There were 187 patients who met eligibility criteria, of whom 48% had hyperoxia during the first 24 hours after cardiac arrest. In-hospital mortality was 41%, with similar mortality between oxygenation groups (hyperoxia 45% vs no hyperoxia 38%). We did not observe an association between hyperoxia and in-hospital mortality or poor neurological outcome after adjusting for confounders (odds ratio 1.2, 95% confidence interval 0.5-2.8). On sensitivity analysis using two additional cutoffs of PaO2 (>150 mmHg and > 300 mmHg), there was also no association with in-hospital mortality or poor neurological outcome after adjusting for confounders. Similarly, on multivariable logistic regression using SpO2 > 99% as the exposure, there was no difference in the frequency of death or poor neurological outcome at hospital discharge.

Conclusion : Hyperoxia after pediatric cardiac arrest was common and was not associated with worse in-hospital outcomes.

Conclusion (proposition de traduction) : L'hyperoxie après un arrêt cardiaque pédiatrique était fréquente et n'était pas associée à de moins bons résultats à l'hôpital.

CPR-related injuries after non-traumatic out-of-hospital cardiac arrest: Survivors versus non-survivors.
Karasek J, Slezak J, Stefela R, Topinka M, Blankova A, Doubková A, Pitasova T, Nahalka D, Bartes T, Hladik J, Adamek T, Jirasek T, Polasek R, Ostadal P.. | Resuscitation. 2022 Feb;171:90-95
DOI: https://doi.org/10.1016/j.resuscitation.2021.12.036
Keywords: Autopsy; CPR realted injury; Out-of-hospital cardiac arrest; Resuscitation.

Clinical paper

Introduction : There have been no direct comparisons of cardiopulmonary resuscitation (CPR)-related injuries between those who die during CPR and those who survive to intensive care unit (ICU) admission. This study aimed to compare the incidence, severity, and impact on survival rate of these injuries and potential influencing factors.

Méthode : This retrospective multicenter study analyzed autopsy reports of patients who experienced out-of-hospital cardiac arrest (OHCA) and were not admitted to hospital. CPR-related injuries were compared to OHCA patients with clinical suspicion of CPR-related injury confirmed on imaging when admitted to the ICU.

Résultats : A total of 859 out-of-hospital cardiac arrests (OHCA) were divided into 2 groups: those who died during CPR and underwent autopsy (DEAD [n = 628]); and those who experienced return of spontaneous circulation and admitted to the ICU (ICU [n = 231]). Multivariable analyses revealed that independent factors of 30-day mortality included no bystander arrest, cardiac etiology, no shockable rhythm, and CPR-related injury. Trauma was independently associated with older age, bystander CPR, cardiac etiology, duration of CPR, and no defibrillation. CPR-related injury occurred in 30 (13%) patients in the ICU group and 547 (87%) in the DEAD group (p < 0.0001). Comparison of injuries revealed that those in the DEAD group experienced more thoracic injuries, rib(s) and sternal fractures, and fewer liver injuries compared to those in the ICU group, without differences in injury severity.

Conclusion : CPR-related injuries were observed more frequently in those who died compared with those who survived to ICU admission. Injury was an independent factor of 30-day mortality.

Conclusion (proposition de traduction) : Les blessures liées à la RCP ont été observées plus fréquemment chez les personnes décédées que chez celles qui ont survécu à l'admission aux soins intensifs. La blessure était un facteur indépendant de la mortalité à 30 :jours.

Factors Associated With Increased Mortality in Severe Abdominopelvic Injury.
Patel N, Harfouche M, Stonko DP, Elansary N, Scalea TM, Morrison JJ. | Shock. 2022 Feb 1;57(2):175-180
DOI: https://doi.org/10.1097/shk.0000000000001851
Keywords: Aucun

Clinical Science Aspect

Introduction : Associated injuries are thought to increase mortality in patients with severe abdominopelvic trauma. This study aimed to identify clinical factors contributing to increased mortality in patients with severe abdominopelvic trauma, with the hypothesis that a greater number of concomitant injuries would result in increased mortality.

Méthode : This was a retrospective review of the Trauma Quality Improvement Program (TQIP) database of patients ≥ 18 years with severe abdominopelvic trauma defined as having an abdominal Abbreviated Injury Score (AIS) ≥ 3 with pelvic fractures and/or iliac vessel injury (2015-2017). Primary outcome was in-hospital mortality based on concomitant body region injuries. Secondary outcomes included mortality at 6 h, 6 to 24 h, and after 24 h based on concomitant injuries, procedures performed, and transfusion requirements.

Résultats : A total of 185,257 patients were included in this study. Survivors had more severely injured body regions than non-survivors (4 vs. 3, P < 0.001). Among those who died within 6 h, 28.5% of patients required a thoracic procedure and 43% required laparotomy compared to 6.3% and 22.1% among those who died after 24 h (P < 0.001). Head AIS ≥ 3 was the only body region that significantly contributed to overall mortality (OR 1.26, P < 0.001) along with laparotomy (OR 3.02, P < 0.001), neurosurgical procedures (2.82, P < 0.001) and thoracic procedures (2.28, P < 0.001). Non-survivors who died in < 6 h and 6-24 h had greater pRBC requirements than those who died after 24 h (15.5 and 19.5 vs. 8 units, P < 0.001).

Conclusion : Increased number of body regions injured does not contribute to greater mortality. Uncontrolled noncompressible torso hemorrhage rather than the burden of concomitant injuries is the major contributor to the high mortality associated with severe abdominopelvic injury.

Conclusion (proposition de traduction) : L'augmentation du nombre de régions blessées du corps ne contribue pas à une plus grande mortalité. L'hémorragie non compressible non contrôlée du thorax, plutôt que l'importance des blessures concomitantes est la principale cause de la mortalité élevée associée aux lésions abdominopelviques graves.

Prognostic Values of the Timing of Antibiotic Administration and the Sepsis Bundle Component in Elderly Patients With Septic Shock: A Retrospective Study.
Liang CY, Yang YY, Hung CC, Wang TH, Hsu YC. | Shock. 2022 Feb 1;57(2):181-188
DOI: https://doi.org/10.1097/shk.0000000000001854
Keywords: Aucun

Clinical Science Aspect

Introduction : Elderly patients are more susceptible to sepsis and septic shock. Early administration of broad-spectrum antibiotics is a key element of the sepsis management of bundle. Our study aimed to investigate the association between the timing of antibiotics administration and the risk of adverse outcomes in elderly patients with septic shock, and to examine the prognostic value of other bundle elements.

Méthode : This is a single-center, retrospective, case-control study including elderly patients (aged ≥ 65 years) diagnosed with septic shock in the emergency department between October 1, 2018, and December 31, 2019. Eligible patients were divided into early (within 1 h) and late (beyond 1 h) groups according to the time interval between septic shock recognition and initial antibiotic administration. The characteristics, sepsis-related severity scores, management strategy, and outcomes were recorded. A multivariate logistic regression model was used to identify the independent prognostic factors.

Résultats : A total of 331 patients were included in the study. The overall 90-day mortality rate was 43.8% (145/331). There were no significant differences in baseline characteristics, sepsis-related severity scores, and management strategy between the two groups. There was no significant difference between the early and late groups in the rate of intensive care unit transfer (46.4% vs. 46.6%, P = 0.96), endotracheal intubation (28.3% vs. 27.5%, P = 0.87), renal replacement therapy (21.7% vs. 21.8%, P = 1.00), or 90-day mortality (44.2% vs. 43.5%, P = 0.90). Serum lactate level (hazard ratio [HR] = 1.15, P < 0.01) and source control (HR = 0.56, P = 0.03) were identified as independent factors associated with 90-day mortality.

Conclusion : The timing of antibiotic administration was not associated with adverse outcomes in elderly patients with septic shock. Serum lactate level and source control implementation were independent prognostic factors in these patients.

Conclusion (proposition de traduction) : Le moment de l’administration des antibiotiques n’a pas été associé à des résultats indésirables chez les patients âgés en choc septique. Le taux de lactate sérique et la mise en œuvre du contrôle à la source étaient des facteurs pronostiques indépendants chez ces patients.

Sex Difference and Rupture Rate of Intracranial Aneurysms: An Individual Patient Data Meta-Analysis.
Zuurbier CCM, Molenberg R, Mensing LA, Wermer MJH, Juvela S, Lindgren AE, Jääskeläinen JE, Koivisto T, Yamazaki T, Uyttenboogaart M, van Dijk JMC, Aalbers MW, Morita A, Tominari S, Arai H, Nozaki K, Murayama Y, Ishibashi T, Takao H, Gondar R, Bijlenga P, Rinkel GJE, Greving JP, Ruigrok YM. | Stroke. 2022 Feb;53(2):362-369
DOI: https://doi.org/10.1161/strokeaha.121.035187
Keywords: intracranial aneurysm; prevalence; risk factor; sex; subarachnoid hemorrhage.

Clinical and Population Science

Introduction : In previous studies, women had a higher risk of rupture of intracranial aneurysms than men, but female sex was not an independent risk factor. This may be explained by a higher prevalence of patient- or aneurysm-related risk factors for rupture in women than in men or by insufficient power of previous studies. We assessed sex differences in rupture rate taking into account other patient- and aneurysm-related risk factors for aneurysmal rupture.

Méthode : We searched Embase and Pubmed for articles published until December 1, 2020. Cohorts with available individual patient data were included in our meta-analysis. We compared rupture rates of women versus men using a Cox proportional hazard regression model adjusted for the PHASES score (Population, Hypertension, Age, Size of Aneurysm, Earlier Subarachnoid Hemorrhage From Another Aneurysm, Site of Aneurysm), smoking, and a positive family history of aneurysmal subarachnoid hemorrhage.

Résultats : We pooled individual patient data from 9 cohorts totaling 9940 patients (6555 women, 66%) with 12 193 unruptured intracranial aneurysms, and 24 357 person-years follow-up. Rupture occurred in 163 women (rupture rate 1.04%/person-years [95% CI, 0.89-1.21]) and 63 men (rupture rate 0.74%/person-years [95% CI, 0.58-0.94]). Women were older (61.9 versus 59.5 years), were less often smokers (20% versus 44%), more often had internal carotid artery aneurysms (24% versus 17%), and larger sized aneurysms (≥7 mm, 24% versus 23%) than men. The unadjusted women-to-men hazard ratio was 1.43 (95% CI, 1.07-1.93) and the adjusted women/men ratio was 1.39 (95% CI, 1.02-1.90).

Conclusion : Women have a higher risk of aneurysmal rupture than men and this sex difference is not explained by differences in patient- and aneurysm-related risk factors for aneurysmal rupture. Future studies should focus on the factors explaining the higher risk of aneurysmal rupture in women.

Conclusion (proposition de traduction) : Les femmes ont un risque plus élevé de rupture d'anévrisme que les hommes et cette différence entre les sexes ne s'explique pas par des différences dans les facteurs de risque de rupture d'anévrisme liés au patient et à l'anévrisme. Les futures études devraient se concentrer sur les facteurs expliquant le risque plus élevé de rupture d'anévrisme chez la femme.

Dispelling myths and misconceptions about the treatment of acute hyperkalemia.
Gupta AA, Self M, Mueller M, Wardi G, Tainter C. | Am J Emerg Med. 2022 Feb;52:85-91
DOI: https://doi.org/10.1016/j.ajem.2021.11.030  | Télécharger l'article au format  
Keywords: Calcium; EKG; Hyperkalemia; Lactated Ringer's; Misconceptions; Myths; Treatment.

Research article

Editorial : Hyperkalemia represents a widespread and potentially lethal condition that affects millions of people across their lives. Despite the prevalence and severity of the condition, there are no consensus guidelines on the treatment of hyperkalemia or even a standard definition. Herein, we provide a succinct review of what we believe to be the most significant misconceptions encountered in the emergency care of hyperkalemia, examine current available literature, and discuss practical points on several modalities of hyperkalemia treatment. Additionally, we review the pathophysiology of the electrocardiographic effects of hyperkalemia and how intravenous calcium preparations can antagonize these effects. We conclude each section with recommendations to aid emergency physicians in making safe and efficacious choices for the treatment of acute hyperkalemia.

Conclusion : Hyperkalemia is a common and potentially life-threatening electrolyte abnormality. Misconceptions and controversies about its management have led to conflicting management strategies. Here, we have addressed four of the most prevalent - and we believe the most significant - of these myths, and provided recommendations based upon the interpretation of available evidence. We recommend that clinicians continue to evaluate the available evidence and make management decisions based on the balance between the potential benefit and harm of each of these interventions.

Conclusion (proposition de traduction) : L'hyperkaliémie est une anomalie électrolytique courante et potentiellement mortelle. Les idées fausses et les controverses sur sa gestion ont conduit à des stratégies de gestion contradictoires. Ici, nous avons abordé quatre des plus répandus - et nous croyons les plus significatifs - de ces mythes, et avons fourni des recommandations basées sur l'interprétation des preuves disponibles. Nous recommandons aux cliniciens de continuer à évaluer les preuves disponibles et à prendre des décisions de gestion basées sur l'équilibre entre les avantages et les inconvénients potentiels de chacune de ces interventions.

Commentaire :  Recommandations pour le traitement calcique de l'hyperkaliémie.

Recommandations :
• En raison des risques potentiels et du manque d'efficacité, le sulfonate de polystyrène sodique (Kayexalate) ne doit pas être systématiquement inclus dans la prise en charge de l'hyperkaliémie aiguë.
• La solution de Ringer Lactate est sûre et appropriée pour une utilisation chez les patients souffrant d'hyperkaliémie.
• Un électrocardiogramme normal n'exclut pas l'hyperkaliémie, mais il est associé à une diminution de la probabilité d'événements indésirables graves.
• Le traitement par calcium intraveineux n'est indiqué que pour les patients présentant une hyperkaliémie manifestant des modifications à l'électrocardiogramme.

The association between the degree of fever as measured in the emergency department and clinical outcomes of hospitalized adult patients.
Marcusohn E, Gibory I, Miller A, Lipsky AM, Neuberger A, Epstein D. | Am J Emerg Med. 2022 Feb;52:92-98
DOI: https://doi.org/10.1016/j.ajem.2021.11.045
Keywords: Acute kidney injury; Emergency department; Fever; Intensive care; Mortality.

Research article

Introduction : Fever is a physiologic response to a wide range of pathologies and one of the most common complaints and clinical signs in the emergency medicine department (ED). The association between fever magnitude and clinical outcomes has been evaluated in specific populations with inconsistent results.
Objectives: In this study we aimed to investigate the association between the degree of fever in the ED and clinical outcomes of hospitalized febrile adult patients.

Méthode : This was a retrospective single-center cohort study of all the patients with maximal body temperature (BT) ≥ 38.0 °C, as recorded during the ED evaluation, who were hospitalized between January 2015 and December 2020. Patients with heatstroke were excluded. The primary outcome was 30-day all-cause mortality and secondary outcomes were intensive care unit (ICU) admission and development of acute kidney injury (AKI).

Résultats : Fever was recorded among 8.1% of patients evaluated in the ED. Elevated BT was associated with increased risk of hospital admission (70.3% vs. 49.4%, p < 0.001), 30-day mortality (12.3% vs. 2.6%, p < 0.001), ICU admission (5.7% vs. 2.8%, p < 0.001), and AKI 11.7% vs. 3.8%, p < 0.001). After exclusion of nine patients with heatstroke, 21,252 hospitalized febrile patients were included in the final analysis. BT > 39.7 °C was progressively associated with increased mortality (OR 1.64-2.22, 95% CI 1.16-2.81, p < 0.005) as compared to BT 38.0-38.1 °C. More AKI events were observed in patients with BT > 39.5 °C (OR 1.48-2.91, 95% CI 1.11-3.66, p < 0.007). Temperature between 39.2 and 39.5 °C was associated with lower mortality (OR 0.62-0.71, 95% CI 0.51-0.87, p < 0.001). In a multiple logistic regression analysis BT > 39.9 °C was independently associated with increased mortality and AKI. BT > 39.7 °C was progressively associated with an increased risk of ICU admission.

Conclusion : Among febrile patients admitted to the hospital, BT > 39.5 °C was associated with adverse clinical course, as compared to patients with lower-grade fever (38.0-38.1 °C). These patients should be flagged on arrival to the ED and likely warrant more aggressive evaluation and treatment.

Conclusion (proposition de traduction) : Parmi les patients fébriles admis à l'hôpital, une température corporelle > 39,5 °C était associée à une évolution clinique défavorable, par rapport aux patients présentant une fièvre de moindre intensité (38,0-38,1° C). Ces patients doivent être signalés à leur arrivée aux urgences et justifient probablement une évaluation et un traitement plus agressifs.

Predicting scale of delayed neuropsychiatric sequelae in patients with acute carbon monoxide poisoning: A retrospective study.
Yang S, Liu H, Peng Q, Li J, Liu Q. | Am J Emerg Med. 2022 Feb;52:114-118
DOI: https://doi.org/10.1016/j.ajem.2021.10.056
Keywords: Carbon monoxide poisoning; Delayed neurological sequelae; Prediction model; Predictive factor.

Original article

Introduction : To establish and validate a predictive formula for calculating the possibility of developing delayed neurological sequelae (DNS) after acute carbon monoxide (CO) poisoning to facilitate better decision-making about treatment strategies.

Méthode : This study retrospectively enrolled 605 consecutive patients who had been newly diagnosed with CO poisoning from the Central Hospital of Enshi Prefecture between January 1, 2015 and December 31, 2020. The cohort was randomly divided into two subgroups: the development cohort (n = 104) and validation cohort (n = 44). Univariate analysis and backward elimination of multivariate logistic regression were used to identify predictive factors, and a predictive formula was established. The performance was assessed using the area under the curve (AUC), the mean AUC of five-fold cross-validation, and calibration plots.

Résultats : The formula included four commonly available predictors: initial GCS score, duration of exposure, CK, and abnormal findings on MRI. We next created a formula to calculate the risk score for developing DNS: Risk score = -4.54 + 3.35 * (Abnormal findings on MRI = yes) - 0.51 * (Initial GCS score) + 0.65 * (Duration of exposure) + 0.01 * (CK). Then, the probability of developing DNS could be calculated: Probability of DNS = 1/(1 + e^{Risk score}). The model revealed good discrimination with AUC, and mean AUC of fivefold cross-validation in two cohort, and the calibration plots showed good calibration.

Conclusion : This study established a prediction predictive formula for predicting developing of DNS, which could facilitate better decision-making about treatment strategies.

Conclusion (proposition de traduction) : Cette étude a établi une formule prédictive de prédiction pour prédire le développement de séquelles neurologiques retardées, ce qui pourrait faciliter une meilleure prise de décision sur les stratégies de traitement.

Traumatic brain injury and intraparenchymal hemorrhage progression: Blood pressure variability matters.
Tran C, Frederick H, Baqai H, Fairchild M, Solomon J, Aligabi A, Olexa J, Bodanapally U, Schwartzbauer G, Tran QK. | Am J Emerg Med. 2022 Feb;52:119-127. 2022 Feb;52:119-127
DOI: https://doi.org/10.1016/j.ajem.2021.12.005
Keywords: Blood pressure variability; Hematoma expansion; Intraparenchymal hemorrhage progression; Mortality; Traumatic brain injury.

Original article

Introduction : Blood pressure variability (BPV) has been shown to correlate with intraparenchymal hematoma progression (HP) and worse outcomes in patients with spontaneous intracerebral hemorrhage (sICH). However, this association has not been elucidated in patients with traumatic intraparenchymal hemorrhage or contusion (tIPH). We hypothesized that 24 h-BPV from time of admission is associated with hemorrhagic progression of contusion or intraparenchymal hemorrhage (HPC), and worse outcomes in patients with tIPH.

Méthode : We performed a retrospective observational analysis of adult patients treated at an academic regional Level 1 trauma center between 01/2018-12/2019. We included patients who had tIPH and ≥ 2 computer tomography (CT) scans within 24 h of admission. HP, defined as ≥30% of admission hematoma volume, was calculated by the ABC/2 method. We performed stepwise multivariable logistic regressions for the association between clinical factors and outcomes.

Résultats : We analyzed 354 patients' charts. Mean age (Standard Deviation [SD]) was 56 (SD = 21) years, 260 (73%) were male. Mean admission hematoma volume was 7 (SD =19) cubic centimeters (cm³), 160 (45%) had HP. Coefficient of variation in systolic blood pressure (SBP_CV) (OR 1.03, 95%CI 1.02-1.3, p = 0.026) was significantly associated with HPC among patients requiring external ventricular drain (EVD). Difference between highest and lowest systolic blood pressure (SBP_max-min) (OR 1.02, 95%CI 1.004-1.03, p = 0.007) was associated with hospital mortality.

Conclusion : SBP_CV was significantly associated with HP among patients who required EVD. Additionally, increased SBP_max-min was associated with an increase in mortality. Clinicians should be cautious with patients' blood pressure until further studies confirm these observations.

Conclusion (proposition de traduction) : Le coefficient de variation de la pression artérielle systolique était significativement associé à la progression de l'hématome chez les patients nécessitant un drainage ventriculaire externe. De plus, l'augmentation de la pression artérielle systolique maximale et minimale était associée à une augmentation de la mortalité. Les cliniciens doivent être prudents avec la tension artérielle des patients jusqu'à ce que d'autres études confirment ces observations.

Chest compression quality during CPR of potential contagious patients wearing personal protection equipment.
Cekmen B, Bildik B, Bozan O, Atis SE, Koksal M, Uzuncu HB, Akilli NB. | Am J Emerg Med. 2022 Feb;52:128-131
DOI: https://doi.org/10.1016/j.ajem.2021.12.009
Keywords: COVID-19; CPR; Chest compression; Fatigue; N95 mask.

Original article

Introduction : In this study we aimed to investigate whether changing rescuers wearing N95 masks every 1 min instead of the standard CPR change over time of 2 min would make a difference in effective chest compressions.

Méthode : This study was a randomized controlled mannequin study. Participants were selected from healthcare staff. They were divided into two groups of two people in each group. The scenario was implemented on CPR mannequin representing patient with asystolic arrest, that measured compression depth, compression rate, recoil, and correct hand position. Two different scenarios were prepared. In Scenario 1, the rescuers were asked to change chest compression after 1 min. In Scenario 2, standard CPR was applied. The participants' vital parameters, mean compression rate, correct compression rate/ratio, total number of compressions, compression depth, correct recoil/ratio, correct hand position/ratio, mean no-flow time, and total CPR time were recorded.

Résultats : The study hence included 14 teams each for scenarios, with a total of 56 participants. In each scenario, 14 participants were physicians and 14 participants were women. Although there was no difference in the first minute of the cycles starting from the fourth cycle, a statistically significant difference was observed in the second minute in all cycles except the fifth cycle.

Conclusion : Changing the rescuer every 1 min instead of every 2 min while performing CPR with full PPE may prevent the decrease in compression quality that may occur as the resuscitation time gets longer.

Conclusion (proposition de traduction) : Changer de sauveteur toutes les 1 min au lieu de toutes les 2 min lors de la RCP avec un EPI complet peut empêcher la diminution de la qualité de la compression qui peut survenir à mesure que le temps de réanimation s'allonge.

Hands-on defibrillation with safety drapes: Analysis of compressions and an alternate current pathway.
Wight JA, Bigham TE, Hanson PR, Zahid A, Iravanian S, Perkins PE, Lloyd MS. | Am J Emerg Med. 2022 Feb;52:132-136
DOI: https://doi.org/10.1016/j.ajem.2021.11.044
Keywords: Aucun

original article

Introduction : Hands-on defibrillation (HOD) could theoretically improve the efficacy of cardiopulmonary resuscitation (CPR) though a few mechanisms. Polyethylene drapes could potentially facilitate safe HOD, but questions remain about the effects of CPR on polyethylene's conductance and the magnitude of current looping through rescuers' arms in contact with patients.

Méthode : This study measured the leakage current through 2 mil (0.002 in.) polyethylene through two different current pathways before and after 30 min of continuous compressions on a CPR mannequin. The two pathways analyzed were the standardized IEC (International Electrotechnical Commission) leakage current analysis and a setup analyzing a current pathway looping through a rescuer's arms and returning to the patient. First, ten measurements involving the two pathways were obtained on a single polyethylene drape. 30 min of continuous compressions were applied to the drape on a CPR mannequin after which the ten measurements were repeated.

Résultats : Twenty patients undergoing elective cardioversion for atrial fibrillation (18/20) or atrial flutter (2/20) at Emory University Hospital underwent analysis all receiving 200 J shocks (age 38-101, 35% female). Through the IEC measurement method the peak leakage current mean was 0.70 +/- 0.02 mA before compressions and 0.59 +/- 0.19 mA after compressions. Only three of the ten measurements assessing current passing through a rescuer's arms had detectable current and each was of low magnitude. All measurements were well below the maximum IEC recommendations of 3.5 mA RMS and 5.0 mA peak.

Conclusion : Polyethylene may facilitate safe HOD even after long durations of compressions. Current looping through a rescuer's arms is likely of insignificant magnitude.

Conclusion (proposition de traduction) : Le polyéthylène peut faciliter une défibrillation en gardant les mains sur le thorax sûre, même après de longues durées de compression. Le courant en boucle dans les bras d’un sauveteur est probablement d’une ampleur insignifiante.

Commentaire : «: Pendant les compressions thoraciques manuelles, la défibrillation en gardant les mains sur le thorax, même avec des gants, représente un risque pour le secouriste. » Perkins GD and al; European Resuscitation Council Guideline Collaborators. European Resuscitation Council Guidelines 2021: Executive summary. (p15) Resuscitation. 2021 Apr;161:1-60  .

«: Les avantages de cette approche ne sont pas prouvés et d'autres études sont nécessaires pour évaluer l'innocuité et l'efficacité de cette technique. Une analyse post-hoc d'un essai multicentrique n'a observé aucun avantage lorsque les chocs étaient délivrés sans interrompre les compressions thoraciques manuelles ou mécaniques. Seuls les gants de sécurité électrique de classe 1, mais pas les gants d'examen clinique standard (ou à mains nues) sont au niveau de l'isolation électrique pour la défibrillation en gardant les mains sur le thorax. Il n'y a pas eu de nouvelles études depuis les lignes directrices de 2015 et la recommandation reste donc inchangée. » (p13) Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation. 2021 Apr;161:115-151  .

The Role of Brain CT in Patients with Out-of-Hospital Cardiac Arrest with Return of Spontaneous Circulation.
Çankaya Gökdere D, Emektar E, Çorbacıoğlu ŞK, Yüzbaşıoğlu Y, Öztürk C, Çevik Y. | Am J Emerg Med. 2022 Feb;52:143-147
DOI: https://doi.org/10.1016/j.ajem.2021.12.008
Keywords: Cardiopulmonary resuscitation; Computed brain tomography; Return of spontaneous circulation.

Original article

Introduction : The diagnosis and treatment process after resuscitation of patients with spontaneous return of circulation (ROSC) after cardiac arrest is important. There is no clear recommendation on utilization of computerized tomography (CT) of the brain in patients with ROSC. In this study, it was aimed to diagnosis the pathology detection rates in the brain tomography of out-of-hospital cardiac arrest (OHCA) patients with ROSC after resuscitation in the emergency department and the effect of these pathologies on treatment management.

Méthode : 131 patients who were admitted to the Emergency Medicine Clinic with cardiac arrest between 08.05.2019 and 07.12.2020, had ROSC after resuscitation and underwent brain CT in the first 24 h were included in the study. The patients were divided into two groups; those with clinically significant pathology in brain CT who underwent treatment changes and those without clinically significant pathology. All data recorded in the study form were analyzed using IBM SPSS 20.0 (Chicago, IL, USA) statistics program. P < 0.005 value was considered statistically significant.

Résultats : 51.1% (67) of the patients were women. The age median value was 73 (IQR25-IQR75;63-83). The most common comorbidity in patients was hypertension with 42% (55). Patients with clinically significant pathology observed in brain tomography studied after ROSC were 12.2% (16) of all patients. The most common management changes were requesting a consultation from the neurology department (n = 9) and adding a new drug to the treatment (n= 5) The 30-day and 1-year mortality rates showed no significant difference between the two groups (p > 0.05).

Conclusion : We have seen that the data obtained from the CT studied in the early period after the ROSC was achieved, did not change the management of our patients x in the early and late periods after resuscitation. We conclude that it is not necessary to have a brain CT scan in the emergency department in the early period.

Conclusion (proposition de traduction) : Nous avons vu que les données obtenues à partir de la tomodensitométrie étudiée dans la période précoce après la reprise spontanée de la circulation, n'ont pas modifié la prise en charge de nos patients dans les périodes précoce et tardive après réanimation. Nous concluons qu'il n'est pas nécessaire de réaliser une tomodensitométrie cérébrale aux urgences dans la période précoce.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness.
Epstein D, Rakedzon S, Kaplan B, Ben Lulu H, Chen J, Samuel N, Lipsky AM, Miller A, Bahouth H, Raz A. | Am J Emerg Med. 2022 Feb;52:159-165
DOI: https://doi.org/10.1016/j.ajem.2021.12.015
Keywords: Airway; Endotracheal intubation; Prehospital trauma care; Traumatic brain injury.

Original article

Introduction : Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason.

Méthode : Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma.

Résultats : In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively.

Conclusion : Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

Conclusion (proposition de traduction) : L'altération de l'état de conscience dans le cadre d'un traumatisme est une raison majeure pour une intubation endotrachéale préhospitalière. Bien que la plupart de ces patients aient subi un traumatisme crânien, un sur quatre n'a pas subi de traumatisme crânien important. Les patients avec une échelle de coma de Glasgow sur place, plus élevé et ceux souffrant d'intoxication ont un risque plus élevé d'erreur de diagnostic. Les études futures devraient explorer de meilleurs outils pour l'évaluation préhospitalière des lésions cérébrales traumatiques et des moyens de mieux définir et caractériser les patients susceptibles de bénéficier d'une intubation endotrachéale précoce.

Fluid Resuscitation and Progression to Renal Replacement Therapy in Patients With COVID-19.
Holt DB, Lardaro T, Wang AZ, Musey PI Jr, Trigonis R, Bucca A, Croft A, Glober N, Peterson K, Schaffer JT, Hunter BR. | J Emerg Med. 2022 Feb;62(2):145-153
DOI: https://doi.org/10.1016/j.jemermed.2021.10.026  | Télécharger l'article au format  
Keywords: COVID-19; acute kidney injury; coronavirus; hemodialysis; renal replacement therapy; resuscitation.

Original Contribution

Introduction : Coronavirus disease 2019 (COVID-19) is associated with respiratory symptoms and renal effects. Data regarding fluid resuscitation and kidney injury in COVID-19 are lacking, and understanding this relationship is critical.
Objectives: To determine if there is an association between fluid volume administered in 24 h and development of renal failure in COVID-19 patients.

Méthode : Retrospective chart review; 14 hospitals in Indiana. Included patients were adults admitted between March 11, 2020 and April 13, 2020 with a positive test for severe acute respiratory syndrome coronavirus 2 within 3 days of admission. Patients requiring renal replacement therapy prior to admission were excluded. Volumes and types of resuscitative intravenous fluids in the first 24 h were obtained with demographics, medical history, and other objective data. The primary outcome was initiation of renal replacement therapy. Logistic regression modeling was utilized in creating multivariate models for determining factors associated with the primary outcome.

Résultats : The fluid volume received in the first 24 h after hospital admission was associated with initiation of renal replacement therapy in two different multivariate logistic regression models. An odds ratio of 1.42 (95% confidence interval 1.01-1.99) was observed when adjusting for age, heart failure, obesity, creatinine, bicarbonate, and total fluid volume. An odds ratio of 1.45 (95% confidence interval 1.02-2.05) was observed when variables significant in univariate analysis were adjusted for.

Conclusion : Each liter of intravenous fluid administered to patients with COVID-19 in the first 24 h of presentation was independently associated with an increased risk for initiation of renal replacement therapy, supporting judicious fluid administration in patients with this disease.

Conclusion (proposition de traduction) : Chaque litre de liquide intraveineux administré aux patients atteints de la COVID-19 au cours des 24 premières heures d'admission était associé de façon indépendante à un risque accru d'initiation d'un traitement d'une insuffisance rénal, ce qui justifie l'administration judicieuse du remplissage chez les patients atteints de cette maladie.

Hemodynamics in Helicopter Emergency Medical Services (HEMS) Patients Undergoing Rapid Sequence Intubation With Etomidate or Ketamine.
Kunkel S, Lenz T. | J Emerg Med. 2022 Feb;62(2):163-170
DOI: https://doi.org/10.1016/j.jemermed.2021.10.004
Keywords: HEMS; etomidate; hypotension; intubation; ketamine; prehospital.

Selected Topics: Aeromedical Emergencies

Editorial : Rapid sequence intubation (RSI) is performed by helicopter emergency medical services (HEMS) providers to establish airway control. Common induction agents are etomidate and ketamine, both touted to have relatively stable hemodynamic profiles. Limited data comparing these medications in the air medical setting exist.
Objective: Compare administration of ketamine and etomidate on peri-intubation hemodynamics.

Introduction : A retrospective chart review of intubations performed by a HEMS program over 69 months was completed. Heart rate (HR) change, systolic blood pressure (SBP) change, and hypotension with etomidate or ketamine use were measured.

Méthode : There were 258 patients induced with etomidate and 48 with ketamine. Etomidate patients showed a +1.161% change in HR (SD ± 22.7) and -0.49% change in SBP (SD ± 25.0). Ketamine patients showed a -4.7% change in HR (SD ± 16.7) and 17.2% change in SBP (SD ± 43.4). The p-values for percentage change in HR and SBP between etomidate and ketamine were 0.0830 and 0.0018, respectively. Twenty-five episodes of postadministration hypotension occurred with etomidate, and two with ketamine (p = 0.028).

Conclusion : Both ketamine and etomidate are appropriate for intubation of HEMS patients. Ketamine was preferentially selected for hypotensive patients with statistically significant improvement in SBP. Although statistically significant, both ketamine and etomidate had relative low incidences of hypotension.

Conclusion (proposition de traduction) : La kétamine et l'étomidate conviennent pour l'intubation des patients transportés par les services médicaux d'urgence par hélicoptère (HéliSMUR). La kétamine a été choisie préférentiellement chez les patients hypotendus avec une amélioration statistiquement significative de la pression artérielle systolique. Bien que statistiquement significatifs, la kétamine et l’étomidate présentaient une incidence relativement faible d’hypotension.

Out-of-Hospital Intubation Success Rates Vary Based on Transport Environment.
Shekhar AC, Blumen I. | J Emerg Med. 2022 Feb;62(2):171-174
DOI: https://doi.org/10.1016/j.jemermed.2021.10.031
Keywords: Emergency Medical Services (EMS); air ambulances; airway management; intubation.

Selected Topics: Prehospital Care

Introduction : Oral endotracheal intubation is a procedure performed by emergency medical services (EMS) providers-who are stationed on ground ambulances, rotor-wing air ambulances (helicopter), and fixed-wing air ambulances (airplane)-for the purpose of securing a patient's airway.
Objective: Historically, intubation success rates have depended on human factors, such as provider familiarity with intubation. There has been relatively little literature examining intubation success rates as a factor of EMS transport environment, despite there being important human factors differences between the different environments.

Méthode : We queried a national database of EMS calls in the United States. Inclusion criteria were oral endotracheal intubations performed in 2019 where providers documented whether or not the intubation was successful and what mode of transport they were assigned to.

Résultats : A total of 98,048 intubations met inclusion criteria. The majority of intubations were performed by providers stationed to ground ambulances (95.38%), followed by rotor-wing air ambulances (4.35%) and fixed-wing air ambulances (0.27%). Intubation success rates were comparable between fixed-wing air ambulances (89.66%) and rotor-wing air ambulances (89.17%)-however, they were significantly lower on ground ambulances (75.69%) (p < .001).

Conclusion : Our data show that flight crew members-either on fixed-wing or rotor-wing air ambulances-are associated with significantly higher rates of intubation success than ground ambulance providers. There are a number of possible explanations for this trend, including more opportunities to intubate in the air medical setting, increased clinical education focused on airway management in the air medical setting, or assistive technologies being more commonly used in the air medical setting.

Conclusion (proposition de traduction) : Nos données montrent que les membres d'équipage de conduite - qu'il s'agisse d'ambulances aériennes à voilure fixe ou à voilure tournante - sont associés à des taux de réussite d'intubation significativement plus élevés que les fournisseurs d'ambulance au sol. Il y a un certain nombre d'explications possibles à cette tendance, notamment davantage de possibilités d'intubation dans le cadre médical aérien, une formation clinique accrue axée sur la gestion des voies respiratoires dans le cadre médical aérien ou des technologies d'assistance plus couramment utilisées dans le cadre médical aérien.

Imaging Utilization Patterns and Injury Characteristics Associated with Electric Standing Scooters in a Major Urban Area.
Bhatnagar A, Al-Hihi M, Ali R, Sharma N, Lai P, Monga A, Hadidchi S, Kayder O, Amalraj B, Kordbacheh H, Johnson S, Abujudeh H, Paxton JH, Lewis N. | J Emerg Med. 2022 Feb;62(2):182-190
DOI: https://doi.org/10.1016/j.jemermed.2021.10.021
Keywords: e-scooter trauma; electric scooter; emergency; scooter fall; trauma.

Brief Report

Introduction : The recent proliferation of electric standing scooters in major urban areas of the United States has been accompanied by injuries of varying severity and nature, representing a growing public health concern.
Objective: Our aim was to characterize imaging utilization patterns for injuries associated with electric scooter (e-scooter) use, including their initial emergency department (ED) management.

Méthode : We conducted a retrospective review of the electronic medical record for all patients presenting to affiliated EDs for e-scooter-related injuries between July 2018 and April 2020. Demographics, date and time of presentation, imaging study type, resultant injury, and procedural details were recorded.

Résultats : Ninety-seven patients were included; mean age was 27.6 years. Of these, 55 patients (57%) had injuries identified on imaging and 40% of all imaging studies were positive. Most identified injuries (61%) were musculoskeletal, with a small number of neurological (2%) and genitourinary (1%) injuries. The highest prevalence of presentations occurred in August; most patients (72%) presented between 3 pm and 1 am and granular peaks were between 12 am and 1 am and 5 pm and 6 pm.

Conclusion : Patients presenting with e-scooter injuries have a high likelihood of injury to the radial head, nasal bone, and malleoli. Emergency physicians should be especially vigilant for injuries in these areas at presentation. Visceral injuries are uncommon but may be severe enough to warrant surgery.

Conclusion (proposition de traduction) : Les patients présentant des blessures en scooter électrique ont une forte probabilité de blessure de la tête radiale, des os propres du nez et des malléoles. Les urgentistes doivent être particulièrement vigilants pour les blessures dans ces zones anatomiques lors de la consultation. Les lésions viscérales sont rares mais peuvent être suffisamment graves pour justifier une intervention chirurgicale.

Effectiveness and Safety of P2Y12 Inhibitors Pretreatment in Primary Percutaneous Coronary Intervention with Long Transfer Times.
Roule V, Rebouh I, Roupie E, Malcor G, Bignon M, Trotel J, Potier B, Lecoq G, Arrot X, Beygui F. | J Emerg Med. 2022 Feb;62(2):240-249
DOI: https://doi.org/10.1016/j.jemermed.2021.10.001
Keywords: P2Y12 inhibitors; ST-elevation myocardial infarction; outcomes; pretreatment.

Pharmacology in Emergency Medicine

Introduction : Early initiation of a new P2Y12 inhibitor in ST-elevation myocardial infarction (STEMI) patients prior to primary percutaneous coronary intervention (PCI) is recommended over clopidogrel. However, comparative data remain limited, especially in semi-rural regions with subsequent longer transfer times.
Objectives: We aimed to assess the determinants, effectiveness, and safety of pretreatment with new P2Y12 inhibitors compared with clopidogrel in a primary PCI regional network.

Méthode : Outcomes of 1235 primary PCI patients pretreated with new P2Y12 inhibitors (n = 1050) or clopidogrel (n = 185) were evaluated using a prospective registry. Primary effectiveness endpoint was the composite of death, recurrent myocardial infarction, stroke, or new revascularization. Serious bleedings were defined as Bleeding Academic Research Consortium ≥ 2.

Résultats : Clopidogrel was more likely to be used in older and female patients with more comorbidities. Mean transfer time was longer in the clopidogrel group (123.3 ± 67.3 vs. 102.3 ± 57.2 min; p < 0.01). The primary endpoint was less frequent with new P2Y12 inhibitors compared with clopidogrel (14.9 vs. 30.3%; odds ratio 0.58, 95% confidence interval [CI] 0.39-0.87; p < 0.01), mostly driven by a reduced rate of death (4.5 vs. 26% respectively; hazard ratio 0.25, 95% CI 0.16-0.38; p < 0.01). Bleeding rates did not differ between groups (1 vs. 0.5%, respectively; p = 0.96).

Conclusion : Compared with clopidogrel, pretreatment with new P2Y12 inhibitors seems to be associated with lower risks of mortality and ischemic outcomes, and similar risks of bleeding in a real-world registry. Our results are in line with the guidelines recommending the preferential pre-PCI administration of new P2Y12 inhibitors in STEMI patients referred for primary PCI.

Conclusion (proposition de traduction) : Comparé au clopidogrel, le prétraitement avec les nouveaux inhibiteurs des P2Y12 semble être associé à des risques plus faibles de mortalité et de résultats ischémiques, et à des risques similaires de saignement dans un registre du monde réel. Nos résultats sont conformes aux recommandations recommandant l'administration pré-PCI préférentielle par les nouveaux inhibiteurs des P2Y12 chez les patients avec un infarctus du myocarde avec sus-décalage du segment ST transférés pour une angioplastie primaire.

Intercostal liposomal bupivacaine injection for rib fractures: A prospective randomized controlled trial.
Wallen TE, Singer KE, Makley AT, Athota KP, Janowak CF, Hanseman D, Salvator A, Droege ME, Strilka R, Droege CA, Goodman MD. | J Trauma Acute Care Surg. 2022 Feb 1;92(2):266-276
DOI: https://doi.org/10.1097/ta.0000000000003462
Keywords: Aucun

2021 AAST PODIUM PAPERS

Introduction : Blunt chest wall injury accounts for 15% of trauma admissions. Previous studies have shown that the number of rib fractures predicts inpatient opioid requirements, raising concerns for pharmacologic consequences, including hypotension, delirium, and opioid dependence. We hypothesized that intercostal injection of liposomal bupivacaine would reduce analgesia needs and improve spirometry metrics in trauma patients with rib fractures.

Méthode : A prospective, double-blinded, randomized placebo-control study was conducted at a Level I trauma center as a Food and Drug Administration investigational new drug study. Enrollment criteria included patients 18 years or older admitted to the intensive care unit with blunt chest wall trauma who could not achieve greater than 50% goal inspiratory capacity. Patients were randomized to liposomal bupivacaine or saline injections in up to six intercostal spaces. Primary outcome was to examine pain scores and breakthrough pain medications for 96-hour duration. The secondary endpoint was to evaluate the effects of analgesia on pulmonary physiology.

Résultats : One hundred patients were enrolled, 50 per cohort, with similar demographics (Injury Severity Score, 17.9 bupivacaine 17.6 control) and comorbidities. Enrolled patients had a mean age of 60.5 years, and 47% were female. Rib fracture number, distribution, and targets for injection were similar between groups. While both groups displayed a decrease in opioid use over time, there was no change in mean daily pain scores. The bupivacaine group achieved higher incentive spirometry volumes over Days 1 and 2 (1095 mL, 1063 mL bupivacaine vs. 900 mL, 866 mL control). Hospital and intensive care unit lengths of stay were similar and there were no differences in postinjection pneumonia, use of epidural catheters or adverse events bet ween groups.

Conclusion : While intercostal liposomal bupivacaine injection is a safe method for rib fracture-related analgesia, it was not effective in reducing pain scores, opioid requirements, or hospital length of stay. Bupivacaine injection transiently improved incentive spirometry volumes, but without a reduction in the development of pneumonia.

Conclusion (proposition de traduction) : Bien que l'injection intercostale de bupivacaïne liposomale soit une méthode sûre pour l'analgésie liée à une fracture costale, elle n'a pas été efficace pour réduire les scores de douleur, les besoins en opioïdes ou la durée du séjour à l'hôpital. L'injection de bupivacaïne a amélioré transitoirement les volumes de spirométrie incitative, mais sans réduction du développement de pneumopathie.

Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial.
Campion EM, Cralley A, Sauaia A, Buchheit RC, Brown AT, Spalding MC, LaRiccia A, Moore S, Tann K, Leskovan J, Camazine M, Barnes SL, Otaibi B, Hazelton JP, Jacobson LE, Williams J, Castillo R, Stewart NJ, Elterman JB, Zier L, Goodman M, Elson N, Miner J, Hardman C, Kapoen C, Mendoza AE, Schellenberg M, Benjamin E, Wakam GK, Alam HB, Kornblith LZ, Callcut RA, Coleman LE, Shatz DV, Burruss S, Linn AC, Perea L, Morgan M, Schroeppel TJ, Stillman Z, Carrick MM, . | J Trauma Acute Care Surg. 2022 Feb 1;92(2):355-361
DOI: https://doi.org/10.1097/ta.0000000000003447
Keywords: Aucun

2021 EAST PODIUM PAPER

Introduction : Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO₂) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO₂ have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO₂ values would be predictive of mortality and need for massive transfusion (MT) in intubated patients.

Méthode : This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused.

Résultats : A total of 1,324 patients were enrolled. ETCO₂ (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO₂ (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO₂ (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO₂ cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%.

Conclusion : Prehospital ETCO₂ is predictive of mortality and MT. ETCO₂ outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO₂ may outperform traditional measures in predicting need for transfusion in occult shock.

Conclusion (proposition de traduction) : L'ETCO₂ préhospitalier est prédictif de mortalité et de transfusion massive. L'ETCO₂ a surpassé les mesures traditionnelles telles que la pression artérielle systolique et le Shock Index dans la prédiction de la mortalité. L'ETCO₂ peut surpasser les mesures traditionnelles pour prédire le besoin de transfusion en cas de choc occulte.

Commentaire : L'analyse des patients normotendus a mis en évidence une ETCO₂ préhospitalier la plus basse, qui était plus prédictif de la mortalité que la pression artérielle systolique ou le Shock Index (p < 0,001). L'ETCO₂ préhospitalier le plus bas, la pression artérielle systolique et le Shock Index étaient prédictifs d'une transfusion massive chez les patients normotendus. Le seuil d'ETCO₂ pour une transfusion massive était de 26 mmHg. La valeur prédictive positive était de 16,1 % et la valeur prédictive négative était élevée à 98,1 %.

Pericardiocentesis: ultrasound guidance is essential.
Blanco P, Figueroa L, Menéndez MF, Berrueta B. | Ultrasound J. 2022 Feb 14;14(1):9
DOI: https://doi.org/10.1186/s13089-022-00259-5  | Télécharger l'article au format  
Keywords: Pericardial effusion; Pericardiocentesis; Point-of-care; Ultrasonography.

Case report

Introduction : Pericardial effusion is a common entity which may have important implications in patient's prognosis. In several cases, pericardiocentesis is indicated for diagnostic and/or therapeutic purposes.

Résultats : A blind pericardiocentesis failed in a 95-year-old woman admitted to the emergency department with a large pericardial effusion incidentally diagnosed in the ambulatory setting. Ultrasound-guided pericardiocentesis aided in easily accessing to the pericardial cavity, without periprocedural complications.

Conclusion : Ultrasound-guided pericardiocentesis is simple, safe and effective, and should replace the blind technique. This procedure should be part of the armamentarium of ultrasound-guided practices of emergency or critical care physicians.

Conclusion (proposition de traduction) : La péricardiocentèse échoguidée est simple, sûre et efficace et devrait remplacer la technique à l'aveugle. Cette procédure devrait faire partie de l'arsenal des pratiques guidées par échographie des médecins d'urgence ou de soins intensifs.