Bibliographie de Médecine d'Urgence

Mois de mars 2022


Academic Emergency Medicine

The prognostic value of emergency department measured hypertension: A systematic review and meta-analysis.
Reynard C, van den Berg P, Oliver G, Naguib MP, Sammut-Powell C, McMillan B, Heagerty A, Body R. | Acad Emerg Med. 2022 Mar;29(3):344-353
DOI: https://doi.org/10.1111/acem.14324  | Télécharger l'article au format  
Keywords: cardiovascular disease; emergency medicine; preventative medicine.

SYSTEMATIC REVIEWS (WITH OR WITHOUT META ANALYSES)

Introduction : The objective was to assess the prognostic value of hypertension detected in the emergency department (ED).

Méthode : The ED presents a unique opportunity to predict long-term cardiovascular disease (CVD) outcomes with its potential for high-footfall, and large-scale routine data collection applied to underserved patient populations. A systematic review and meta-analyses were conducted to assess the prognostic performance and feasibility of ED-measured hypertension as a risk factor for long-term CVD outcomes. We searched MEDLINE and Embase databases and gray literature sources. The target populations were undifferentiated ED patients. The prognostic factor of interest was hypertension. Feasibility outcomes included prevalence, reliability, and follow-up attendance. Meta-analyses were performed for feasibility using a random effect and exact likelihood.

Résultats : The searches identified 1072 studies after title and abstract review, 53 studies had their full text assessed for eligibility, and 26 studies were included. Significant heterogeneity was identified, likely due to the international populations and differing study design. The meta-analyses estimate of prevalence for ED-measured hypertension was 0.31 (95% confidence interval 0.25-0.37). ED hypertension was persistent outside the ED (FE estimate of 0.50). The proportion of patients attending follow-up was low with an exact likelihood estimate of 0.41. Three studies examined the prognostic performance of hypertension and demonstrated an increased risk of long-term CVD outcomes.

Conclusion : Hypertension can be measured feasibly in the ED and consequently used in a long-term cardiovascular risk prediction model. There is an opportunity to intervene in targeted individuals, using routinely collected data.

Conclusion (proposition de traduction) : L'hypertension peut être mesurée de manière réaliste au service des urgences et par conséquent utilisée dans un modèle de prédiction du risque cardiovasculaire à long terme. Il est possible d'intervenir auprès d'individus ciblés, en utilisant des données recueillies en routine.

Colchicine for acute gout.
Gottlieb M, Rabah W, Long B. | Acad Emerg Med. 2022 Mar;29(3):387-388
DOI: https://doi.org/10.1111/acem.14425
Keywords: colchicine, gout

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Gout is a common inflammatory condition of the joints. Episodes often begin rapidly and have a duration of days to weeks. The prevalence increases with age, occurring in up to 7% of men over the age of 65 years. Gout occurs due to an increase in the serum uric acid, with deposition in the joints eventually leading to inflammation that may present with pain, swelling, and redness (erythema) of the affected joint. Gout can be precipitated by toxins (e.g., alcohol), cellular breakdown (e.g., chemotherapy) or joint trauma. Although gout is self-resolving, medications can expedite resolution, reduce pain, and help patients return to their normal daily activities. Gout is commonly treated with anti-inflammatory medications, which can include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or glucocorticoids. The American College of Rheumatology guidelines recommend that NSAIDs, oral colchicine, or glucocorticoids may all be considered for the treatment of an acute gout flare.

Conclusion : Colchicine was associated with better pain control and more adverse events than placebo for acute gouty arthritis in small studies. Given the limitations of these studies, we have assigned a color recommendation of yellow (unclear if benefits) to this intervention particularly in light of the lack of benefit over common NSAIDs. Future studies should be performed with larger sample sizes that factor in patient comorbidities.

Conclusion (proposition de traduction) : La colchicine était associée à un meilleur contrôle de la douleur et à plus d'événements indésirables que le placebo dans le traitement des poussées aiguës de goutte dans de petites études. Compte tenu des limites de ces études, nous avons attribué une recommandation de couleur jaune (incertain pour les avantages) à cette intervention, en particulier à la lumière du manque de bénéfices par rapport aux AINS courants. Les études futures devraient être réalisées avec des échantillons plus importants qui tiennent compte des comorbidités des patients.

Commentaire : Quelques références :
• FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout [Recommandation pour la prise en charge de la goutte]. Arthritis Care Res (Hoboken). 2020;72(6):744-760  .
• McKenzie BJ, Wechalekar MD, Johnston RV, Schlesinger N, Buchbinder R. Colchicine for acute gout [La colchicine dans le traitement des poussées aiguës de goutte]. Cochrane Database Syst Rev. 2021 Aug 26;8(8):CD006190  . & analyse de l'article dans Colchicine dans le traitement des poussées aiguës de goutte   sur la version française du site Internet Cochrane  , en août 2021.
• van Durme CM, Wechalekar MD, Landewé RB, Pardo Pardo J, Cyril S, van der Heijde D, Buchbinder R. Non-steroidal anti-inflammatory drugs for acute gout [Anti-inflammatoires non stéroïdiens dans la crise de goutte aiguë]. Cochrane Database Syst Rev. 2021 Dec 9;12(12):CD010120  .

Can right ventricular assessments improve triaging of low risk pulmonary embolism?.
Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, O'Connell NS, Weekes AJ. | Acad Emerg Med. 2022 Mar 15
DOI: https://doi.org/10.1111/acem.14484
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the simplified pulmonary embolism severity index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to 1) determine if RV assessment variables add prognostic accuracy for 5-day clinical deterioration in patients classified low risk by sPESI, and 2) determine the prognostic importance of RV assessments compared to other variables and to each other.

Méthode : We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed and compared prognostic accuracy of full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE.

Résultats : Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by computed tomography (CT), 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77-0.82) and 0.71 (0.68-0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5-day clinical deterioration by the multivariable logistic regression.

Conclusion : A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5-day clinical deterioration versus one without.

Conclusion (proposition de traduction) : Une stratégie de triage de l'embolie pulmonaire avec une évaluation par imagerie du ventricule droit (écho) avait une performance pronostique supérieure pour classer le faible risque de détérioration clinique (évalué sur la base du sPESI) à 5 jours par rapport à une stratégie sans.

Acute Medicine & Surgery

Airway obstruction time and outcomes in patients with foreign body airway obstruction: multicenter observational choking investigation.
Igarashi Y, Norii T, Sung-Ho K, Nagata S, Yoshino Y, Hamaguchi T, Nagaosa R, Nakao S, Tagami T, Yokobori S. | Acute Med Surg. 2022 Mar 13;9(1):e741.
DOI: https://doi.org/10.1002/ams2.741  | Télécharger l'article au format  
Keywords: Airway management; cardiac arrest; foreign body airway obstruction; resuscitation; vegetative state.

Original Article

Introduction : Foreign body airway obstruction (FBAO) is a major public health concern worldwide for infants and older adults. This study determines the association between airway obstruction time and neurological outcomes to plan an effective response for patients with FBAO.

Méthode : This multicenter retrospective observational study was carried out among patients with life-threatening FBAO in Japan over a period of 4 years. The duration of airway obstruction was calculated from the time of the accident to the time of foreign body removal. The study examined the relationship between airway obstruction time and outcome. The primary outcome was vegetative state or death at hospital discharge.

Résultats : Among 119 patients, 68 were in the category of vegetative state or death. Logistic regression analysis showed that longer airway obstruction time (adjusted odds ratio 1.04; 95% confidence interval 1.01-1.07) was associated with vegetative state or death. When the cut-off value was set at 10, the sensitivity was 0.88, the specificity 0.47, with the area under the curve 0.69. Using the other cut-off value of 4 min, the negative predictive value was 1.00.

Conclusion : Longer airway obstruction time was associated with vegetative state or death for patients with FBAO. The incidence of vegetative state or death increased when the airway obstruction time exceeded 10 min. Meanwhile, 4 min or less may be set as a target time for foreign body removal in order to prevent vegetative state or death and plan an effective response.

Conclusion (proposition de traduction) : Une durée d'obstruction des voies respiratoires supérieures plus longue était associée à un état végétatif ou à la mort chez les patients présentant une obstruction des voies respiratoires par un corps étranger. L'incidence de l'état végétatif ou de la mort augmentait lorsque le temps d'obstruction des voies respiratoires dépassait 10 min. Pendant ce temps, 4 minutes ou moins peuvent être définies comme temps cible pour l'élimination des corps étrangers afin de prévenir l'état végétatif ou la mort et de planifier une réponse efficace.

American Journal of Respiratory and Critical Care Medicine

Association of ICU Admission and Outcomes in Sepsis and Acute Respiratory Failure.
Anesi GL, Liu VX, Chowdhury M, Small DS, Wang W, Delgado MK, Bayes B, Dress E, Escobar GJ, Halpern SD. | Am J Respir Crit Care Med. 2022 Mar 1;205(5):520-528
DOI: https://doi.org/10.1164/rccm.202106-1350oc
Keywords: ICU admission; acute respiratory failure; capacity strain; sepsis; triage.

Original Article

Introduction : Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness.
Objectives: To measure the benefits of ICU admission for patients with sepsis or acute respiratory failure.

Méthode : At 27 United States hospitals across two health systems from 2013 to 2018, we performed a retrospective cohort study using two-stage instrumental variable quantile regression with a strong instrument (hospital capacity strain) governing ICU versus ward admission among high-acuity patients (i.e., laboratory-based acute physiology score v2 ⩾ 100) with sepsis and/or acute respiratory failure who did not require mechanical ventilation or vasopressors in the emergency department.

Résultats : Among patients with sepsis (n = 90,150), admission to the ICU was associated with a 1.32-day longer hospital length of stay (95% confidence interval [CI], 1.01-1.63; P < 0.001) (when treating deaths as equivalent to long lengths of stay) and higher in-hospital mortality (odds ratio, 1.48; 95% CI, 1.13-1.88; P = 0.004). Among patients with respiratory failure (n = 45,339), admission to the ICU was associated with a 0.82-day shorter hospital length of stay (95% CI, -1.17 to -0.46; P < 0.001) and reduced in-hospital mortality (odds ratio, 0.75; 95% CI, 0.57-0.96; P = 0.04). In sensitivity analyses of length of stay, excluding, ignoring, or censoring death, results were similar in sepsis but not in respiratory failure. In subgroup analyses, harms of ICU admission for patients with sepsis were concentrated among older patients and those with fewer comorbidities, and the benefits of ICU admission for patients with respiratory failure were concentrated among older patients, highest-acuity patients, and those with more comorbidities.

Conclusion : Among high-acuity patients with sepsis who did not require life support in the emergency department, initial admission to the ward, compared with the ICU, was associated with shorter length of stay and improved survival, whereas among patients with acute respiratory failure, triage to the ICU compared with the ward was associated with improved survival.

Conclusion (proposition de traduction) : Chez les patients présentant une septicémie aigüe qui n'avaient pas besoin de réanimation aux urgences, l'admission initiale dans un service, par rapport aux soins intensifs, était associée à une durée de séjour plus courte et à une amélioration de la survie, tandis que chez les patients souffrant d'insuffisance respiratoire aiguë, le triage vers l'unité de soins intensifs par rapport au service était associée à une meilleure survie.

Annales françaises de médecine d'urgence

Perinatal Management of Newborns in Out-of-Hospital Births.
Javaudin F, Zayat N, Bagou G, Mitha A, Chapoutot AG. | Ann Fr Med Urgence. 2022 Mars;12:95–110
DOI: https://doi.org/10.3166/afmu-2022-0396
Keywords: Prehospital; Newborn; Neonatal resuscitation; Perinatal care; Out-of-hospital births

Mise au point

Editorial : Les accouchements inopinés extrahospitaliers représentent environ 0,3 % des accouchements en France. La prise en charge du nouveau-né en préhospitalier par une équipe Smur fait partie de l’activité courante. L’évaluation initiale du nouveau-né comprend systématiquement la mesure de sa fréquence cardiaque (FC) et respiratoire (FR), l’appréciation de son tonus ainsi que la mesure de sa température axillaire. En cas de doute ou de transition incomplète un monitoring cardiorespiratoire sera immédiatement mis en place (FC, FR, SpO2). Nous faisons ici une mise au point sur les données connues et avons adapté les pratiques, si besoin, au contexte extrahospitalier, car la majeure partie des données rapportées dans la littérature concernent les prises en charge en maternité ou en milieu hospitalier. Nous abordons les points essentiels de la prise en charge des nouveau-nés, à savoir la réanimation cardiopulmonaire, le clampage tardif du cordon ombilical, la lutte contre l’hypothermie et l’hypoglycémie; ainsi que des situations particulières comme la prématurité, la conduite à tenir en cas de liquide méconial ou de certaines malformations congénitales. Nous proposons aussi quels peuvent être : le matériel nécessaire à la prise en charge des nouveau-nés en extrahospitalier, les critères d’engagement d’un renfort pédiatrique à la régulation ainsi que les méthodes de ventilation et d’abord vasculaire que l’urgentiste doit maîtriser. L’objectif de cette mise au point est de proposer des prises en charge les plus adaptées au contexte préhospitalier.

Conclusion (proposition de traduction) : L’évaluation initiale du nouveau-né comprend systématiquement la mesure de sa FC et FR, l’appréciation de son tonus ainsi que la mesure de sa température axillaire. En cas de doute ou de transition incomplète, un monitoring cardiorespiratoire sera immédiatement mis en place (FC, FR, SpO2). En cas de transition incomplète ou d’échec de transition, des manoeuvres de réanimation sont nécessaires. Si possible le clampage du cordon sera retardé à plus d’une minute et le nouveau-né réchauffé grâce à un bonnet, mis dans un sac polyéthylène puis en peau-à-peau. En préhospitalier, la glycémie ne sera mesurée qu’en cas de symptômes ou de facteurs de risque d’hypoglycémie. À tout moment de la prise en charge, la nécessité d’un renfort par une équipe Smur pédiatrique doit être évaluée.

Commentaire :  Algorithme de réanimation cardiopulmonaire du nouveau-né, inspiré des recommandations de l’ERC 2021.
ERC : European Resuscitation Council ; SpO2 : saturation pulsée en oxygène ; MSD : membre supérieur droit ; FiO2 : fraction inspirée en oxygène ; PEP : pression expiratoire positive ; PIP : pression d’insufflation ; SA : semaines d’aménorrhée ; ATB : antibiothérapie ; FC : fréquence cardiaque ; CTE : compressions thoraciques externes ; ETCO2 : concentration télé-expiratoire de CO2 (capnographie) ; IV : intraveineux ; RCP : réanimation cardiopulmonaire ; Pi : pression d’insufflation

Febrile Seizures: a Perspective for the Emergency Physician.
Guedj R, De Suremain N, Cavau A, Enault M, Carbajal R. | Ann Fr Med Urgence. 2022 Mar;12:87-94
DOI: https://doi.org/10.3166/afmu-2022-0389
Keywords: Febrile seizure; Lumbar puncture; Neuroimaging; Epilepsy; Pediatrics

Mise au point

Introduction : Les crises fébriles (CF), définies comme des crises d’épilepsie en contexte fébrile chez un enfant âgé entre six mois et cinq ans sans infection du système nerveux central affectent entre 2 et 5 % des enfants. Leur pronostic à long terme est excellent, n’exposant ni à un excès de mortalité ni à une diminution des compétences intellectuelles et comportementales. Poser le diagnostic de CF nécessite d’éliminer les autres causes de crises d’épilepsie en contexte fébrile, dont une méningite bactérienne et une méningoencéphalite herpétique. Cependant, le diagnostic de CF ne nécessite généralement aucun examen complémentaire sous réserve d’un interrogatoire et d’un examen clinique minutieux. L’indication des examens complémentaires pour identifier l’étiologie de la fièvre n’est pas modifiée par le fait que l’enfant ait présenté une CF. Bien qu’un tiers des enfants ayant eu une CF récidiveront au moins une fois avant l’âge de cinq ans, aucune mesure prophylactique (traitement antiépileptique, prise en charge agressive de la fièvre) n’est indiquée pour éviter ces récidives pour la quasi-totalité de ces enfants. Plusieurs facteurs de risque d’épilepsie sont à rechercher pour identifier les rares patients nécessitant un avis spécialisé sans urgence. Enfin, assister à un épisode de CF est une expérience très éprouvante pour les parents. Plusieurs messages clés doivent être délivrés aux parents avant le retour au domicile dans le but d’améliorer leur compréhension de l’épisode qui a eu lieu et de prévenir un syndrome posttraumatique ainsi que des modifications du comportement parental face à la fièvre.

Conclusion (proposition de traduction) : Tout médecin travaillant dans une structure d’urgence accueillant des enfants est amené à prendre en charge des patients ayant présenté une CF, du fait de leur fréquence. Plusieurs challenges sont associés à la prise en charge de cette pathologie dont l’évolution est dans la très grande majorité des cas bénigne : ne pas rater les rares patients ayant une infection du SNC se présentant sous la forme de crise d’épilepsie fébrile tout en limitant au maximum les examens complémentaires chez les patients n’en ayant pas besoin ; identifier les quelques patients dont la CF est l’épisode inaugural d’une épilepsie ; identifier les quelques patients à risque de récidive de CF sous forme d’état de mal épileptique afin de discuter la prescription d’un traitement antiépileptique d’urgence au domicile ; enfin, prendre le temps de délivrer de nombreux messages clés aux parents lors de la visite aux urgences dans le but d’améliorer leur compréhension de l’épisode qui a eu lieu et de prévenir un syndrome post-traumatique ainsi que des modifications du comportement parental face à la fièvre.

Annals of Emergency Medicine

External Aortic Compression in Noncompressible Truncal Hemorrhage and Traumatic Cardiac Arrest: A Scoping Review.
Soeyland T, Hollott JD, Garner A. | Ann Emerg Med. 2022 Mar;79(3):297-310
DOI: https://doi.org/10.1016/j.annemergmed.2021.07.132
Keywords: Aucun

Trauma

Editorial : External aortic compression has been investigated as a treatment for non-compressible truncal haemorrhage in trauma patients. We sought to systematically gather and tabulate the available evidence around external aortic compression. We were specifically interested in its ability to achieve hemostasis and aid in resuscitation of traumatic arrest and severe shock and to consider physiological changes and adverse effects. A scoping review approach was chosen due to the highly variable existing literature. We were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the specific extension for scoping reviews. Searches were done on PubMed and Scopus databases in October 2020. We found that a range of studies have investigated external aortic compression in a variety of settings, including case reports and small case series, porcine hemorrhage models and effects on healthy volunteers. External aortic compression for postpartum hemorrhage in a single center provided some evidence of effectiveness. Overall the level of evidence is limited, however, external aortic compression does appear able to achieve cessation of distal blood flow. Furthermore, it appears to improve many relevant physiological parameters in the setting of hypovolemic shock. Application for more than 60 minutes appears to cause increasingly problematic complications. In conclusion we find that the role of external aortic compression warrants further research. The intervention may have a role as a bridge to definitive treatment of noncompressible truncal haemorrahge.

Conclusion : It is our interpretation that external aortic compression may have a role in rural, remote, and austere management of trauma as a bridge to definitive care, given the simplicity of the technique compared to the more invasive interventions. For some trauma and obstetric situations, the use of external aortic compression in extreme circumstances is probably warranted now as a last-ditch measure pending further developments in this field. The role of external aortic compression should be investigated further in parallel with other treatment modalities such as REBOA and preperitoneal packing.
Finally, if external aortic compression is applied with clinical improvement, the release phase of treatment needs to be carefully planned. Preparation to treat a likely crush syndrome needs to be made in parallel with the definitive treatment of the underlying pathology, be it through surgery or interventional endovascular techniques.

Conclusion (proposition de traduction) : Selon notre interprétation, la compression aortique externe peut jouer un rôle dans la gestion rurale, éloignée et austère des traumatismes en tant que passerelle vers des soins définitifs, étant donné la simplicité de la technique par rapport aux interventions plus invasives. Pour certaines situations traumatiques et obstétriques, l'utilisation de la compression aortique externe dans des circonstances extrêmes est probablement justifiée maintenant comme mesure de dernier recours en attendant de nouveaux développements dans ce domaine. Le rôle de la compression aortique externe doit être étudié plus avant en parallèle avec d'autres modalités de traitement telles que REBOA et l'emballage prépéritonéal.
Enfin, si la compression aortique externe est appliquée avec une amélioration clinique, la phase de libération du traitement doit être soigneusement planifiée. La préparation pour traiter un syndrome d'écrasement probable doit être faite en parallèle avec le traitement définitif de la pathologie sous-jacente, que ce soit par la chirurgie ou les techniques endovasculaires interventionnelles.

Commentaire : 

Archives of Academic Emergency Medicine

Skin Cooling to Reduce the Pain Associated with Local Anesthetic Injection; a Randomized Controlled Trial.
Majidinejad S, Heidari F, Famil Chitgarian A. | Arch Acad Emerg Med. 2022 Mar 10;10(1):e20
DOI: https://doi.org/10.22037/aaem.v10i1.1562  | Télécharger l'article au format  
Keywords: Anesthesia; Emergency Service; Hospital; Injections; Lidocaine; Local; Pain; Wounds and Injuries.

Original/Research Article

Introduction : Different methods have been proposed for the reduction of the pain caused by the injection of local anesthetics. This study aimed to evaluate the effect of skin cooling on reduction of pain associated with local injection of lidocaine buffered with sodium bicarbonate.

Méthode : This randomized controlled trial included 108 adult patients with arm/forearm wounds who referred to the emergency departments. Participants were randomly allocated to two equal groups. Patients in both groups received subcutaneous injection of buffered lidocaine. In the intervention group, an ice cube measuring 2 × 2 × 2 cm (at 0 ° C) in sterile gloves were placed on the wound for 2 minutes before the injection of buffered lidocaine. The primary outcome was severity of pain during lidocaine injection using a visual analog scale (VAS).

Résultats : One hundred and eight patients were enrolled in the study, 54 in each group. There was no statistically significant difference in age (p = 0.777), sex (p = 0.466), and length of laceration (p = 0.410) between the two groups. The pain scores during lidocaine injection were significantly lower in the intervention group compared to control group (2.39 ± 1.14 vs 4.26 ± 0.94, p < 0.001).

Conclusion : Skin cooling prior to the injection of local anesthetics can significantly reduce the pain caused by local anesthetic infiltration.

Conclusion (proposition de traduction) : Le refroidissement de la peau avant l'injection d'anesthésiques locaux peut réduire considérablement la douleur causée par l'infiltration d'anesthésique local.

Australasian Emergency Care

Challenges in the recognition and management of paediatric sepsis - The journey.
Harley A, Schlapbach LJ, Johnston ANB, Massey D. | Australas Emerg Care. 2022 Mar;25(1):23-29
DOI: https://doi.org/10.1016/j.auec.2021.03.006  | Télécharger l'article au format  
Keywords: Community; Emergency nurse; Guideline; Long-term outcome; Paediatric; Sepsis.

Discussion

Editorial : Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.

Conclusion : In conclusion, integration of the community, healthcare and university sector targeting the recognition and management of children with sepsis is needed to enable a sustainable improve- ment in paediatric sepsis outcomes. This critical discussion can help direct healthcare workers and policy makers as they develop, implement and evaluate interventions to improve the recognition and management of paediatric sepsis.

Conclusion (proposition de traduction) : En conclusion, l'intégration des secteurs communautaire (médecine de ville), soins de santé et des universités visant la reconnaissance et la prise en charge des enfants présentant une septicémie est nécessaire pour permettre une amélioration durable des résultats du sepsis pédiatrique. Cette discussion critique peut aider à orienter les travailleurs de la santé et les décideurs politiques à mesure qu'ils élaborent, mettent en œuvre et évaluent des interventions visant à améliorer la reconnaissance et la prise en charge de la septicémie en pédiatrie.

Are chest X-rays valuable for patients presenting to emergency departments with acute abdominal pain?.
Evans B, Ali H, Ekpo E. | Australas Emerg Care. 2022 Mar;25(1):84-87
DOI: https://doi.org/10.1016/j.auec.2021.03.009
Keywords: Abdominal pain; Diagnosis; Evidence-based medicine; Radiography.

Full length article

Introduction : Emergency department patients presenting with acute abdominal pain are often prescribed a chest X-ray; however, the value of chest X-rays in acute abdominal pain is poorly understood. The aim of this study was to assess the value of chest X-rays in acute abdominal pain.

Méthode : A retrospective analysis of 944 chest X-rays performed for acute abdominal pain was conducted. Patient clinical information, radiology reports, and findings of other diagnostic investigations were also collected. MedCal® software was used to calculate diagnostic performance of chest X-rays. A Chi-Square test was used to assess the association between positive chest X-ray findings and both age and gender.

Résultats : Of the 944 chest X-rays identified as satisfying inclusion factors, only 10 cases (approximately 1%) demonstrated pathology that was likely to be the cause of the abdominal pain. Further analysis demonstrated the following performance metrics at 95%CI: sensitivity (12.8; 8.78-17.72); specificity (100; 98.4-100); positive predictive value (100%); negative predictive value (52.76; 51.54-53.98); accuracy (55.82; 51.17-60.40).

Conclusion : Chest X-ray has limited sensitivity and diagnostic value in patients presenting to the emergency department with abdominal pain and does not appear to be a useful diagnostic investigation for abdominal pain.

Conclusion (proposition de traduction) : La radiographie thoracique a une sensibilité et une valeur diagnostique limitées chez les patients se présentant aux urgences avec des douleurs abdominales et ne semble pas être un examen diagnostique utile pour les douleurs abdominales.

A state-of-the-art review of factors that predict mortality among traumatic injury patients following a road traffic crash.
Alharbi RJ, Lewis V, Miller C. | Australas Emerg Care. 2022 Mar;25(1):13-22
DOI: https://doi.org/10.1016/j.auec.2021.01.005  | Télécharger l'article au format  
Keywords: Mortality risk factors; Traffic crashes; Transport injury; Traumatic injury.

Review article

Introduction : Traffic related injuries are a major public health problem worldwide with millions of people dying every year. The objective of this state-of-the-art review was to identify the factors reported in the literature as being associated with mortality for trauma patients following road traffic crashes.

Méthode : A systematic search was undertaken of PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library databases to identify articles published in the past two decades (2000-2020). Of 8257 records, 4507 remained for title, abstract and full text screening after duplicates were removed. The level of evidence of selected studies was assessed using The National Health and Medical Research Council (NHMRC) guideline.

Résultats : This review included eighty primary research studies examining mortality risk factors following a road traffic crash. The study identified factors in five categories; (i) demographic factors; (ii) behavioural factors; (iii) crash characteristics; (iv) environmental and timing factors; (v) injury severity and pre-injury/condition. The primary studies are summarised in a matrix. Included studies included level II to level IV levels of evidence based on the NHMRC criteria.

Conclusion : This study shows that there are a large number of factors associated with increased risk of mortality following diverse types of traffic crashes. Understanding these wide-ranging factors can strengthen injury and mortality prevention by guiding decision makers about where to focus strategy implementation.

Conclusion (proposition de traduction) : Cette étude montre qu'il existe un grand nombre de facteurs associés à un risque accru de mortalité à la suite de divers types d'accidents de la route. La compréhension de ces facteurs de grande envergure peut renforcer la prévention des blessures et de la mortalité en guidant les décideurs sur les domaines sur lesquels concentrer la mise en œuvre de la stratégie.

Commentaire :  Synthèse des principaux facteurs prédictifs de risque et de mortalité suite à différents types d'accidents de la route.

BMC Emergency Medicine

Predictive performances of ALS and BLS termination of resuscitation rules in out-of-hospital cardiac arrest for different resuscitation protocols.
Lin YY, Lai YY, Chang HC, Lu CH, Chiu PW, Kuo YS, Huang SP, Chang YH, Lin CH. | BMC Emerg Med. 2022 Mar 27;22(1):53
DOI: https://doi.org/10.1186/s12873-022-00606-8  | Télécharger l'article au format  
Keywords: Advanced life support; Basic life support; Out-of-hospital cardiac arrest; Predictive performance; Resuscitation; Termination of resuscitation.

Research article

Introduction : Resuscitation guidance has advanced; however, the predictive performance of the termination of resuscitation (TOR) rule has not been validated for different resuscitation protocols published by the American Heart Association (AHA).

Méthode : A retrospective study validating the basic life support (BLS) and advanced life support (ALS) TOR rules was conducted using an Utstein-style database in Tainan city, Taiwan. Adult patients with nontraumatic out-of-hospital cardiac arrests from January 1, 2015, to December 31, 2015, (using the AHA 2010 resuscitation protocol) and from January 1, 2020, to December 31, 2020, (using the AHA 2015 resuscitation protocol) were included. The characteristics of rule performance were calculated, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value.

Résultats : Among 1260 eligible OHCA patients in 2015, 757 met the BLS TOR rule and 124 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 61.1% and 99.0%, respectively, for the BLS TOR rule and 93.8% and 99.2%, respectively, for the ALS TOR rule. A total of 970 OHCA patients were enrolled in 2020, of whom 438 met the BLS TOR rule and 104 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 85.7% and 100%, respectively, for the BLS TOR rule and 99.5% and 100%, respectively, for the ALS TOR rule.

Conclusion : Both the BLS and ALS TOR rules performed better when using the 2015 AHA resuscitation protocols compared to the 2010 protocols, with increased PPVs and decreased false-positive rates in predicting survival to discharge and good neurological outcomes at discharge. The BLS and ALS TOR rules can perform differently while the resuscitation protocols are updated. As the concepts and practices of resuscitation progress, the BLS and ALS TOR rules should be evaluated and validated accordingly.

Conclusion (proposition de traduction) : Les règles TOD du BLS et de l'ALS ont obtenu de meilleurs résultats lors de l'utilisation des protocoles de réanimation AHA 2015 par rapport aux protocoles 2010, avec des valeurs prédictives positives accrues et une diminution des taux de faux positifs dans la prédiction de la survie à la sortie et de bons résultats neurologiques à la sortie. Les règles TOR du BLS et de l'ALS peuvent fonctionner différemment lors de la mise à jour des protocoles de réanimation. Au fur et à mesure que les concepts et les pratiques de réanimation progressent, les règles TOR du BLS et de l'ALS doivent être évaluées et validées en conséquence.

Serum D-dimer level as a predictor of neurological functional prognosis in cases of head injuries caused by road traffic accidents.
Asami M, Nakahara S, Miyake Y, Kanda J, Onuki T, Matsuno A, Sakamoto T. | BMC Emerg Med. 2022 Mar 26;22(1):51
DOI: https://doi.org/10.1186/s12873-022-00613-9  | Télécharger l'article au format  
Keywords: Head injuries; Neurological functional predictors; Road traffic accidents; Serum D-dimer.

Research

Introduction : The number of traffic fatalities is declining in Japan; however, a large proportion of head injuries are still attributable to traffic accidents. Severe head trauma may cause progressive and devastating coagulopathy owing to exacerbated coagulation and fibrinolysis, which results in massive bleeding and poor patient outcomes. D-dimer is a fibrinolytic marker, which remarkably increases in severe coagulopathy due to the exacerbated fibrinolytic system. Because the degree of coagulopathy is associated with patient outcomes, the D-dimer level is a useful prognostic predictor in patients with head trauma. However, the usefulness of D-dimer in cases of head trauma caused by road traffic accidents remains inadequately explored. In this study, we investigated the relationship between D-dimer levels and outcomes in head injuries caused by traffic accidents.

Méthode : We extracted data on traffic injuries from Japan Neuro-Trauma Data Bank Project 2015, which is a prospective multicenter registry of head injuries. The analysis included 335 individuals with no missing data. The outcome variable was the score of the Glasgow Outcome Scale (GOS), a neurological outcome index. The participants were categorized into the favorable outcome (GOS score ≥ 4) and poor outcome (GOS score ≤ 3) groups. The serum D-dimer levels at the time of admission were divided into four categories at the quartiles, and the reference category was less than the first quartile (< 17.4 µg/mL). We performed a logistic regression analysis with GOS as the dependent variable and D-dimer as a predictor and performed a multivariate analysis that was adjusted for 10 physiological parameters.

Résultats : In the univariate analysis, all groups with serum D-dimer values ≥ 17.4 μg/dL showed significantly poorer outcomes than those of the reference group. In the multivariate analysis, after adjusting for other factors, D-dimer levels ≥ 89.3 μg/dL were an independent predictor of poor outcome.

Conclusion : After adjusting for physiological parameters, high serum D-dimer levels can be an independent factor for predicting neurological prognosis in head trauma caused by road traffic accidents.

Conclusion (proposition de traduction) : Après ajustement des paramètres physiologiques, des niveaux élevés de D-dimères sériques peuvent être un facteur indépendant pour prédire le pronostic neurologique des traumatismes crâniens causés par les accidents de la route.

Commentaire : Dans l'analyse univariée, tous les groupes avec des valeurs de D-dimères sériques ≥ 17,4 μg/dL (174 µg/l) ont montré des résultats significativement moins bons que ceux du groupe de référence. Dans l'analyse multivariée, après ajustement pour d'autres facteurs, les taux de D-dimères ≥ 89,3 (893 µg/l) μg/dL étaient un facteur prédictif indépendant de mauvais résultat.

Sodium and potassium disorders in patients with COPD exacerbation presenting to the emergency department.
Lindner G, Herschmann S, Funk GC, Exadaktylos AK, Gygli R, Ravioli S. | BMC Emerg Med. 2022 Mar 24;22(1):49
DOI: https://doi.org/10.1186/s12873-022-00607-7  | Télécharger l'article au format  
Keywords: COPD; Electrolyte disorders; Emergency; Potassium; Sodium.

Research

Méthode : Electrolyte disorders are common in the emergency department. Hyponatremia is known to be associated with adverse outcome in community-acquired pneumonia (CAP) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD). No studies investigating the prevalence and influence of hypernatremia or potassium disorders in patients with AECOPD exist.

Résultats : In this retrospective cohort analysis, the prevalence of sodium and potassium disorders was investigated in patients with AECOPD presenting to an emergency department (ED) between January 1st 2017 and December 31st 2018 and compared to all ED patients with electrolyte measurements and patients presenting with CAP. Exclusion criteria were age younger than 18 years, written or verbal withdrawal of consent and outpatient treatment. Additionally, the influence of dysnatremias and dyskalemias on outcome measured by ICU admission, need for mechanical ventilation, length of hospital stay, 30-day re-admission, 180-day AECOPD recurrence and in-hospital mortality and their role as predictors of disease severity measured by Pneumonia Severity Index (PSI) were investigated in patients with AECOPD.

Discussion : Nineteen point nine hundred forty-eight ED consultations with measurements of sodium and potassium were recognized between January 1st 2017 and December 31st 2018 of which 102 patients had AECOPD. Of these 23% had hyponatremia, 5% hypernatremia, 16% hypokalemia and 4% hyperkalemia on admission to the ED. Hypo- and hypernatremia were significantly more common in patients with AECOPD than in the overall ED population: 23 versus 11% (p = 0.001) for hypo- and 5% versus 0.6% (p < 0.001) for hypernatremia. In the logistic regression analysis, no association between the presence of either sodium or potassium disorders and adverse outcome were found.

Conclusion : Dysnatremias and dyskalemias are common in patients with AECOPD with as many as 1 in 5 having hyponatremia and/or hypokalemia. Hypo- and hypernatremia were significantly more common in AECOPD than overall. No significant association was found for dysnatremias, dyskalemias and adverse outcomes in AECOPD.

Conclusion (proposition de traduction) : Les dysnatrémies et les dyskaliémies sont fréquentes chez les patients présentant une exacerbation aiguë de la maladie pulmonaire obstructive chronique, jusqu'à 1 sur 5 présentant une hyponatrémie et/ou une hypokaliémie. L'hypo- et l'hypernatrémie étaient significativement plus fréquentes dans l'exacerbation aiguë de la maladie pulmonaire obstructive chronique que dans l'ensemble. Aucune association significative n'a été trouvée pour les dysnatrémies, les dyskaliémies et les effets indésirables dans l'exacerbation aiguë de la maladie pulmonaire obstructive chronique.

The effects of Pre-hospital Trauma Life Support (PHTLS) training program on the on-scene time interval.
Esmaeilzadeh MH, Rostamian M, Khorasani-Zavareh D, Shirazi FB, Mogharab M. | BMC Emerg Med. 2022 Mar 19;22(1):45
DOI: https://doi.org/10.1186/s12873-022-00591-y  | Télécharger l'article au format  
Keywords: Emergency medical services; Pre-hospital Trauma Life Support; Time management; Trauma.

Research

Introduction : Recent studies have shown that reducing pre-hospital time could improve the outcomes of trauma victims. Due to the importance of pre-hospital time management, this study aims to determine the effects of the Pre-hospital Trauma Life Support (PHTLS) training program on the on-scene time interval reduction.

Méthode : The PHTLS training program was implemented based on global standards for pre-hospital emergency technicians. The research tool was a questionnaire designed by the Ministry of Health and Medical Education in Iran. The mean on-scene time interval was calculated before, after and one month after the intervention in the control (n = 32) and experimental group (n = 32). The data were analyzed using SPSS.

Résultats : The mean on-scene time interval in the target group (one month after intervention) has been significantly lower than that of the control group. Moreover, the mean and standard deviation from the on-scene time interval in the target group has been reduced from 17.6 ± 5.5 (before intervention) to 12 ± 3.8 min (one month after intervention) which was statistically significant.

Conclusion : The implementation of the PHTLS training program can lead to the reduction of on-scene time interval. Therefore, considering the role of reducing on-scene time intervals on victims' survival, the integration of the PHTLS training programs with pre-hospital emergency medical service systems seems inevitable.

Conclusion (proposition de traduction) : La mise en œuvre du programme de formation PHTLS peut conduire à la réduction de l'intervalle de temps sur les lieux. Par conséquent, compte tenu du rôle de la réduction des intervalles de temps sur les lieux sur la survie des victimes, l'intégration des programmes de formation PHTLS dans les systèmes de services médicaux d'urgence préhospitaliers semble inévitable.

Management of intoxicated patients - a descriptive outcome analysis of 4,267 ICU patients.
Rezar R, Jung C, Mamandipoor B, Seelmaier C, Felder TK, Lichtenauer M, Wernly S, Zwaag SM, De Lange DW, Wernly B, Osmani V. | BMC Emerg Med. 2022 Mar 12;22(1):38
DOI: https://doi.org/10.1186/s12873-022-00602-y  | Télécharger l'article au format  
Keywords: Critical illness; Epidemiology; Hospital mortality; Intensive care units; Poisoning.

Research

Introduction : Intoxications are common in intensive care units (ICUs). The number of causative substances is large, mortality usually low. This retrospective cohort study aims to characterize differences of intoxicated compared to general ICU patients, point out variations according to causative agents, as well as to highlight differences between survivors and non-survivors among intoxicated individuals in a large-scale multi-center analysis.

Méthode : A total of 105,998 general ICU patients and 4,267 individuals with the admission diagnoses "overdose" and "drug toxicity" from the years 2014 and 2015 where included from the eICU Collaborative Research Database. In addition to comparing these groups with respect to baseline characteristics, intensive care measures and outcome parameters, differences between survivors and non-survivors from the intoxication group, as well as the individual groups of causative substances were investigated.

Résultats : Intoxicated patients were younger (median 41 vs. 66 years; p<0.001), more often female (55 vs. 45%; p<0.001), and normal weighted (36% vs. 30%; p<0.001), whereas more obese individuals where observed in the other group (37 vs. 31%; p<0.001). Intoxicated individuals had a significantly lower mortality compared to general ICU patients (1% vs. 10%; aOR 0.07 95%CI 0.05-0.11; p<0.001), a finding which persisted after multivariable adjustment (aOR 0.17 95%CI 0.12-0.24; p<0.001) and persisted in all subgroups. Markers of disease severity (SOFA-score: 3 (1-5) vs. 4 (2-6) pts.; p<0.001) and frequency of vasopressor use (5 vs. 15%; p<0.001) where lower, whereas rates of mechanical ventilation where higher (24 vs. 26%; p<0.001) in intoxicated individuals. There were no differences with regard to renal replacement therapy in the first three days (3 vs. 4%; p=0.26). In sensitivity analysis (interactions for age, sex, ethnicity, hospital category, maximum initial lactate, mechanical ventilation, and vasopressor use), a trend towards lower mortality in intoxicated patients persisted in all subgroups.

Conclusion : This large-scale retrospective analysis indicates a significantly lower mortality of intoxicated individuals compared to general ICU patients.

Conclusion (proposition de traduction) : Cette analyse rétrospective à grande échelle indique une mortalité significativement plus faible des personnes intoxiqués par rapport aux patients généraux des soins intensifs.

Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn.
Huang RY, Chen SJ, Hsiao YC, Kuo LW, Liao CH, Hsieh CH, Bajani F, Fu CY. | BMC Emerg Med. 2022 Mar 8;22(1):36
DOI: xhttps://doi.org/10.1186/s12873-022-00594-9  | Télécharger l'article au format  
Keywords: Endotracheal tube; Facial burn; Short of breath; TBSA.

Research

Introduction : After clinical evaluation in the emergency department (ED), facial burn patients are usually intubated to protect their airways. However, the possibility of unnecessary intubation or delayed intubation after admission exists. Objective criteria for the evaluation of inhalation injury and the need for airway protection in facial burn patients are needed.

Méthode : Facial burn patients between January 2013 and May 2016 were reviewed. Patients who were and were not intubated in the ED were compared. All the intubated patients received routine bronchoscopy and laboratory tests to evaluate whether they had inhalation injuries. The patients with and without confirmed inhalation injuries were compared. Multivariate logistic regression analysis was used to identify the independent risk factors for inhalation injuries in the facial burn patients. The reasons for intubation in the patients without inhalation injuries were also investigated.

Résultats : During the study period, 121 patients were intubated in the ED among a total of 335 facial burn patients. Only 73 (60.3%) patients were later confirmed to have inhalation injuries on bronchoscopy. The comparison between the patients with and without inhalation injuries showed that shortness of breath (odds ratio = 3.376, p = 0.027) and high total body surface area (TBSA) (odds ratio = 1.038, p = 0.001) were independent risk factors for inhalation injury. Other physical signs (e.g., hoarseness, burned nostril hair, etc.), laboratory examinations and chest X-ray findings were not predictive of inhalation injury in facial burn patients. All the patients with a TBSA over 60% were intubated in the ED even if they did not have inhalation injuries.

Conclusion : In the management of facial burn patients, positive signs on conventional physical examinations may not always be predictive of inhalation injury and the need for endotracheal tube intubation in the ED. More attention should be given to facial burn patients with shortness of breath and a high TBSA. Airway protection is needed in facial burn patients without inhalation injuries because of their associated injuries and treatments.

Conclusion (proposition de traduction) : Dans la prise en charge des patients brûlés au visage, les signes positifs de l'examen clinique conventionnels peuvent ne pas toujours être prédictifs d'une lésion par inhalation et de la nécessité d'une intubation par sonde endotrachéale au service des urgences. Une plus grande attention doit être accordée aux patients brûlés au visage présentant une dyspnée et une surface corporelle totale élevée. Une protection des voies respiratoires est nécessaire chez les patients brûlés au visage sans blessures par inhalation en raison des blessures et des traitements associés.

Burns

Clinical outcomes in 'diabese' burn patients: A systematic review and meta-analysis.
Born LJ, Quiroga LH, Lagziel T, Hultman CS, Asif M. | Burns. 2022 Mar;48(2):281-292
DOI: https://doi.org/10.1016/j.burns.2021.04.001
Keywords: Burns; Clinical outcomes; Complications; Diabesity; Diabetes; Obesity.

Review article

Introduction : The objective of this study was to update the current status of clinical outcomes in diabetic (type II) and obese (BMI: 30-39.9 kg/m2) burn patients.

Méthode : We adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched MEDLINE (PubMed), Google Scholar, Scopus, and Embase for studies related to a number of comorbidities and burn outcomes. Search terms for each of these databases are listed in the Appendix. From this search, we screened 6923 articles. Through our selection criteria, 12 articles focusing on either diabetes or obesity were selected for systematic review and meta-analysis. Data was analyzed using the "meta" package in R software to produce pooled odds ratios from the random effect model.

Résultats : Diabetic patients had 2.38 times higher odds of mortality [OR: 2.38, 95% CI:1.66, 3.41], however no statistically significant difference was found in mortality in obese patients [OR: 2.49, 95% CI: 0.36, 17.19]. Obese patients had 2.18 times higher odds of inhalation injury [95%CI: 1.23, 3.88], whereas diabetic patients did not show a difference in odds of inhalation injury [OR:1.02, 95% CI: 0.57, 1.81]. Diabetic patients had higher odds of complications resulting from infection: 5.47 times higher odds of wound, skin, or soft tissue infections [95% CI:1.97, 15.18]; 2.28 times higher odds of UTI or CAUTI [95% CI:1.50, 3.46]; and 1.78 times higher odds of pneumonia or respiratory tract infections [95% CI:1.15, 2.77]. Obese patients also had similar complications related to infection: 2.15 times higher odds of wound infection [95% CI: 1.04, 4.42] and 1.96 times higher odds of pneumonia [95% CI: 1.08, 3.56]. Other notable complications in diabetic patients were higher odds of amputation [OR: 37, 95% CI: 1.76, 779.34], respiratory failure [OR: 4.39, 95% CI: 1.85, 10.42], heart failure [OR: 6.22, 95% CI: 1.93, 20.06], and renal failure [OR: 2.95, 95% CI: 1.1, 7.86].

Conclusion : Diabetic patients have higher odds of mortality, whereas no statistically significant difference of mortality was found in obese patients. Obese patients had higher odds of inhalation injury, whereas odds of inhalation injury was unchanged in diabetic patients. Diabetic patients had higher odds of failure in multiple organs, whereas such failure in obese patients was not reported. Both diabetic and obese patients had multiple complications related to infection.

Conclusion (proposition de traduction) : Les patients diabétiques ont un risque de mortalité plus élevé, alors qu'aucune différence statistiquement significative de mortalité n'a été trouvée chez les patients obèses. Les patients obèses présentaient une probabilité plus élevée de lésions par inhalation, alors que la probabilité de lésions par inhalation demeurait inchangée chez les patients diabétiques. Les patients diabétiques avaient un risque plus élevé de défaillance multiviscérale, alors qu'une telle défaillance n’a pas été rapportée chez les patients obèses. Les patients diabétiques et obèses avaient de multiples complications liées à l'infection.

Canadian Journal of Emergency Management

Diagnosis and management of wide complex tachycardia in the emergency department.
Linton JJ, Eagles D, Green MS, Alchi S, Nemnom MJ, Stiell IG. | CJEM. 2022 Mar;24(2):174-184
DOI: https://doi.org/10.1007/s43678-021-00243-3  | Télécharger l'article au format  
Keywords: Arrhythmia; Emergency department; Wide QRS complex.

Original Research

Introduction : While wide complex tachycardia (WCT) is potentially lethal, little is known about its incidence in the ED or about expertise of ED physicians in diagnosing and treating it. We sought to compare WCT ED cases that were primary arrhythmias versus those with rapid heart rate secondary to medical issues, as well as the accuracy of ED diagnosis and appropriateness of treatment.

Méthode : We conducted a health records review at a large academic hospital ED staffed by 95 physicians and included consecutive patients over 28 months (2018-2020) with WCT (heart rate ≥ 120 bpm and QRS ≥ 120 ms). Cases were adjudicated for the accuracy of ECG diagnosis versus the cardiology read and for correctness of treatment as per guidelines by two ED physicians and one cardiologist.

Résultats : We identified 306 eligible cases (0.2% of all ED visits): mean age 73.9 years, male 66.0%, admitted 53.3%, died in ED 2.3%. Primary arrhythmias and secondary tachycardias were each 50.0% (95% CI 44.4-55.6%). ED physicians correctly interpreted 81.2% of ECGs. The most common presenting arrythmias and % correct were: atrial fibrillation 42.7% (95.0%), atrial flutter 22.2% (63.5%), sinus tachycardia 12.0% (78.6%), and supraventricular tachycardia (SVT) 11.1% (68.0%). Treatments were judged optimal in 84.3% of primary WCT and 86.9% in secondary WCT. Treatments were suboptimal for: inappropriate drug (3.9% for primary versus 1.3% for secondary), failure to reduce heart rate < 100 prior to discharge home (9.1% for primary versus 34.4% for secondary), and not treating the underlying cause in 5.9% of secondary WCT.

Conclusion : WCT cases were evenly split between primary arrhythmias and secondary cases. ED physicians interpreted the ECG correctly in 81% but over-called atrial flutter and SVT. They implemented appropriate care in most cases but sometimes failed to adequately control heart rate or to treat the underlying condition, suggesting opportunities to improve care of WCT in the ED.

Conclusion (proposition de traduction) : Les cas de tachycardie à complexes larges étaient répartis uniformément entre les arythmies primaires et les cas secondaires. Les urgentistes ont interprété correctement l'ECG dans 81 % des cas, mais ont sur-évalué le flutter auriculaire et la tachycardie supraventriculaire. Ils ont mis en œuvre des soins appropriés dans la plupart des cas, mais n'ont pas toujours réussi à contrôler adéquatement la fréquence cardiaque ou à traiter l'affection sous-jacente, ce qui laisse entrevoir des possibilités d'améliorer les soins de la tachycardie à complexes larges au service des urgences.

Circulation

Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications.
Singh T, Khan H, Gamble DT, Scally C, Newby DE, Dawson D. | Circulation. 2022 Mar 29;145(13):1002-1019
DOI: https://doi.org/10.1161/circulationaha.121.055854  | Télécharger l'article au format  
Keywords: Takotsubo cardiomyopathy; physiopathology; treatment outcomes

State of the Art

Editorial : Takotsubo syndrome is a condition characterized by acute transient left ventricular systolic dysfunction, which at presentation can be challenging to distinguish from acute myocardial infarction. Although previously thought to be a benign, self-limiting condition, recent studies have confirmed that patients with takotsubo syndrome have persistent subtle ongoing cardiac dysfunction, and many continue to have limiting symptoms despite restoration of left ventricular ejection fraction. Moreover, these patients have a substantial burden of morbidity and mortality, as well, with high rates of subsequent major adverse cardiovascular events that approach those of patients with acute coronary syndrome. The mechanisms behind this condition remain elusive. Despite substantial research, the medical community continues to have an incomplete understanding of its underlying pathogenesis and pathophysiology. Catecholamine-induced myocardial injury is the most established and well-known theory, but this does not explain all the clinical features and presentations of the condition, and numerous other pathways and abnormalities are emerging. Because of the poor understanding of its underlying pathophysiology, there is a lack of evidence-based interventions to treat the acute episode, to avoid recurrences, and to prevent major adverse cardiovascular events. This highlights the need for further research to gain a better understanding of the underlying pathophysiology to inform appropriate randomized controlled trials of interventions targeting the causative pathways. Only then can evidence-based management strategies be established to improve clinical outcomes of this potentially lethal condition.

Conclusion : Takotsubo syndrome is increasing in incidence and becoming more widely recognized in the medical community. The diagnosis can be challenging, and clinicians must look for signs distinguishing takotsubo syndrome from other causes of acute myocardial injury. The use of multimodality imaging may help in this regard and improve our understanding of its underlying pathogenesis and pathophysiology. At present, takotsubo syndrome remains a poorly understood condition with substantial morbidity and mortality without proven or effective treatments that urgently need to be addressed.

Conclusion (proposition de traduction) : Le syndrome de Takotsubo augmente en incidence et devient plus largement reconnu dans la communauté médicale. Le diagnostic peut être difficile et les cliniciens doivent rechercher des signes distinguant le syndrome de takotsubo des autres causes de lésion myocardique aiguë. L'utilisation de l'imagerie multimodalité peut aider à cet égard et améliorer notre compréhension de sa pathogenèse sous-jacente et de sa physiopathologie. À l'heure actuelle, le syndrome de takotsubo reste une affection mal comprise avec une morbidité et une mortalité substantielles sans traitements éprouvés ou efficaces qui doivent être traités de toute urgence.

Commentaire : • Ghadri JR, Wittstein IS, Prasad A and al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018 Jun 7;39(22):2032-2046  .
• Ghadri JR, Wittstein IS, Prasad A and al. International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. Eur Heart J. 2018 Jun 7;39(22):2047-2062  .
• Dias A, Núñez Gil IJ, Santoro F and al. Takotsubo syndrome: State-of-the-art review by an expert panel - Part 1. Cardiovasc Revasc Med. 2019 Jan;20(1):70-79  .
• Dias A, Núñez Gil IJ, Santoro F and al. Takotsubo syndrome: State-of-the-art review by an expert panel - Part 2. Cardiovasc Revasc Med. 2019 Feb;20(2):153-166  .

Cochrane Database of Systematic Reviews

Oral dextrose gel for the treatment of hypoglycaemia in newborn infants.
Edwards T, Liu G, Battin M, Harris DL, Hegarty JE, Weston PJ, Harding JE. | Cochrane Database Syst Rev. 2022 Mar 18;3(3):CD011027
DOI: https://doi.org/10.1002/14651858.cd011027.pub3
Keywords: Aucun

Intervention

Introduction : Neonatal hypoglycaemia, a common condition, can be associated with brain injury. It is frequently managed by providing infants with an alternative source of glucose, often given enterally with milk-feeding or intravenously with dextrose solution, which may decrease breastfeeding success. Intravenous dextrose also often requires that mother and baby are cared for in separate environments. Oral dextrose gel is simple and inexpensive, and can be administered directly to the buccal mucosa for rapid correction of hypoglycaemia, in association with continued breastfeeding and maternal care. This is an update of a previous review published in 2016.
Objectives: To assess the effectiveness of oral dextrose gel in correcting hypoglycaemia in newborn infants from birth to discharge home and reducing long-term neurodevelopmental impairment.

Méthode : We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase from database inception to October 2021. We also searched international clinical trials networks, the reference lists of included trials, and relevant systematic reviews identified in the search. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing oral dextrose gel versus placebo, no treatment, or other therapies for the treatment of neonatal hypoglycaemia in newborn infants from birth to discharge home.
Data collection and analysis: Two review authors independently assessed study quality and extracted data; they did not assess publications for which they were study authors. We contacted investigators to obtain additional information. We used fixed-effect models and the GRADE approach to assess the certainty of evidence.

Résultats : We included two studies conducted in high-income countries, involving 312 late preterm and at-risk term infants and comparing oral dextrose gel (40% concentration) to placebo gel. One study was at low risk of bias, and the other (an abstract) was at unclear to high risk of bias. Oral dextrose gel compared with placebo gel probably increases correction of hypoglycaemic events (rate ratio 1.08, 95% confidence interval (CI) 0.98 to 1.20; rate difference 66 more per 1000, 95% CI 17 fewer to 166 more; 1 study; 237 infants; moderate-certainty evidence), and may result in a slight reduction in the risk of major neurological disability at age two years or older, but the evidence is uncertain (risk ratio (RR) 0.46, 95% CI 0.09 to 2.47; risk difference (RD) 24 fewer per 1000, 95% CI 41 fewer to 66 more; 1 study, 185 children; low-certainty evidence). The evidence is very uncertain about the effect of oral dextrose gel compared with placebo gel or no gel on the need for intravenous treatment for hypoglycaemia (RR 0.78, 95% CI 0.46 to 1.32; RD 37 fewer per 1000, 95% CI 91 fewer to 54 more; 2 studies, 312 infants; very low-certainty evidence). Investigators in one study of 237 infants reported no adverse events (e.g. choking or vomiting at the time of administration) in the oral dextrose gel or placebo gel group (low-certainty evidence). Oral dextrose gel compared with placebo gel probably reduces the incidence of separation from the mother for treatment of hypoglycaemia (RR 0.54, 95% CI 0.31 to 0.93; RD 116 fewer per 1000, 95% CI 174 fewer to 18 fewer; 1 study, 237 infants; moderate-certainty evidence), and increases the likelihood of exclusive breastfeeding after discharge (RR 1.10, 95% CI 1.01 to 1.18; RD 87 more per 1000, 95% CI 9 more to 157 more; 1 study, 237 infants; moderate-certainty evidence).

Conclusion : Oral dextrose gel (specifically 40% dextrose concentration) used to treat hypoglycaemia in newborn infants (specifically at-risk late preterm and term infants) probably increases correction of hypoglycaemic events, and may result in a slight reduction in the risk of major neurological disability at age two years or older. Oral dextrose gel treatment probably reduces the incidence of separation from the mother for treatment and increases the likelihood of exclusive breastfeeding after discharge. No adverse events have been reported. Oral dextrose gel is probably an effective and safe first-line treatment for infants with neonatal hypoglycaemia in high-income settings. More evidence is needed about the effects of oral dextrose gel treatment on later neurological disability and the need for other treatments for hypoglycaemia. Future studies should be conducted in low-and middle-income settings, in extremely and moderately preterm infants, and compare oral dextrose gel with other therapies such as intravenous dextrose. There are two ongoing studies that may alter the conclusions of this review when published.

Conclusion (proposition de traduction) : Le gel de dextrose oral (spécifiquement à une concentration de dextrose à 40 %) utilisé pour traiter l'hypoglycémie chez les nouveau-nés (en particulier les nourrissons peu prématurés et nés à terme à risque) augmente probablement la correction des événements hypoglycémiques et peut entraîner une légère réduction du risque d'incapacité neurologique majeure à âge de deux ans ou plus. Le traitement au gel de dextrose oral réduit probablement l'incidence de la séparation d'avec la mère pour le traitement et augmente la probabilité d'allaitement exclusif après la sortie. Aucun événement indésirable n'a été signalé. Le gel de dextrose oral est probablement un traitement de première intention efficace et sûr pour les nourrissons souffrant d'hypoglycémie néonatale dans les milieux à revenu élevé. Des preuves supplémentaires sont nécessaires concernant les effets du traitement par gel de dextrose oral sur l'incapacité neurologique ultérieure et la nécessité d'autres traitements pour l'hypoglycémie. De futures études devraient être menées dans des milieux à revenu faible et moyen, chez des nourrissons extrêmement et modérément prématurés, et comparer le gel de dextrose oral avec d'autres thérapies telles que le dextrose intraveineux. Deux études en cours pourraient modifier les conclusions de cette revue une fois publiées.

Commentaire : Mise à jour de :
Weston PJ, Harris DL, Battin M, Brown J, Hegarty JE, Harding JE. Oral dextrose gel for the treatment of hypoglycaemia in newborn infants. Cochrane Database Syst Rev. 2016 May 4;(5):CD011027. doi: 10.1002/14651858.CD011027.pub2  .

Voir l'analyse de l'article sur le site La Collaboration Cochrane : Gel oral de dextrose dans le traitement des nouveau-nés à faible taux de glucose dans le sang  . Rédigé le 18 mars 2022.

Antiseizure medications for neonates with seizures.
Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. | Cochrane Database Syst Rev. 2022 Mar 18;3(3):CD014967
DOI: https://doi.org/10.1002/14651858.CD014967  | Télécharger l'article au format  
Keywords: Aucun

Protocol - Intervention

Introduction : This is a protocol for a Cochrane Review (intervention). The objectives are as follows:
1. To assess whether any anti‐seizure medication (ASM) is more or less effective than an alternative ASM (both ASMs used as first‐, second‐ or third‐line treatment) in achieving seizure control and improving neurodevelopmental outcomes in neonates with seizures. We will analyse EEG‐confirmed seizures and clinically‐diagnosed seizures separately.
2. To assess maintenance therapy with ASM compared to no maintenance therapy after achieving seizure control. We will analyse EEG‐confirmed seizures and clinically‐diagnosed seizures separately.
3. To assess any ASM treatment compared to no ASM treatment for clinically‐diagnosed or only‐electrographic seizures.

Méthode : We will include randomised controlled trials (RCTs), quasi‐RCTs, and cluster‐RCTs in this review. We will include studies on any class of ASMs that are known to be used in neonatal seizures. We will exclude studies on the use of vitamins, medical gas or other interventions such as therapeutic hypothermia, which may have a role in seizure control in neonates. We will also exclude trials with prophylactic use of ASMs to prevent neonatal seizures or to improve neurodevelopmental outcomes.

Conclusion : This is a protocol for a Cochrane Review (intervention). The objectives are as follows:
To assess whether any anti-seizure medication is more or less effective than an alternative anti-seizure medication (both anti-seizure medications used as first-, second- or third-line treatment) in achieving seizure control and improving neurodevelopmental outcomes in neonates with seizures. We will analyse EEG-confirmed seizures and clinically-diagnosed seizures separately.
To assess maintenance therapy with anti-seizure medication compared to no maintenance therapy after achieving seizure control. We will analyse EEG-confirmed seizures and clinically-diagnosed seizures separately.
To assess any anti-seizure medication treatment compared to no anti-seizure medication treatment for clinically-diagnosed or only-electrographic seizures.

Conclusion (proposition de traduction) : Il s'agit d'un protocole pour une revue Cochrane (intervention). Les objectifs sont les suivants :
Évaluer si un médicament anti-épileptique est plus ou moins efficace qu'un médicament anti-épileptique alternatif (les deux anti-épileptiques utilisés comme traitement de première, deuxième ou troisième intention) pour contrôler les crises et améliorer les résultats neurodéveloppementaux chez les nouveau-nés atteints convulsions. Nous analyserons séparément les crises confirmées par EEG et les crises diagnostiquées cliniquement.
Évaluer le traitement d'entretien avec des médicaments anti-épileptiques par rapport à l'absence de traitement d'entretien après avoir atteint le contrôle des crises. Nous analyserons séparément les crises confirmées par EEG et les crises diagnostiquées cliniquement.
Évaluer tout traitement médicamenteux anti-épileptique par rapport à l'absence de traitement médicamenteux anti-épileptique pour les crises diagnostiquées cliniquement ou uniquement électrographiques.

Commentaire : Mise à jour de :
Booth D, Evans DJ. Anticonvulsants for neonates with seizures. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004218. DOI: 10.1002/14651858.CD004218.pub2  .

Critical Care

Advanced Life Support Update.
Perkins GD, Nolan JP. | Crit Care. 2022 Mar 22;26(1):73
DOI: https://doi.org/10.1186/s13054-022-03912-6  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022  . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901  .

Conclusion : Cardiac arrest remains an important cause of morbidity and mortality. Evidence based resuscitation treatment guidelines enable clinicians to incorporate best evidence into practice. High quality CPR, rapid defibrillation, and early treatment with epinephrine improve survival. Anti-arrhythmic drugs may be considered in those with shock-refractory cardiac arrest. Post-resuscitation care should focus on identifying and treating reversible causes of cardiac arrest and restoring normal physiology. The evidence highlights that clinicians should prioritize avoidance of pyrexia over any specific hypothermia temperature targets. Careful attention to the timing of prognostication (no earlier than 72 h) and use of multimodal tests to assess prognosis will help inform difficult decisions regarding the continuation or withdrawal of life-sustaining treatments.

Conclusion (proposition de traduction) : L'arrêt cardiaque reste une cause importante de morbi-mortalité. Les recommandations de traitement de réanimation fondées sur des données probantes permettent aux cliniciens d'intégrer les meilleures données probantes dans leur pratique. Une RCP de haute qualité, une défibrillation rapide et un traitement précoce par l'adrénaline améliorent la survie. Les médicaments anti-arythmiques peuvent être envisagés chez les personnes présentant un arrêt cardiaque réfractaire aux chocs. Les soins post-réanimation doivent se concentrer sur l'identification et le traitement des causes réversibles de l'arrêt cardiaque et le rétablissement de la physiologie normale. Les données probantes soulignent que les cliniciens devraient accorder la priorité à la lutte contre l'hyperthermie plutôt qu'à toute cible spécifique de température d'hypothermie. Une attention particulière au moment du pronostic (pas avant 72 h) et l'utilisation de tests multimodaux pour évaluer le pronostic aideront à éclairer les décisions difficiles concernant la poursuite ou l'arrêt des traitements de maintien de la vie.

Vasopressor Choice and Timing in Vasodilatory Shock.
Wieruszewski PM, Khanna AK. | Crit Care. 2022 Mar 22;26(1):76
DOI: https://doi.org/10.1186/s13054-022-03911-7  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : Vasodilatory shock is the most common form of circulatory shock encountered in patients admitted to the intensive care unit (ICU). Sepsis is the predominant etiology, but other causes of vasodilatory shock include postoperative vasoplegia, anaphylaxis, spinal cord injury (i.e., neurogenic shock), systemic inflammatory response from acute pancreatitis, and direct vascular relaxation from general and neuraxial anesthetics. Vasodilatory shock is a medical emergency that requires prompt diagnosis and treatment. Regardless of etiology, vasodilatory shock is characterized by reduced systemic vascular resistance and arterial hypotension that warrants intravascular fluid resuscitation and pharmacological vasopressors to restore the vascular tone. Left untreated, perfusion pressures suffer, leading to inadequate cellular oxygen utilization, conversion to anaerobic metabolism, multiorgan failure, and death.

Conclusion : The classic approach to vasodilatory shock management consists of a stepwise escalation of vasopressors which leads to prolonged states of hypoperfusion, hyperlactatemia, excessive catecholamine exposure, and poor outcome. An early, balanced, multimodal vasopressor therapy strategy provides a physiologic-guided approach to the complex, multifactorial pathogenesis of vasodilatory shock. Data are desperately needed in the development and deployment of biomarkers in the individualized approach to vasopressor therapy to improve shock outcomes.

Conclusion (proposition de traduction) : L'approche classique de la gestion du choc avec vasodilatation consiste en une escalade progressive de l'administration des vasopresseurs qui conduit à des états prolongés d'hypoperfusion, d'hyperlactatémie, d'exposition excessive aux catécholamines et à de mauvais résultats. Une stratégie de traitement vasopresseur précoce, équilibrée et multimodale fournit une approche guidée par la physiologie de la pathogenèse complexe et multifactorielle du choc avec vasodilatation. Les données sont désespérément nécessaires dans le développement et le déploiement de biomarqueurs dans l'approche individualisée des traitements vasopresseurs pour améliorer les résultats dans le choc.

Drug dosing in hospitalized obese patients with COVID-19.
Barletta JF, Erstad BL. | Crit Care. 2022 Mar 14;26(1):60
DOI: https://doi.org/10.1186/s13054-022-03941-1  | Télécharger l'article au format  
Keywords: Baricitinib; COVID-19; Dexamethasone; Dosing; Obesity; Remdesivir; Sarilumab; Tocilizumab; Tofacitinib

Review

Editorial : Obesity is highly prevalent in hospitalized patients admitted with COVID-19. Evidence based guidelines are available for COVID-19-related therapies but dosing information specific to patients with obesity is lacking. Failure to account for the pharmacokinetic alterations that exist in this population can lead to underdosing, and treatment failure, or overdosing, resulting in an adverse effect. The objective of this manuscript is to provide clinicians with guidance for making dosing decisions for medications used in the treatment of patients with COVID-19. A detailed literature search was conducted for medications listed in evidence-based guidelines from the National Institutes of Health with an emphasis on pharmacokinetics, dosing and obesity. Retrieved manuscripts were evaluated and the following prioritization strategy was used to form the decision framework for recommendations: clinical outcome data > pharmacokinetic studies > adverse effects > physicochemical properties. Most randomized controlled studies included a substantial number of patients who were obese but few had large numbers of patients more extreme forms of obesity. Pharmacokinetic data have described alterations with volume of distribution and clearance but this variability does not appear to warrant dosing modifications. Future studies should provide more information on size descriptors and stratification of data according to obesity and body habitus.

Conclusion : The studies serving as the basis for the drug recommendations in the NIH guidelines for hospitalized patients with COVID-19 provide little guidance for clinicians on the applicability of available dosing information for patients with more extreme forms of obesity. This problem is not unique to drug therapy for COVID-19 management, since drug dosing in obesity is not a required subsection of the section titled USE IN SPECIAL POPULATIONS in FDA approved labeling, a section which typically contains information on special populations such as pregnancy, lactation, pediatrics, and renal or hepatic impairment.

Conclusion (proposition de traduction) : Les études servant de base aux recommandations d'administration de médicaments dans les directives du NIH pour les patients hospitalisés atteints de COVID-19 fournissent peu de conseils aux cliniciens sur l'applicabilité des informations de dosage disponibles pour les patients atteints de formes plus extrêmes d'obésité. Ce problème n'est pas unique à la pharmacothérapie pour la gestion du COVID-19, car le dosage des médicaments dans l'obésité n'est pas une sous-section obligatoire de la section intitulée UTILISATION DANS DES POPULATIONS SPÉCIALES dans l'étiquetage approuvé par la FDA, une section qui contient généralement des informations sur des populations particulières telles que la grossesse, allaitement, pédiatrie et insuffisance rénale ou hépatique.

Critical Care and Resuscitation

A pilot study of the pharmacokinetics of continuous magnesium infusion in critically ill patients.
Chan JW, Yanase F, See E, McCue C, Yong ZT, Talbot LJ, Flanagan J PM, Eastwood GM. | Crit Care Resusc. 2022; 24 (1): 29-38
DOI: https://doi.org/10.51893/2022.1.OA4  | Télécharger l'article au format  
Keywords: Aucun

Original Article

Introduction : The pharmacokinetics and haemodynamic effect of continuous magnesium infusion in non-cardiac intensive care unit (ICU) patients are poorly understood. We aimed to measure serum and urine magnesium levels during bolus and continuous infusion in critically ill adults, compare serum levels with those of a control population, and assess its haemodynamic effect.

Méthode : The primary outcome was the change in total serum magnesium concentration. The main secondary outcome was mean arterial pressure (MAP)-adjusted vasopressor dose.

Résultats : We matched 31 treated patients with 93 controls. Serum total magnesium concentration increased from a median 0.94 mmol/L (interquartile range [IQR], 0.83–1.10 mmol/L) to 1.38 mmol/L (IQR, 1.25–1.69 mmol/L; P < 0.001) and stabilised between a median 1.64 mmol/L (IQR, 1.38–1.88 mmol/L) at 7 hours and 1.77 mmol/L (IQR, 1.53–1.85 mmol/L) at 25 hours. This was significantly greater than in the control group (P < 0.001). The MAP-adjusted vasopressor dose decreased during magnesium infusion (P < 0.001).

Conclusion : In critically ill patients, a magnesium sulfate bolus followed by continuous infusion achieved moderately elevated levels of total serum magnesium with a decrease in MAP-adjusted vasopressor dose.

Conclusion (proposition de traduction) : Chez des patients gravement malades, un bolus de sulfate de magnésium suivi d'une perfusion continue a permis d'atteindre des niveaux modérément élevés de magnésium sérique total avec une diminution de la dose de vasopresseurs ajustée à la pression artérielle moyenne.

High flow nasal catheter therapy versus non-invasive positive pressure ventilation in acute respiratory failure (RENOVATE trial): protocol and statistical analysis plan.
Maia IS, and al.. | Crit Care Resusc. 2022; 24 (1): 61-70
DOI: https://doi.org/10.51893/2022.1.OA8  | Télécharger l'article au format  
Keywords: Aucun

Original Article

Introduction : The best way to offer non-invasive respiratory support across several aetiologies of acute respiratory failure (ARF) is presently unclear. Both high flow nasal catheter (HFNC) therapy and non-invasive positive pressure ventilation (NIPPV) may improve outcomes in critically ill patients by avoiding the need for invasive mechanical ventilation (IMV).
Objective: Describe the details of the protocol and statistical analysis plan designed to test whether HFNC therapy is non-inferior or even superior to NIPPV in patients with ARF due to different aetiologies.

Méthode : RENOVATE is a multicentre adaptive randomised controlled trial that is recruiting patients from adult emergency departments, wards and intensive care units (ICUs). It takes advantage of an adaptive Bayesian framework to assess the effectiveness of HFNC therapy versus NIPPV in four subgroups of ARF (hypoxaemic non-immunocompromised, hypoxaemic immunocompromised, chronic obstructive pulmonary disease exacerbations, and acute cardiogenic pulmonary oedema). The study will report the posterior probabilities of non-inferiority, superiority or futility for the comparison between HFNC therapy and NIPPV. The study assumes neutral priors and the final sample size is not fixed. The final sample size will be determined by a priori determined stopping rules for non-inferiority, superiority and futility for each subgroup or by reaching the maximum of 2000 patients.

Conclusion : RENOVATE is designed to provide evidence on whether HFNC therapy improves, compared with NIPPV, important patient-centred outcomes in different aetiologies of ARF. Here, we describe the rationale, design and status of the trial.

Conclusion (proposition de traduction) : L'essai RENOVATE a pour but de déterminer si le traitement par oxygénothérapie nasale à haut débit améliore, par rapport à la VNI, des résultats importants centrés sur le patient dans différentes étiologies d'insuffisance respiratoire aiguë. Nous décrivons ici la raison d'être, la conception et le statut de l'essai.

Critical Care Medicine

Peripheral Oxygen Saturation Facilitates Assessment of Respiratory Dysfunction in the Sequential Organ Failure Assessment Score With Implications for the Sepsis-3 Criteria.
Valik JK, Mellhammar L, Sundén-Cullberg J, Ward L, Unge C, Dalianis H, Henriksson A, Strålin K, Linder A, Nauclér P. | Crit Care Med. 2022 Mar 1;50(3):e272-e283
DOI: https://doi.org/10.1097/ccm.0000000000005318
Keywords: Aucun

Online Clinical Investigations

Introduction : Sequential Organ Failure Assessment score is the basis of the Sepsis-3 criteria and requires arterial blood gas analysis to assess respiratory function. Peripheral oxygen saturation is a noninvasive alternative but is not included in neither Sequential Organ Failure Assessment score nor Sepsis-3. We aimed to assess the association between worst peripheral oxygen saturation during onset of suspected infection and mortality.

Méthode : Cohort study of hospital admissions from a main cohort and emergency department visits from four external validation cohorts between year 2011 and 2018. Data were collected from electronic health records and prospectively by study investigators.
Setting: Eight academic and community hospitals in Sweden and Canada.
Patients: Adult patients with suspected infection episodes.
Interventions: None.

Résultats : The main cohort included 19,396 episodes (median age, 67.0 [53.0-77.0]; 9,007 [46.4%] women; 1,044 [5.4%] died). The validation cohorts included 10,586 episodes (range of median age, 61.0-76.0; women 42.1-50.2%; mortality 2.3-13.3%). Peripheral oxygen saturation levels 96-95% were not significantly associated with increased mortality in the main or pooled validation cohorts. At peripheral oxygen saturation 94%, the adjusted odds ratio of death was 1.56 (95% CI, 1.10-2.23) in the main cohort and 1.36 (95% CI, 1.00-1.85) in the pooled validation cohorts and increased gradually below this level. Respiratory assessment using peripheral oxygen saturation 94-91% and less than 91% to generate 1 and 2 Sequential Organ Failure Assessment points, respectively, improved the discrimination of the Sequential Organ Failure Assessment score from area under the receiver operating characteristics 0.75 (95% CI, 0.74-0.77) to 0.78 (95% CI, 0.77-0.80; p < 0.001). Peripheral oxygen saturation/Fio2 ratio had slightly better predictive performance compared with peripheral oxygen saturation alone, but the clinical impact was minor.

Conclusion : These findings provide evidence for assessing respiratory function with peripheral oxygen saturation in the Sequential Organ Failure Assessment score and the Sepsis-3 criteria. Our data support using peripheral oxygen saturation thresholds 94% and 90% to get 1 and 2 Sequential Organ Failure Assessment respiratory points, respectively. This has important implications primarily for emergency practice, rapid response teams, surveillance, research, and resource-limited settings.

Conclusion (proposition de traduction) : Ces résultats fournissent des preuves pour évaluer la fonction respiratoire avec la saturation du sang périphérique en oxygène avec le score SOFA et les critères Sepsis-3. Nos données supportent l’utilisation de seuils de saturation périphérique en oxygène de 94 % et 90 % pour obtenir respectivement 1 et 2 points à l'item respiratoire du SOFA. Cela a des implications importantes principalement pour la pratique d'urgence, les équipes d'intervention rapide, la surveillance, la recherche et les milieux à ressources limitées. Nos données supportent l’utilisation de seuils périphériques de saturation en oxygène 94% et 90% pour obtenir 1 et 2 points à l'item respiratoires Sequential Organ Failure Assessment, respectivement. Cette situation a d’importantes répercussions surtout sur la pratique d’urgence, les équipes d’intervention rapide, la surveillance, la recherche et les milieux où les ressources sont limitées.

Commentaire : Pour rappel 
Item « Respiration » du score SOFA
0 - PaO2/FiO2 > 400.
1 - PaO2/FiO2 > 300 et ≤ 400.
2 - PaO2/FiO2 > 200 et ≤ 300.
3 - PaO2/FiO2 > 100 et ≤ 200 avec ventilation artificielle.
4 - PaO2/FiO2 ≤ 100 avec ventilation artificielle.

Neuromuscular Blocker Use in Critically Ill Children: Assessing Mortality Risk by Propensity Score-Weighted Analysis.
Daverio M, Sperotto F, Stefani C, Mondardini MC, Tessari A, Biban P, Izzo F, Montani C, Lapi M, Picconi E, Racca F, Marinosci GZ, Savron F, Wolfler A, Amigoni A; Italian Network of PICU Study Group (TIPNet). | Crit Care Med. 2022 Mar 1;50(3):e294-e303
DOI: https://doi.org/10.1097/ccm.0000000000005334
Keywords: Aucun

Online Clinical Investigations

Introduction : We aim to describe the use of continuous infusion of neuromuscular blocking agents in mechanically ventilated critically ill children and to test its association with in-hospital mortality.

Méthode : Multicenter, registry-based, observational, two-cohort-comparison retrospective study using prospectively collected data from a web-based national registry.
Setting: Seventeen PICUs in Italy.
Patients: We included children less than 18 years who received mechanical ventilation and a neuromuscular blocking agent infusion from January 2010 to October 2017. A propensity score-weighted Cox regression analysis was used to assess the relationship between the use of neuromuscular blocking agents and in-hospital mortality.
Interventions: None.

Résultats : Of the 23,227 patients admitted to the PICUs during the study period, 3,823 patients were included. Patients who received a continuous infusion of neuromuscular blocking agent were more likely to be younger (p < 0.001), ex-premature (p < 0.001), and presenting with less chronic respiratory insufficiency requiring home mechanical ventilation (p < 0.001). Reasons for mechanical ventilation significantly differed between patients who received a continuous infusion of neuromuscular blocking agent and patients who did not receive a continuous infusion of neuromuscular blocking agent, with a higher frequency of respiratory and cardiac diagnosis among patients who received neuromuscular blocking agents compared with other diagnoses (all p < 0.001). The covariates were well balanced in the propensity-weighted cohort. The mortality rate significantly differed among the two cohorts (patients who received a continuous infusion of neuromuscular blocking agent 21% vs patients who did not receive a continuous infusion of neuromuscular blocking agent 11%; p < 0.001 by weighted logistic regression). Patients who received a continuous infusion of neuromuscular blocking agent experienced longer mechanical ventilation and PICU stay (both p < 0.001 by weighted logistic regression). A weighted Cox regression analysis found the use of neuromuscular blocking agents to be a significant predictor of in-hospital mortality both in the unadjusted analysis (hazard ratio, 1.7; 95% CI, 1.3-2.2) and in the adjusted one (hazard ratio, 1.6; 95% CI, 1.2-2.1).

Conclusion : Thirteen percent of mechanically ventilated children in PICUs received neuromuscular blocking agents. When adjusting for selection bias with a propensity score approach, the use of neuromuscular blocking agent was found to be a significant predictor of in-hospital mortality.

Conclusion (proposition de traduction) : Treize pour cent des enfants bénéficiant d'une ventilation mécanique en USI pédiatrique ont reçu des curares. Lors de l'ajustement du biais de sélection avec une approche par score de propension, l'utilisation d'un curare s'est avérée être un prédicteur significatif de la mortalité hospitalière.

IV Vitamin C in Critically Ill Patients: A Systematic Review and Meta-Analysis.
Patel JJ, Ortiz-Reyes A, Dhaliwal R, Clarke J, Hill A, Stoppe C, Lee ZY, Heyland DK. | Crit Care Med. 2022 Mar 1;50(3):e304-e312
DOI: https://doi.org/10.1097/ccm.0000000000005320
Keywords: Aucun

Online Review Articles

Introduction : To conduct a systematic review and meta-analysis to evaluate the impact of IV vitamin C on outcomes in critically ill patients.

Méthode : Systematic search of MEDLINE, EMBASE, CINAHL, and the Cochrane Register of Controlled Trials.
Study selection: Randomized controlled trials testing IV vitamin C in critically ill patients.
Data abstraction: Two independent reviewers abstracted patient characteristics, treatment details, and clinical outcomes.

Résultats : Fifteen studies involving 2,490 patients were identified. Compared with placebo, IV vitamin C administration is associated with a trend toward reduced overall mortality (relative risk, 0.87; 95% CI, 0.75-1.00; p = 0.06; test for heterogeneity I2 = 6%). High-dose IV vitamin C was associated with a significant reduction in overall mortality (relative risk, 0.70; 95% CI, 0.52-0.96; p = 0.03), whereas low-dose IV vitamin C had no effect (relative risk, 0.94; 95% CI, 0.79-1.07; p = 0.46; test for subgroup differences, p = 0.14). IV vitamin C monotherapy was associated with a significant reduction in overall mortality (relative risk, 0.64; 95% CI, 0.49-0.83; p = 0.006), whereas there was no effect with IV vitamin C combined therapy. No trial reported an increase in adverse events related to IV vitamin C.

Conclusion : IV vitamin C administration appears safe and may be associated with a trend toward reduction in overall mortality. High-dose IV vitamin C monotherapy may be associated with improved overall mortality, and further randomized controlled trials are warranted.

Conclusion (proposition de traduction) : L'administration IV de vitamine C semble sûre et peut être associée à une tendance à la réduction de la mortalité globale. La monothérapie IV à forte dose de vitamine C peut être associée à une amélioration de la mortalité globale, et d'autres essais contrôlés randomisés sont justifiés.

Commentaire : Retrouvez quelque articles récents sur l'utilisation de la vitamine C :
• Shokri-Mashhadi N, Aliyari A, Hajhashemy Z and al. Is it time to reconsider the administration of thiamine alone or in combination with vitamin C in critically ill patients? A meta-analysis of clinical trial studies. J Intensive Care. 2022 Feb 17;10(1):8  .
• Ao G, Li J, Yuan Y, Wang Y and al. Intravenous vitamin C use and risk of severity and mortality in COVID-19: A systematic review and meta-analysis. Nutr Clin Pract. 2022 Apr;37(2):274-281  .
• Shrestha DB, Budhathoki P, Sedhai YR, Mandal SK, Shikhrakar S, Karki S, Baniya RK, Kashiouris MG, Qiao X, Fowler AA. Vitamin C in Critically Ill Patients: An Updated Systematic Review and Meta-Analysis. Nutrients. 2021 Oct 12;13(10):3564  .

Tranexamic Acid in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.
Dionne JC, Oczkowski SJW, Hunt BJ, Antonelli M, Wijnberge M, Raasveld SJ, Vlaar APJ; ESICM Transfusion Taskforce and the GUIDE Group. | Crit Care Med. 2022 Mar 1;50(3):e313-e319
DOI: https://doi.org/10.1097/ccm.0000000000005362
Keywords: Aucun

Online Review Articles

Introduction : Tranexamic acid is proposed as a treatment for gastrointestinal bleeding. The Haemorrhage Alleviation with Tranexamic Acid-Intestinal System trial evaluated extended-use (24 hr) high-dose tranexamic acid, prompting a reappraisal for tranexamic acid in gastrointestinal bleeding.

Méthode : We conducted a systematic review and meta-analysis of randomized controlled trials comparing tranexamic acid with usual care or placebo in adults with gastrointestinal bleeding. We searched MEDLINE, EMBASE, and CENTRAL (inception to September 2019).
Data selection: Two reviewers independently screened citations, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool in duplicate. The main outcomes were mortality, bleeding, and adverse events.
Data extraction: Studies were analyzed as high-dose IV tranexamic acid versus all other dosing strategies for tranexamic acid using fixed-effects models. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Résultats : Five randomized controlled trials evaluated extended-use high-dose IV tranexamic acid, seven evaluating low-dose IV or enteral tranexamic acid. Extended-use high-dose IV tranexamic acid did not reduce mortality (relative risk, 0.98%; 95% CI, 0.88-1.09; I2 = 63%; high certainty) or bleeding (relative risk, 0.92; 95% CI, 0.82-1.04; p = 0.17 and absolute risk differences, -0.7%; 95% CI, -1.5 to 0.3; high certainty) but resulted in a small increase in deep venous thrombosis (relative risk, 2.01; 95% CI, 1.08-3.72; I2 = 0%), pulmonary embolism (relative risk, 1.78; 95% CI, 1.06-3.0; I2 = 0%), and seizure (relative risk, 1.73; 95% CI, 1.03-2.93) with high certainty. Low-dose IV/enteral tranexamic acid did not reduce mortality (relative risk, 0.62; 95% CI, 0.36-1.09; I2 = 0%) but did reduce risk of rebleeding (relative risk, 0.5; 95% CI, 0.33-0.75; I2 = 9%) and need for surgery (relative risk, 0.58; 95% CI, 0.38-0.88; I2 = 11%), with moderate certainty.

Conclusion : Extended-use high-dose IV tranexamic acid does not improve mortality or bleeding outcomes and increases adverse events. Low-dose/enteral tranexamic acid may be effective in reducing hemorrhage; more evidence is required to demonstrate its safety.

Conclusion (proposition de traduction) : L’utilisation prolongée d’acide tranexamique IV à forte dose n'améliore pas la mortalité ou les saignements et augmente les effets indésirables. L'acide tranexamique à faible dose/entéral peut être efficace pour réduire les hémorragies ; il faut davantage de preuves pour démontrer son innocuité.

Emergency Care Journal

Non-operative management in blunt splenic trauma: A ten-years-experience at a Level 1 Trauma Center.
Musetti S, Coccolini F, Tartaglia D, Cremonini C, Strambi S, Cicuttin E, Cobuccio L, Cengeli I, Zocco G, Chiarugi M. | Emerg Care J. 2022 March;18(1):10339
DOI: https://doi.org/10.4081/ecj.2022.10339  | Télécharger l'article au format  
Keywords: Trauma; spleen, mortality; morbidity; classification; results

ORIGINAL ARTICLE

Editorial : Spleen injuries are among the most frequent trauma-related injuries. The approach for diagnosis and management of Blunt Splenic Injury (BSI) has been considerably shifted towards Non- Operative Management (NOM) in the last few decades. NOM of blunt splenic injuries includes Splenic Angio-Embolization (SAE). Aim of this study was to analyze Pisa Level 1 trauma center (Italy) last 10-years-experience in the management of Blunt Splenic Trauma (BST), and more specifically to evaluate NOM rate and failure. Retrospective analysis of all patients admitted with blunt splenic trauma was done. They were divided into two groups according to the treatment: hemodynamically unstable patients treated operatively (OM group) and patients underwent a nonoperative management (NOM group). The CT scan performed in all NOM group patients. Univariate analysis was performed to identify differences between the two groups. Multivariate analysis adjusting for factors with a p value < 0.05 or with clinical relevance was used to identify possible risk factors for NOM failure. 193 consecutive patients with blunt splenic trauma were admitted. Emergency splenectomies were performed in 53 patients (OM group); 140 were managed non-operatively with or without SAE (NOM group). NOM rate in high grade injuries is 57%. Overall NOM failure rate is 9%, and success rate in high grade splenic injuries is 48%; multivariate analysis showed AAST score ≥3 as a risk factor for NOM failure.

Conclusion : Non-operative management currently represents the gold standard management for hemodynamically stable patient with blunt splenic trauma even in high grade splenic injuries. AAST≥3 spleen lesion is a failure risk factor but not a contraindication to for nonoperative management.

Conclusion (proposition de traduction) : La prise en charge non chirurgicale représente actuellement la prise en charge de référence pour les patients hémodynamiquement stables présentant un traumatisme splénique contondant, même en cas de lésions spléniques de haut grade. Un score AAST (American Association for the Surgery of Trauma) ≥ 3 lésions spléniques est un facteur de risque d'échec mais pas une contre-indication à une prise en charge non chirurgicale.

Emergency Medicine International

Association between Paramedic Workforce and Survival Rate in Prehospital Advanced Life Support in Out-of-Hospital Cardiac Arrest Patients.
Han K, Jo YH, Jin Kim Y, Park SM, Keon Lee D, Kim DW, Ja Lee K, Ju Choi H, Jang DH. | Emerg Med Int. 2022 Mar 17;2022:9991944
DOI: https://doi.org/10.1155/2022/9991944  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Editorial : The low survival rate of out-of-hospital cardiac arrest (OHCA) patients is a global public health challenge. We analyzed the relationship between the number of prehospital EMS personnel and survival admission, survival discharge, and good neurologic outcomes in OHCA patients. This was a retrospective observational study. Adult nontraumatic OHCA patients from January 1, 2015, to December 31, 2018, were included from 12 cities in the Gyeonggi province, a metropolitan area located in the suburbs of the capital of the Republic of Korea. By comparing the insufficient EMS team (four or five EMS personnel) and the sufficient EMS team (six EMS personnel), we showed the survival rate of each group. Using propensity score matching, we reduced the bias of the confounding variables. A total of 3,632 OHCA patients were included. After propensity score matching, survival to admission was higher in the sufficient EMS team than in the insufficient EMS team (odds ratio (OR): 1.38, 95% confidence interval (CI): 1.04-1.84, P=0.03). Survival-to-discharge was similar (OR: 1.70, CI: 1.20-2.40, P=0.03), but there was no significant outcome in good neurologic outcomes (OR: 0.88, CI: 0.57-1.36, P=0.58). Our findings suggest that a sufficient EMS team (six EMS personnel) could improve the survival admission and discharge of OHCA patients compared to an insufficient EMS team (four or five EMS personnel). However, there was no significant difference in neurologic outcomes according to the number of EMS personnel.

Conclusion : Our findings suggest that a sufficient emergency medical services team (six personnel) could improve the survival till admission and the survival at the discharge of OHCA patients in prehospital advanced life support than an insufficient EMS team (four or five personnel).

Conclusion (proposition de traduction) : Nos résultats suggèrent qu'une équipe suffisante de services médicaux d'urgence (six personnes) pourrait améliorer le taux de survie jusqu'à l'admission et le taux de survie à la sortie des patients victimes d'un arrêt cardiaque en soins avancés préhospitaliers par rapport à une équipe insuffisante (quatre ou cinq personnes).

Characteristics and Demographics of Patients Requiring Emergent Air Medical.
Van Tuyl A, Quilon M, Dudley T, Grant O, Rao N, Barbara P, Kugler DS, McLoone-Cepin KC, Greenstein J, Hahn B. | Emerg Med Int. 2022 Mar 1;2022:3044891
DOI: https://doi.org/10.1155/2022/3044891  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Introduction : As integrated health systems become more common, interfacility patient transfers will increase and air transport programs will be prioritized. Understanding characteristics of patients triaged to air medical transport will assist with resource allocation and needs assessment. The objective of this study was to investigate the demographics and clinical characteristics of patients that presented to the emergency department (ED) and subsequently required emergent air medical interfacility transport.

Méthode : This was a retrospective, multicenter study conducted at eight hospitals within Northwell Health, the largest academic health system in New York state. The study was conducted between December 1, 2014, and July 31, 2020, and included patients who presented to an ED and subsequently required emergent air medical interfacility transport.

Résultats : Overall, the median age was 37 years (IQR 4-66), and 231 (54%) subjects were males. The majority of subjects (59%) had no reported comorbidities, arrived by ambulance (52%), and were emergency severity index triage 2 (48%). Frequent indications for transfer were nontraumatic neurologic (37%), pulmonary or respiratory (13%), trauma (12%), and cardiovascular (12%). Most patients were not ventilated before transport (71%). The median time to call for transport at the sending institution was 2:42 hours (IQR 1:14-6:54), and the median length of stay was 4:12 (IQR 2:31-8:48). Most patients were subsequently admitted (96%) at the receiving institution to an intensive care unit (72%).

Conclusion : This study describes patients' demographic and clinical characteristics who required emergent air medical transport. Helicopter transport is costly, and data from these patients may further help our understanding of who is transported by air and how important air transport is to the health system.

Conclusion (proposition de traduction) : Cette étude décrit les caractéristiques démographiques et cliniques des patients qui ont nécessité un transport médical aérien urgent. Le transport par hélicoptère est coûteux, et les données concernant ces patients peuvent nous aider à mieux comprendre qui est transporté par avion et quelle est l'importance du transport aérien pour le système de santé.

Eurasian Journal of Emergency Medicine

Management of Arrhythmias in COVID-19.
Şener YZ, Canpolat U, Yorgun H, Aytemir K. | Eurasian J Emerg Med. 2022 March; 21: 1-7
DOI: https://doi.org/10.4274/eajem.galenos.2020.27880  | Télécharger l'article au format  
Keywords: COVID-19; Cardiac arrhythmia; QT prolongation

Review

Editorial : Coronavirus disease-2019 (COVID-19) disease is caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus infection and firstly appeared in China and then became a pandemic. The leading cause of mortality is respiratory failure in COVID-19; however, cardiovascular manifestations are frequent and also important causes of death in COVID-19. The incidence of arrhythmia is increased in patients with COVID-19 due to increased systemic inflammatory response, hypoxia, and administered drugs. All kinds of arrhythmias, including bradyarrhythmias, supraventricular and ventricular arrhythmias, may develop during COVID-19 course. QT prolongation plays a central role in COVID-19 related arrhythmias. Therefore, QT duration should be strictly followed. All the clinicians should know the management of arrhythmias that they might face with frequently during the pandemic.

Conclusion : Both COVID-19 itself and drugs used for the treatment of the disease are responsible for increased incidence of arrhythmia in patients with COVID-19. QTc prolongation plays a central role in COVID-19 related ventricular arrhythmias. Therefore, the QTc interval should be followed strictly according to the recommendations. Drugs reducing heart rate should be discontinued in patients with bradyarrhythmias, and patients should be reassessed for the need for a permanent pacemaker after completion of the COVID-19 treatment. Fever should be reduced in patients with BrS, and catecholamines should be avoided in patients with CPVT. Clinicians should be aware of the increased risk of arrhythmia during COVID-19.

Conclusion (proposition de traduction) : La COVID-19 elle-même et les médicaments utilisés pour son traitement sont responsables de l'augmentation de l'incidence des arythmies chez les patients atteints de COVID-19. L'allongement de l'intervalle QTc joue un rôle central dans les arythmies ventriculaires liées à la COVID-19. Par conséquent, l'intervalle QTc doit être suivi strictement selon les recommandations. Les médicaments réduisant la fréquence cardiaque doivent être interrompus chez les patients présentant des bradyarythmies, et les patients doivent être réévalués quant à la nécessité d'un stimulateur cardiaque permanent après la fin du traitement pour la COVID-19. La fièvre doit être réduite chez les patients atteints du syndrome de Brugada, et les catécholamines doivent être évitées chez les patients atteints de TV polymorphe catécholaminergique. Les cliniciens doivent être conscients du risque accru d'arythmie pendant le traitement pour la COVID-19.

European Journal of Trauma and Emergency Surgery

Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis.
Vang M, Østberg M, Steinmetz J, Rasmussen LS. | Eur J Trauma Emerg Surg. 2022 Mar 8
DOI: https://doi.org/10.1007/s00068-022-01932-z
Keywords: Emergency department; Massive blood transfusion; Mortality; Shock index; Trauma.

Review Article

Introduction : The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1.

Méthode : This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa.

Résultats : We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low.

Conclusion : This systematic review found a fourfold increased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

Conclusion (proposition de traduction) : Cette revue systématique a trouvé un risque quatre fois plus élevé de mortalité hospitalière chez les patients adultes traumatisés avec un Shock index initial ≥ 1 au service des urgences ou au centre de traumatologie.

European Respiratory Journal

Helmet noninvasive ventilation compared to facemask noninvasive ventilation and high-flow nasal cannula in acute respiratory failure: a systematic review and meta-analysis.
Chaudhuri D, Jinah R, Burns KEA, Angriman F, Ferreyro BL, Munshi L, Goligher E, Scales D, Cook DJ, Mauri T, Rochwerg B. | Eur Respir J. 2022 Mar 10;59(3):2101269
DOI: https://doi.org/10.1183/13993003.01269-2021
Keywords: Aucun

Acute lung injury and critical care

Introduction : Although small randomised controlled trials (RCTs) and observational studies have examined helmet noninvasive ventilation (NIV), uncertainty remains regarding its role. We conducted a systematic review and meta-analysis to examine the effect of helmet NIV compared to facemask NIV or high-flow nasal cannula (HFNC) in acute respiratory failure.

Méthode : We searched multiple databases to identify RCTs and observational studies reporting on at least one of mortality, intubation, intensive care unit (ICU) length of stay, NIV duration, complications or comfort with NIV therapy. We assessed study risk of bias using the Cochrane Risk of Bias 2 tool for RCTs and the Ottawa-Newcastle Scale for observational studies, and rated certainty of pooled evidence using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) framework.

Résultats : We separately pooled data from 16 RCTs (n=949) and eight observational studies (n=396). Compared to facemask NIV, based on low certainty of evidence, helmet NIV may reduce mortality (relative risk 0.56, 95% CI 0.33-0.95) and intubation (relative risk 0.35, 95% CI 0.22-0.56) in both hypoxic and hypercapnic respiratory failure, but may have no effect on duration of NIV. There was an uncertain effect of helmet NIV on ICU length of stay and development of pressure sores. Data from observational studies were consistent with the foregoing findings but of lower certainty. Based on low and very low certainty data, helmet NIV may reduce intubation compared to HFNC, but its effect on mortality is uncertain.

Conclusion : Compared to facemask NIV, helmet NIV may reduce mortality and intubation; however, the effect of helmet NIV compared to HFNC remains uncertain.

Conclusion (proposition de traduction) : Par rapport à la VNI avec masque facial, la VNI avec un casque de ventilation peut réduire la mortalité et l'intubation ,; cependant, l'effet de la VNI au casque de ventilation par rapport à l'oxygénothérapie nasale à haut débit (OHD) reste incertain.

Hong Kong Journal of Emergency Medicine

How to treat patients with acute respiratory failure? Conventional oxygen therapy versus high-flow nasal cannula in the emergency department.
Gedikloglu M, Gulen M, Satar S, Icen YK, Avci A, Yesiloglu O, Karcioglu O. | Hong Kong J Emerg Med. 2022 March;29(2):84–93
DOI: https://doi.org/10.1177/1024907919886245  | Télécharger l'article au format  
Keywords: High-flow nasal cannula oxygen therapy; conventional oxygen therapy; acute respiratory failure; hypercapnia

Original Article

Introduction : To investigate whether high-flow nasal cannula oxygen therapy could reduce the rate of endotracheal intubation and improve arterial blood gas values, vital signs, and clinical outcomes of patients with hypoxemic acute respiratory failure as compared with conventional oxygen therapy alone.

Méthode : This retrospective, observational study was performed in the 15-month study period and included adult patients with tachypnea and hypoxemia, whose vital signs and arterial blood gas were monitored. The high-flow nasal cannula oxygen group consisted of patients admitted to the emergency department with acute respiratory failure when high-flow nasal cannula oxygen treatment was available in the hospital, while the conventional oxygen therapy group consisted of patients who have presented to the emergency department with acute respiratory failure in the absence of high-flow nasal cannula oxygen device in the hospital. The primary outcome of the study was improvement in vital signs and arterial blood gas values within first and fourth hours of the treatment. The second outcome was the need for intubation in the emergency department, length of hospital stay, and hospital mortality.

Résultats : The decrease in the pulse and respiratory rate of high-flow nasal cannula oxygen–treated group was significantly greater than the conventional oxygen therapy group on the first and fourth hours of treatment (p<0.001). PaO2 values were significantly higher in the high-flow nasal cannula oxygen group at the first and fourth hours of treatment (p ⩽ 0.001). Likewise, mean SaO2 levels of patients receiving high-flow nasal cannula oxygen treatment was significantly higher than those of patients in the conventional oxygen therapy group (p=0.006 at 1h and p<0.001 at 4h). In the hypercapnic patients, the decrease in PaCO2 and increase in pH and PaO2 values were significantly greater in high-flow nasal cannula oxygen group (p<0.001). The difference between the groups regarding the need for invasive mechanical ventilation was not statistically significant (p = 0.179).

Conclusion : High-flow nasal cannula oxygen treatment has been associated with favorable effects in vital signs and arterial blood gas values in patients with acute respiratory failure. High-flow nasal cannula oxygen might be considered as the first-line therapy for patients with hypoxemic and/or hypercapnic acute respiratory failure.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit a été associée à des effets favorables sur les signes vitaux et les valeurs des gaz du sang artériel chez les patients souffrant d'insuffisance respiratoire aiguë. L'oxygénothérapie nasale à haut débit d’oxygène peut être considéré comme le traitement de première intention pour les patients souffrant d'insuffisance respiratoire aiguë hypoxémique et/ou hypercapnique.

Intensive Care Medicine

Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock.
Bougouin W, Slimani K, Renaudier M, Binois Y, Paul M, Dumas F, Lamhaut L, Loeb T, Ortuno S, Deye N, Voicu S, Beganton F, Jost D, Mekontso-Dessap A, Marijon E, Jouven X, Aissaoui N, Cariou A; Sudden Death Expertise Center Investigators. | Intensive Care Med. 2022 Mar;48(3):300-310
DOI: https://doi.org/10.1007/s00134-021-06608-7  | Télécharger l'article au format  
Keywords: Epinephrine; Norepinephrine; Out-of-hospital cardiac arrest; Post-resuscitation shock; Vasopressor therapy.

ORIGINAL

Introduction : Whether epinephrine or norepinephrine is preferable as the continuous intravenous vasopressor used to treat post-resuscitation shock is unclear. We assessed outcomes of patients with post-resuscitation shock after out-of-hospital cardiac arrest according to whether the continuous intravenous vasopressor used was epinephrine or norepinephrine.

Méthode : We conducted an observational multicenter study of consecutive patients managed in 2011-2018 for post-resuscitation shock. The primary outcome was all-cause hospital mortality, and secondary outcomes were cardiovascular hospital mortality and unfavorable neurological outcome (Cerebral Performance Category 3-5). A multivariate regression analysis and a propensity score analysis were performed, as well as several sensitivity analyses.

Résultats : Of the 766 patients included in five hospitals, 285 (37%) received epinephrine and 481 (63%) norepinephrine. All-cause hospital mortality was significantly higher in the epinephrine group (OR 2.6; 95%CI 1.4-4.7; P = 0.002). Cardiovascular hospital mortality was also higher with epinephrine (aOR 5.5; 95%CI 3.0-10.3; P < 0.001), as was the proportion of patients with CPC of 3-5 at hospital discharge. Sensitivity analyses produced consistent results. The analysis involving adjustment on a propensity score to control for confounders showed similar findings (aOR 2.1; 95%CI 1.1-4.0; P = 0.02).

Conclusion : Among patients with post-resuscitation shock after out-of-hospital cardiac arrest, use of epinephrine was associated with higher all-cause and cardiovascular-specific mortality, compared with norepinephrine infusion. Until additional data become available, intensivists may want to choose norepinephrine rather than epinephrine for the treatment of post-resuscitation shock after OHCA.

Conclusion (proposition de traduction) : Chez les patients en état de choc post-réanimation après un arrêt cardiaque en dehors de l'hôpital, l'utilisation d'adrénaline était associée à une mortalité toutes causes et spécifique cardiovasculaire plus élevée, par rapport à la perfusion de noradrénaline. Jusqu'à ce que des données supplémentaires soient disponibles, les intensivistes peuvent choisir la norépinéphrine plutôt que l'adrénaline pour le traitement du choc post-réanimation après un arrêt cardiaque en dehors de l'hôpital.

Internal and Emergency Medicine

Type 2 myocardial infarction: a diagnostic and therapeutic challenge in contemporary cardiology.
Merlo AC, Bona RD, Ameri P, Porto I. | Intern Emerg Med. 2022 Mar;17(2):317-324
DOI: https://doi.org/10.1007/s11739-021-02920-8  | Télécharger l'article au format  
Keywords: Cardiac troponin; Coronary angiography; Myocardial infarction; Myocardial injury.

IM-Point of view

Editorial : In the expanding world of cardiovascular diseases, rapidly reaching pandemic proportions, the main focus is still on coronary atherosclerosis and its clinical consequences. However, at least in the Western world, middle-aged male patients with acute myocardial infarction are no more the rule. Due to a higher life expectancy and major medical advances, physicians are to treat older and frailer individuals, usually with multiple comorbidities. In this context, myocardial ischaemia and infarction frequently result from an imbalance between myocardial oxygen supply and demand-i.e., type 2 myocardial infarction (T2MI), according to the current universal definition-rather than coronary atherothrombosis. Moreover, the increasing use of high-sensitivity cardiac troponin assays has led to a heightened detection of T2MI-often causing relatively little myocardial injury-, which seems to have doubled its numbers in recent years. Nevertheless, owing to its multifaceted pathophysiology and clinical presentation, T2MI is still underdiagnosed. Perhaps more importantly, T2MI is also victim of undertreatment, as drugs that constitute the cornerstone of therapy in most cardiovascular diseases are much more unlikely to be prescribed in T2MI than in coronary atherothrombosis. In this paper, we review the recent literature on the classification, pathophysiology, epidemiology, and management of T2MI, trying to summarise the state-of-the-art knowledge about this increasingly important pathologic condition. Finally, based on the current scientific evidence, we also propose an algorithm that may be easily utilised in clinical practice, in order to improve T2MI diagnosis and risk stratification.

Conclusion : Notably, T2MI and MINOCA are deeply related, as par- ticularly young patients and those with fewer comorbidities may not have IHD. As stated by the 2020 ESC non-STE ACS guidelines, all MINOCA patients should undergo CMR in the absence of an obvious underlying cause. Accordingly, we strongly support the use of CMR in these patients, as we think that cardiomyocyte necrosis of ischaemic origin, even in the absence of significant IHD, requires further investigation.

Conclusion (proposition de traduction) : L'infarctus du myocarde de type 2 et le MINOCA sont profondément liés, car les patients particulièrement jeunes et ceux qui présentent moins de comorbidités peuvent ne pas avoir de cardiopathie ischémique. Comme indiqué par les directives 2020 de l'ESC sur le syndrome coronarien aigu sans élévation du segment ST, tous les patients MINOCA doivent subir une IRM cardiaque en l'absence de cause sous-jacente évidente. En conséquence, nous soutenons fortement l'utilisation de l'IRM cardiaque chez ces patients, car nous pensons que la nécrose myocardique d'origine ischémique, même en l'absence de cardiopathie ischémique significative, nécessite des investigations plus approfondies.

Commentaire :  Algorithme pour la gestion pratique des augmentations de cTn en fonction du risque du patient, basé sur la définition universelle actuelle de l'infarctus du myocarde et les preuves scientifiques disponibles.
AMI = acute myocardial infarction;
CKD = chronic kidney disease;
CMR = cardiac magnetic resonance;
COPD = chronic obstructive pulmonary disease;
CTA = computed tomography angiography;
cTn = cardiac troponin;
CV = cardiovascular;
ECG = electrocardiogram;
GRACE = Global Registry of Acute Coronary Events;
HF = heart failure;
IHD = ischaemic heart disease;
LGE = late gadolinium enhancement;
RWMA = regional wall motion abnormalities;
T1MI = type 1 myocardial infarction;
T2MI = type 2 myocardial infarction;
TTE = transthoracic echocardiography;
TTS = takotsubo syndrome;
UDMI = Universal Definition of Myocardial Infarction;
ULN = upper level of normal;
VHD = valvular heart disease

International Journal of Emergency Medicine

Impact of cardiopulmonary resuscitation duration on the neurological outcomes of out-of-hospital cardiac arrest.
Albinali H, Alumran A, Alrayes S. | Int J Emerg Med. 2022 Mar 19;15(1):12
DOI: https://doi.org/10.1186/s12245-022-00418-4  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Cerebral performance category; Neurological outcome; Patient outcomes.

Original Research

Introduction : Patients experiencing cardiac arrest outside medical facilities are at greater risk of death and might have negative neurological outcomes. Cardiopulmonary resuscitation duration affects neurological outcomes of such patients, which suggests that duration of CPR may be vital to patient outcomes.
Objectives: The study aims to evaluate the impact of cardiopulmonary resuscitation duration on neurological outcome of patients who have suffered out-of-hospital cardiac arrest.

Méthode : This is a quantitate cross-sectional study where data is collected from emergency cases handled by a secondary hospital in industrial Jubail, Saudi Arabia, between January 2015 and December 2020. There were 257 out-of-hospital cardiac arrest cases, 236 of which resulted in death. The outcome is the survival of OHCA or death, and the neurological outcome by the cerebral performance category (CPC) score for survivors. A score of 1 or 2 defined as good CPC outcome and 3, 4, and 5 as poor outcome.

Résultats : The mean for the duration of emergency CPR procedures in surviving patients is 26.5 ± 7.20 min, whereas in patients who died after the procedure it is 29.6 ± 9.15 min. Bivariate analysis showed no significant association between duration of CPR and Cerebral Performance Category (CPC) outcome but could be significant if the sample size is large. Age, however, is significantly related to the survivorship of OHCA and to a better CPC outcome. Younger patients are more likely to have better CPC outcome. A good CPC outcome was reported with a limited duration of 8.1 min of CPR, whereas, poor CPC outcomes were associated with prolonged periods of CPR, 13.2 min.

Conclusion : Cardiopulmonary Resuscitation Duration out-of-hospital cardiac arrest does not significantly influence the patient neurological outcome in the current study hospital. Variables such as the patient population's uniqueness, underlying medical conditions, or the specific study conditions may explain this variance between the bivariate analysis and the study conclusion. Therefore, a more comprehensive study is recommended in future.

Conclusion (proposition de traduction) : La durée de réanimation cardiopulmonaire en dehors de l’hôpital n’a pas d’incidence significative sur le résultat neurologique du patient dans l’hôpital à l’étude. Des variables telles que le caractère unique de la population de patients, les conditions médicales sous-jacentes ou les conditions particulières de l’étude peuvent expliquer cet écart entre l’analyse bivariée et la conclusion de l’étude. Par conséquent, une étude plus approfondie est recommandée à l’avenir.

Peripheral venous lactate levels substitute arterial lactate levels in the emergency department.
Oi Y, Mori K, Yamagata H, Nogaki A, Takeda T, Watanabe C, Sakaguchi Y, Ogawa F, Abe T, Imaki S, Takeuchi I. | Int J Emerg Med. 2022 Jan 28;15(1):7
DOI: https://doi.org/10.1186/s12245-022-00410-y  | Télécharger l'article au format  
Keywords: Arterial lactate; Blood gas analysis; Critical patients; Emergency service; Peripheral venous lactate.

Original Research

Introduction : Arterial lactate (AL) level is an important predictor of patient prognosis. AL and peripheral venous lactate (PVL) in blood gas analysis have a low concordance rate, and PVL cannot be used as a substitute for AL. However, if the AL range can be predicted from PVL, PVL may be an alternative method for predicting patient prognosis, and the risk of arterial puncture complications with AL may be reduced. This could be a safe and rapid test method.

Méthode : This was a retrospective observational study of 125 cases in which blood gas analysis was performed on both arterial and venous blood with an infectious disease in an emergency department. Spearman's rank correlation coefficient (r) and Bland-Altman analyses were performed. Sensitivity, specificity, and area under the curve (AUC) were calculated for PVL to predict AL < 2 mmol/L or < 4 mmol/L.

Résultats : The median [interquartile range] AL and PVL were 1.82 [1.25-2.46] vs. 2.08 [1.57-3.28], respectively, r was 0.93 (p < 0.0001), and a strong correlation was observed; however, Bland-Altman analysis showed disagreement. When AL < 2 mmol/L was used as the outcome, AUC was 0.970, the PVL cutoff value was 2.55 mmol/L, sensitivity was 85.71%, and specificity was 96.05%. If PVL < 2 mmol/L was the outcome, the sensitivity for AL < 2mmol/L was 100%, and for PVL levels ≥ 3 mmol/L, the specificity was 100%. When AL < 4 mmol/L was used as the outcome, AUC was 0.967, the PVL cutoff value was 3.4 mmol/L, sensitivity was 100%, and specificity was 85.84%. When PVL < 3.5 mmol/L was the outcome, the sensitivity for AL < 4 mmol/L was 100%, and for PVL levels ≥ 4 mmol/L, the specificity was 93.81%.

Conclusion : his study revealed that PVL and AL levels in the same critically ill patients did not perfectly agree with each other but were strongly correlated. Furthermore, the high accuracy for predicting AL ranges from PVL levels explains why PVL levels could be used as a substitute for AL level ranges.

Conclusion (proposition de traduction) : Cette étude a révélé que les taux de lactate veineux périphérique et de lactate artériel chez les mêmes patients gravement malades ne concordaient pas parfaitement mais étaient fortement corrélés. De plus, la grande précision pour prédire les plages de lactate artériel à partir des niveaux de lactate veineux périphérique explique pourquoi les niveaux de lactate veineux périphérique pourraient être utilisés comme substitut aux plages de niveaux de lactate artériel.

Tenecteplase vs. alteplase for acute ischemic stroke: a systematic review.
Potla N, Ganti L. | Int J Emerg Med. 2022 Jan 4;15(1):1
DOI: https://doi.org/10.1186/s12245-021-00399-w  | Télécharger l'article au format  
Keywords: Aucun

Review

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

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

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

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

Journal of Emergencies, Trauma, and Shock

Outcomes of trauma patients present to the emergency department with a shock index of ≥1.0.
Chowdhury S, Parameaswari PJ, Leenen L. | J Emerg Trauma Shock. 2022;15:17‐22
DOI: https://doi.org/10.4103/jets.jets_86_21  | Télécharger l'article au format  
Keywords: Blood transfusion; emergencies; emergency treatment; shock; wounds and injuries

ORIGINAL ARTICLE

Introduction :  The study aimed primarily to evaluate the association between the initial shock index (SI) ≥1.0 with blood transfusion requirement in the emergency department (ED) after acute trauma. The study’s secondary aim was to look at the outcomes regarding patients’ disposition from ED, intensive care unit (ICU) and hospital length of stay, and deaths.

Méthode : It was a retrospective, cross-sectional study and utilized secondary data from the Saudi Trauma Registry (STAR) between September 2017 and August 2020. We extracted the data related to patient demographics, mechanism of injuries, the intent of injuries, mode of arrival at the hospital, characteristics on presentation to ED, length of stay, and deaths from the database and compared between two groups of SI <1.0 and SI ≥1.0. A P < 0.05 was statistically considered significant.

Résultats : Of 6667 patients in STAR, 908 (13.6%) had SI ≥1.0. With SI ≥1.0, there was a significantly higher incidence of blood transfusion in ED compared to SI <1.0 (8.9% vs. 2.4%, P < 0.001). Furthermore, SI ≥ 1.0 was associated with significant ICU admission (26.4% vs. 12.3%, P < 0.001), emergency surgical intervention (8.5% vs. 2.8%, P < 0.001), longer ICU stay (5.0 ± 0.36 vs. 2.2 ± 0.11days, P < 0.001), longer hospital stays (14.8 ± 0.61 vs. 13.3 ± 0.24 days, P < 0.001), and higher deaths (8.4% vs. 2.8%, P < 0.001) compared to the patient with SI <1.0.

Conclusion : In our cohort, a SI ≥ 1.0 on the presentation at the ED carried significantly worse outcomes. This simple calculation based on initial vital signs may be used as a screening tool and therefore incorporated into initial assessment protocols to manage trauma patients.

Conclusion (proposition de traduction) : Dans notre cohorte, un Shock Index ≥ 1,0 lors de l'admission aux urgences entraînait des résultats significativement moins bons. Ce simple calcul basé sur les signes vitaux initiaux peut être utilisé comme outil de dépistage et donc intégré dans les protocoles d'évaluation initiale pour la prise en charge des patients traumatisés.

Commentaire : Shock Index = Fréquence cardiaque ÷ Pression Artérielle Systolique.
Le Shock Index permet d'évaluer la gravité d'un patient en état de choc, en particulier chez le polytraumatisé. Un index ≥ 0,9 est corrélé à une mortalité élevée. Sur une hémorragie, un index ou un index modifié élevés peuvent aider à poser l'indication de transfusion.

Chest compression fraction and factors influencing it.
Mathew D, Krishnan SV, Abraham SV, Varghese S, Thomas MR, Palatty BU. | J Emerg Trauma Shock. 2022;15:41-6
DOI: https://doi.org/10.4103/JETS.JETS_36_21  | Télécharger l'article au format  
Keywords: Cardiac arrest; cardiopulmonary resuscitation; chest compression fraction; defibrillation; emergency department

Original article

Introduction : Chest compression fraction (CCF) is the cumulative time spent providing chest compressions divided by the total time taken for the entire resuscitation. Targeting a CCF of at least 60% is intended to limit interruptions in compressions and maximize coronary perfusion during resuscitation. We aimed to identify the mean CCF and its relationship with various factors affecting it.

Méthode : Patients presenting to the emergency department in cardiac arrest at a single center were prospectively included in this study. Resuscitation was provided by trained health-care providers. The feedback device Cprmeter2TM was placed on the patient’s sternum at the beginning of resuscitation. The total time taken for the entire resuscitation was noted by the device and CCF calculated.

Résultats : The mean CCF was analyzed using descriptive statistics and was found to be 71.60% ± 7.52%. The total duration of resuscitation (R = −0.55, P = < 0.001, min-max, 2.02–34.31, mean 12.25 ± 6.54), number of people giving chest compressions (R = −0.48, P = < 0.001, min-max, 1–6, mean 4.04 ± 1.12), and total number of team members in resuscitation (R = −0.50, P = < 0.001, min-max, 4–10, mean 6.65 ± 1.32) had negative correlation with CCF. Diurnal variation (day, n = 35; mean 69.20% ± 7% and night, n = 20; mean 75.80% ± 5.6%, P = 0.001) and patients receiving defibrillation (receiving n = 10 mean 67.00% ± 4.11% and not receiving n = 45 mean 72.62 ± 7.42%, P = 0.005) were found to significantly affect CCF.

Conclusion : The mean CCF for cardiac arrest patients was well within the targets of guideline recommendation. CCF decreased when resuscitation lasted longer, during daytime when the defibrillator was used, the total team members increased, and also when the number of people giving chest compressions increased. CCF during resuscitation may improve if there is a focus on improving these factors and requires validation in multicentric settings.

Conclusion (proposition de traduction) : La proportion moyenne de compressions thoraciques chez les patients en arrêt cardiaque se situait bien dans les cibles des recommandations des lignes directrices. La proportion de compressions thoraciques a diminué lorsque la réanimation a duré plus longtemps, pendant la journée lorsque le défibrillateur a été utilisé, le nombre total de membres de l'équipe a augmenté, et également lorsque le nombre de personnes effectuant des compressions thoraciques a augmenté. La proportion de compressions thoraciques pendant la réanimation peut s'améliorer si l'accent est mis sur l'amélioration de ces facteurs et nécessite une validation dans des contextes multicentriques.

Journal of Intensive Care

A prospective observational cohort study to identify inflammatory biomarkers for the diagnosis and prognosis of patients with sepsis.
D'Onofrio V, Heylen D, Pusparum M, Grondman I, Vanwalleghem J, Meersman A, Cartuyvels R, Messiaen P, Joosten LAB, Netea MG, Valkenborg D, Ertaylan G, Gyssens IC. | J Intensive Care. 2022 Mar 9;10(1):13
DOI: https://doi.org/10.1186/s40560-022-00602-x  | Télécharger l'article au format  
Keywords: Biomarkers; Disease severity; Inflammation; Sepsis

Research

Introduction : Sepsis is a life-threatening organ dysfunction. A fast diagnosis is crucial for patient management. Proteins that are synthesized during the inflammatory response can be used as biomarkers, helping in a rapid clinical assessment or an early diagnosis of infection. The aim of this study was to identify biomarkers of inflammation for the diagnosis and prognosis of infection in patients with suspected sepsis.

Méthode : In total 406 episodes were included in a prospective cohort study. Plasma was collected from all patients with suspected sepsis, for whom blood cultures were drawn, in the emergency department (ED), the department of infectious diseases, or the haemodialysis unit on the first day of a new episode. Samples were analysed using a 92-plex proteomic panel based on a proximity extension assay with oligonucleotide-labelled antibody probe pairs (OLink, Uppsala, Sweden). Supervised and unsupervised differential expression analyses and pathway enrichment analyses were performed to search for inflammatory proteins that were different between patients with viral or bacterial sepsis and between patients with worse or less severe outcome.

Résultats : Supervised differential expression analysis revealed 21 proteins that were significantly lower in circulation of patients with viral infections compared to patients with bacterial infections. More strongly, higher expression levels were observed for 38 proteins in patients with high SOFA scores (> 4), and for 21 proteins in patients with worse outcome. These proteins are mostly involved in pathways known to be activated early in the inflammatory response. Unsupervised, hierarchical clustering confirmed that inflammatory response was more strongly related to disease severity than to aetiology.

Conclusion : Several differentially expressed inflammatory proteins were identified that could be used as biomarkers for sepsis. These proteins are mostly related to disease severity. Within the setting of an emergency department, they could be used for outcome prediction, patient monitoring, and directing diagnostics.

Conclusion (proposition de traduction) : Plusieurs protéines inflammatoires différentiellement exprimées ont été identifiées qui pourraient être utilisées comme biomarqueurs dans la septicémie. Ces protéines sont principalement liées à la gravité de la maladie. Dans le cadre d'un service d'urgence, ils pourraient être utilisés pour la prédiction des résultats, la surveillance des patients et l'orientation des diagnostics.

Commentaire :  Protéines dans les modèles les plus optimaux, prédisant avec précision les différences d'étiologie, de gravité de la maladie et de résultat

Accuracy evaluation of mainstream and sidestream end-tidal carbon dioxide monitoring during noninvasive ventilation: a randomized crossover trial (MASCAT-NIV trial).
Sakuraya M, Douno E, Iwata W, Takaba A, Hadama K, Kawamura N, Maezawa T, Iwamoto K, Yoshino Y, Yoshida K. | J Intensive Care. 2022 Mar 18;10(1):17
DOI: https://doi.org/10.1186/s40560-022-00603-w  | Télécharger l'article au format  
Keywords: Blood gas analysis; End-tidal partial pressure of carbon dioxide; Mainstream capnography; Noninvasive ventilation; Partial pressure of carbon dioxide; Post-extubation.

Research

Introduction : The end-tidal partial pressure of carbon dioxide (PETCO2) can be used to estimate the arterial partial pressure of carbon dioxide (PaCO2) in patients who undergo mechanical ventilation via endotracheal intubation. However, no reliable method for measuring PETCO2 during noninvasive ventilation (NIV) has been established. The purpose of this study was to evaluate the correlation and agreement between PaCO2 and PETCO2 measured by these two methods and to compare them in patients who underwent NIV after extubation.

Méthode : This study was a randomized, open-label, crossover trial in a mixed intensive care unit. We included patients who were planned for NIV after extubation and for whom the difference between PETCO2 and PaCO2 was ≤ 5 mmHg. We compared mainstream capnography using an inner cup via face mask (the novel method) with sidestream capnography (the previous method) during NIV. The relationships between PaCO2 and PETCO2 were evaluated by computing the Pearson correlation coefficient, and the agreement between PaCO2 and PETCO2 was estimated using the Bland-Altman method.

Résultats : From April 2020 to October 2021, 60 patients were included to the study. PaCO2 and PETCO2 were well correlated in both methods (the novel methods: r = 0.92, P < 0.001; the previous method: r = 0.79, P < 0.001). Mean bias between PaCO2 and PETCO2 measured using the novel method was 2.70 (95% confidence interval [CI], 2.15-3.26) mmHg with 95% limits of agreement (LoA) ranging from - 1.61 to 7.02 mmHg, similar to the result of measurement during SBT (mean bias, 2.51; 95% CI, 2.00-3.02; 95% LoA, - 1.45 to 6.47 mmHg). In contrast, measurement using the previous method demonstrated a larger difference (mean bias, 6.22; 95% CI, 5.22-7.23; 95% LoA, - 1.54 to 13.99 mmHg).

Conclusion : The current study demonstrated that the novel PETCO2 measurement was superior to the previous method for PaCO2 prediction. During NIV, the novel method may collect as sufficient exhalation sample as during intubation. Continuous PETCO2 measurement combined with peripheral oxygen saturation monitoring is expected to be useful for early recognition of respiratory failure among high-risk patients after extubation.

Conclusion (proposition de traduction) : L'étude actuelle a démontré que la nouvelle mesure du PETCO2 était supérieure à la méthode précédente de prédiction de la PaCO2. Pendant la VNI, la nouvelle méthode peut recueillir un échantillon d'exhalation aussi suffisant que chez le patient intubé. La mesure continue de la PETCO2 combinée à la surveillance de la saturation périphérique en oxygène devrait être utile pour la détection précoce de l'insuffisance respiratoire chez les patients à haut risque après extubation.

Commentaire : • Le système « sidestream » transporte par une pompe aspirative le CO2 de la bouche du patient vers le module de mesure du CO2 situé dans le moniteur.
• Le système « mainstream » mesure le CO2 directement dans une petite chambre située à la bouche du patient et reliée au moniteur par un câble.

Surveillance généralisée à l'aide de la nouvelle méthode.
Une illustration du masque NPPV cap ONE mask® utilisé dans cette étude. Le capnomètre a été calibré en fonction de la lecture du PETCO2 avant chaque utilisation du ventilateur NKV 330 (Nihon Kohden Tokyo, Japon). De plus, le capteur PETCO2 grand public est doté d'un film antibuée spécial sur la fenêtre de l'échantillon, ce qui garantit des mesures précises pendant 72 h.

Journal of Intensive Care Medicine

Assessing the Cushion Effect: A Systematic Review and Meta-Analysis of the Role of Obesity in Motor Vehicle Injuries and Fatalities.
Hoebee S, Ron E, Alattar Z, Kang P, vanSonnenberg E. | J Intensive Care Med. 2022 Mar;37(3):293-303
DOI: https://doi.org/10.1177/0885066621989978
Keywords: injury; motor vehicle accidents; obesity; trauma.

Analytic Reviews

Introduction : A systematic review and meta-analysis were done to evaluate the effect of obesity in injury and mortality due to motor vehicle accidents.

Méthode : The systematic review consisted of 20 studies meeting the inclusion criteria. The meta-analysis was conducted on these studies to analyze obesity as a risk factor for specific injuries, as well as overall injury and mortality compared to non-obese patients.

Résultats : The data revealed that obesity was associated with increased lower extremity injuries (odds ratio [OR] = 1.44, 95% confidence interval [CI] = 1.19-1.69, P ≤ 0.05), neck injuries (OR = 3.38, 95% CI = 1.58-5.19, P ≤ 0.05), and overall mortality (OR = 1.51, 95% CI = 1.40-1.61, P ≤ 0.05). When stratified for obesity class with class I as BMI >30.1-34.9, class II BMI 35-39.9, and class III BMI >40, only class II (OR = 1.20, 95% CI = 1.15-1.24, P ≤ 0.05) and class III (OR = 1.49, 95% CI = 1.30-1.68, P ≤ 0.05) were associated with increased mortality risk. No significant differences were seen with head, upper extremity, thoracic, abdominal, or pelvic injuries.

Conclusion : Obesity is a risk factor in motor vehicle accidents for fatality and injury, specifically lower extremity and neck injuries.

Conclusion (proposition de traduction) : L'obésité est un facteur de risque de décès et de blessures dans les accidents de la route, en particulier les blessures aux membres inférieurs et au cou.

Vitamin C, Thiamine, and Hydrocortisone in the Treatment of Sepsis: A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials..
Zayed Y, Alzghoul BN, Banifadel M, Venigandla H, Hyde R, Sutchu S, Khasawneh M, Borok Z, Urbine D, Jantz M, Reddy R. | J Intensive Care Med. 2022 Mar;37(3):327-336
DOI: https://doi.org/10.1177/0885066620987809
Keywords: hydrocortisone; meta-analysis; sepsis; septic shock; thiamine; vitamin C.

Original Research

Introduction : There is a conflicting body of evidence regarding the benefit of vitamin C, thiamine, and hydrocortisone in combination as an adjunctive therapy for sepsis with or without septic shock. We aimed to assess the efficacy of this treatment among predefined populations.

Méthode : A literature review of major electronic databases was performed to include randomized controlled trials (RCTs) evaluating vitamin C, thiamine, and hydrocortisone in the treatment of patients with sepsis with or without septic shock in comparison to the control group.

Résultats : Seven studies met our inclusion criteria, and 6 studies were included in the final analysis totaling 839 patients (mean age 64.2 ± 18; SOFA score 8.7 ± 3.3; 46.6% female). There was no significant difference between both groups in long term mortality (Risk Ratio (RR) 1.05; 95% CI 0.85-1.30; P = 0.64), ICU mortality (RR 1.03; 95% CI 0.73-1.44; P = 0.87), or incidence of acute kidney injury (RR 1.05; 95% CI 0.80-1.37; P = 0.75). Furthermore, there was no significant difference in hospital length of stay, ICU length of stay, and ICU free days on day 28 between the intervention and control groups. There was, however, a significant difference in the reduction of SOFA score on day 3 from baseline (MD -0.92; 95% CI -1.43 to -.41; P < 0.05). In a trial sequential analysis for mortality outcomes, our results are inconclusive for excluding lack of benefit of this therapy.

Conclusion : Among patients with sepsis with or without septic shock, treatment with vitamin C, thiamine, and hydrocortisone was not associated with a significant reduction in mortality, incidence of AKI, hospital and ICU length of stay, or ICU free days on day 28. There was a significant reduction of SOFA score on day 3 post-randomization. Further studies with a larger number of patients are needed to provide further evidence on the efficacy or lack of efficacy of this treatment.

Conclusion (proposition de traduction) : Parmi les patients présentant une septicémie avec ou sans choc septique, le traitement par la vitamine C, la thiamine et l'hydrocortisone n'a pas été associé à une réduction significative de la mortalité, de l'incidence de l'IRA, de la durée du séjour à l'hôpital et en USI, ou des jours sans USI au 28<ème/sup> jour. Il y avait une réduction significative du score SOFA au 3<ème/sup> jour après la randomisation. D'autres études avec un plus grand nombre de patients sont nécessaires pour fournir des preuves supplémentaires sur l'efficacité ou le manque d'efficacité de ce traitement.

Prolonged Capillary Refilling as a Predictor of Mortality in Patients With Septic Shock.
Morocho JP, Martínez AF, Cevallos MM, Vasconez-Gonzalez J, Ortiz-Prado E, Barreto-Grimaldos A, Vélez-Páez JL. | J Intensive Care Med. 2022 Mar;37(3):423-429
DOI: https://doi.org/10.1177/08850666211003507
Keywords: CO2 delta; capillary refilling time (CRT); central venous oxygen saturation; lactate; septic shock.

Original Research

Introduction : Microcirculatory alterations characterize septic shock; increased blood lactate level has been described as markers of microcirculation alteration in patients with septic shock. Although useful, this serological analysis is not always feasible in all settings worldwide.

Méthode : To determine if a prolonged capillary refilling is a predictor of mortality in patients with septic shock.

Résultats : A 10-months prospective cohort study was carried out on 175 patients admitted to the Intensive Care Unit (ICU) with the diagnosis of septic shock. The capillary refilling time (CRT) was evaluated Immediately upon admission and after 6 hours post-resuscitation. Traditional tissue perfusion markers were also used to compare and analyze their predictive value on mortality at 28 days.

Conclusion : The area under the ROC curve (AUC) to estimate mortality in patients with septic shock with CRT at admission was 0.666 (0.584-0.748), while at 6 hours was 0.819 (0.753-0.885), with a cut-off point of 4.5 seconds at admission (PPV 52.87% NPV 72.73%) and 3.5 sec at 6 hours (PPV 95.56% NPV 79.23%). In those with CRT > 3.5 seconds at 6 hours, they had a RR of 4.60, while a CRT > 4.5 seconds at admission had a RR of 1.94, with a non-survivor proportion of 95.56% for a CRT > 3.5 sec at 6 hours vs 20.77% for CRT ≤ 3.5 sec (P value < 0.001). The CRT at 6 hours showed significant differences in the survival curves with P-value < 0.001, where for values > 3.5 sec, survival at 28 days was 4.44% vs 79.20% for values ≤ 3.5 sec.

Conclusion (proposition de traduction) : Le TRC est un puissant facteur prédictif de mortalité chez les patients en choc septique. L'évaluation des changements de TRC pendant la réanimation d'un choc septique pourrait être utilisée comme un outil clinique important pour prédire la mortalité ; en particulier dans les milieux à faibles ressources où l'utilisation d'autres biomarqueurs peut parfois être difficile.

Commentaire : La mesure automatisée du TRC est en cours de déploiement en réanimation. Quelques appareils de mesures son actuellement disponibles, d'autres en cours de développement, pour l'évaluation objective et en continu de l'hypoperfusion tissulaire.
Classiquement, la mesure du TRC se réalise au membre supérieur placé au niveau du coeur, chez un patient en décubitus dorsal. On réalise une compression modérée de la pulpe de l’index, du majeur ou de l’annulaire durant 5 secondes. Au relâchement de la compression, l’observateur mesure le temps que met la pulpe à se recolorer.
Trois mesures sont habituellement recommandées et moyennées. Chez l’enfant et l’adulte jeune le TRC est normalement inférieur à 2 secondes. Chez la femme et les patients des deux sexes de plus de 65 ans, la limite de normalité est respectivement de 3 et 4 secondes.
Des facteurs tels que la luminosité de l’endroit dans lequel est effectué la mesure, la température ambiante (mécanisme de thermorégulation)... peuvent influencer le temps que va prendre la peau à retrouver son état initial, faussant ainsi le diagnostic qui va être posé. Enfin, il existe une certaine subjectivité avec une reproductibilité interobservateur allant de médiocre à bonne.
Delahaye A and al. Hémodynamique non invasive au cours des insuffisances circulatoires aiguës. Urgences 2011  .

Journal of the American Medical Association

Association of Type of Oral Anticoagulant Dispensed With Adverse Clinical Outcomes in Patients Extending Anticoagulation Therapy Beyond 90 Days After Hospitalization for Venous Thromboembolism.
Pawar A, Gagne JJ, Gopalakrishnan C, Iyer G, Tesfaye H, Brill G, Chin K, Bykov K. | JAMA. 2022 Mar 15;327(11):1051-1060
DOI: https://doi.org/10.1001/jama.2022.1920
Keywords: Aucun

Original Investigation

Introduction : Guidelines for managing venous thromboembolism (VTE) recommend at least 90 days of therapy with oral anticoagulants. Limited evidence exists about the optimal drug for continuing therapy beyond 90 days.
Objective: To compare having prescriptions dispensed for apixaban, rivaroxaban, or warfarin after an initial 90 days of anticoagulation therapy for the outcomes of hospitalization for recurrent VTE, major bleeding, and death.

Méthode : This exploratory retrospective cohort study used data from fee-for-service Medicare (2009-2017) and from 2 commercial health insurance (2004-2018) databases and included 64 642 adults who initiated oral anticoagulation following hospitalization discharge for VTE and continued treatment beyond 90 days.
Exposures: Apixaban, rivaroxaban, or warfarin prescribed after an initial 90-day treatment for VTE.
Main outcomes and measures: Primary outcomes included hospitalization for recurrent VTE and hospitalization for major bleeding. Analyses were adjusted using propensity score weighting. Patients were followed up from the end of the initial 90-day treatment episode until treatment cessation, outcome, death, disenrollment, or end of available data. Weighted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs.

Résultats : The study included 9167 patients prescribed apixaban (mean [SD] age, 71 [14] years; 5491 [59.9%] women), 12 468 patients prescribed rivaroxaban (mean [SD] age, 69 [14] years; 7067 [56.7%] women), and 43 007 patients prescribed warfarin (mean [SD] age, 70 [15] years; 25 404 [59.1%] women). The median (IQR) follow-up was 109 (59-228) days for recurrent VTE and 108 (58-226) days for major bleeding outcome. After propensity score weighting, the incidence rate of hospitalization for recurrent VTE was significantly lower for apixaban compared with warfarin (9.8 vs 13.5 per 1000 person-years; HR, 0.69 [95% CI, 0.49-0.99]), but the incidence rates were not significantly different between apixaban and rivaroxaban (9.8 vs 11.6 per 1000 person-years; HR, 0.80 [95% CI, 0.53-1.19]) or rivaroxaban and warfarin (HR, 0.87 [95% CI, 0.65-1.16]). Rates of hospitalization for major bleeding were 44.4 per 1000 person-years for apixaban, 50.0 per 1000 person-years for rivaroxaban, and 47.1 per 1000 person-years for warfarin, yielding HRs of 0.92 (95% CI, 0.78-1.09) for apixaban vs warfarin, 0.86 (95% CI, 0.71-1.04) for apixaban vs rivaroxaban, and 1.07 (95% CI, 0.93-1.24) for rivaroxaban vs warfarin.

Conclusion : In this exploratory analysis of patients prescribed extended-duration oral anticoagulation therapy after hospitalization for VTE, prescription dispenses for apixaban beyond 90 days, compared with warfarin beyond 90 days, were significantly associated with a modestly lower rate of hospitalization for recurrent VTE, but no significant difference in rate of hospitalization for major bleeding. There were no significant differences for comparisons of apixaban vs rivaroxaban or rivaroxaban vs warfarin.

Conclusion (proposition de traduction) : Dans cette analyse exploratoire des patients auxquels un traitement anticoagulant oral de longue durée a été prescrit après une hospitalisation pour thrombophlébite veineuse, les prescriptions d'apixaban au-delà de 90 jours, par rapport à la warfarine au-delà de 90 jours, ont été significativement associées à un taux légèrement inférieur d'hospitalisation pour thrombophlébite veineuse récurrente, mais pas de différence significative dans le taux d'hospitalisation pour hémorragie majeure. Il n'y avait pas de différences significatives pour les comparaisons apixaban vs rivaroxaban ou rivaroxaban vs warfarine.

Médecine Intensive Réanimation

Poiroux L | Med Intensive Rea. 2022;31(1):21-28
DOI: https://doi.org/10.37051/mir-00091  | Télécharger l'article au format  
Keywords: Norepinephrine administration; changeover; critical care nursing; evidence based nursing; patient safety

MISE AU POINT

Editorial : Les catécholamines sont le traitement de première ligne dans la prise en charge des patients en état de choc. Ces médicaments, et la noradrénaline en particulier, ont une demi-vie très courte et une marge thérapeutique extrême-ment étroite. Leur administration nécessite des précautions afin de garantir une efficacité optimale du traitement et la sécurisation de leur utilisation. Les choix des équipements biomédicaux, des dispositifs médicaux, des stratégies d’administration peuvent avoir une grande influence sur la constance du débit massique des médicaments. Ces varia-tions peuvent avoir des conséquences cliniques allant de la faible variation de la pression artérielle à des événements indésirables plus graves. Même si les publications qui se sont intéressées à ces questions sont peu nombreuses et de qualité méthodologique inégale, elles rapportent néanmoins des données intéressantes pour guider la pratique infirmière en réanimation. Cet article a pour objectif de proposer un état des connaissances sur la gestion des catécholamines avec un focus particulier sur le management des relais de noradrénaline.

Conclusion (proposition de traduction) : Les catécholamines sont des médicaments couramment utilisés en réanimation. Leurs particularités pharmacologiques (demi-vie courte et une marge thérapeutique étroite) impliquent que les infirmiers appuient leurs pratiques d’administration de ces traitements sur des données acquises de la science. Même si la recherche s’avère encore nécessaire dans ce domaine, des grands principes permettent de garantir l’efficacité et la sécurité de l’administration intraveineuse continue de noradrénaline en réanimation : utiliser des tubulures rigides, simplifier les montages des lignes de perfusion, éviter les espaces morts, réduire le tronc commun, envisager l’utilisation de valves anti-retour, protocoler les dilutions, former les infirmières à la réalisation des relais et prévenir tout mouvement vertical des pousse-seringues.

Pediatric Critical Care Medicine

Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis*.
Lehr AR, Rached-d'Astous S, Barrowman N, Tsampalieros A, Parker M, McIntyre L, Sampson M, Menon K. | Pediatr Crit Care Med. 2022 Mar 1;23(3):181-191
DOI: https://doi.org/10.1097/pcc.0000000000002890
Keywords: Aucun

FEATURE REVIEW ARTICLE

Introduction : The ideal crystalloid fluid bolus therapy for fluid resuscitation in children remains unclear, but pediatric data are limited. Administration of 0.9% saline has been associated with hyperchloremic metabolic acidosis and acute kidney injury. The primary objective of this systematic review was to compare the effect of balanced versus unbalanced fluid bolus therapy on the mean change in serum bicarbonate or pH within 24 hours in critically ill children.

Méthode : We searched MEDLINE including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, CENTRAL Trials Registry of the Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform.
Study selection: Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guidelines, we retrieved all controlled trials and observational cohort studies comparing balanced and unbalanced resuscitative fluids in critically ill children. The primary outcome was the change in serum bicarbonate or blood pH. Secondary outcomes included the prevalence of hyperchloremia, acute kidney injury, renal replacement therapy, and mortality.
Data extraction: Study screening, inclusion, data extraction, and risk of bias assessments were performed independently by two authors.

Résultats : Among 481 references identified, 13 met inclusion criteria. In the meta-analysis of three randomized controlled trials with a population of 162 patients, we found a greater mean change in serum bicarbonate level (pooled estimate 1.60 mmol/L; 95% CI, 0.04-3.16; p = 0.04) and pH level (pooled mean difference 0.03; 95% CI, 0.00-0.06; p = 0.03) after 4-12 hours of rehydration with balanced versus unbalanced fluids. No differences were found in chloride serum level, acute kidney injury, renal replacement therapy, or mortality.

Conclusion : Our systematic review found some evidence of improvement in blood pH and bicarbonate values in critically ill children after 4-12 hours of fluid bolus therapy with balanced fluid compared with the unbalanced fluid. However, a randomized controlled trial is needed to establish whether these findings have an impact on clinical outcomes before recommendations can be generated.

Conclusion (proposition de traduction) : Notre revue systématique a trouvé des preuves d'amélioration du pH sanguin et des taux de bicarbonate chez les enfants gravement malades après 4 à 12 heures de traitement par administration d'un bolus de cristalloïde balancé par rapport au cristalloïde non balancé. Cependant, un essai contrôlé randomisé est nécessaire pour déterminer si ces résultats ont un impact sur les résultats cliniques avant que des recommandations puissent être générées.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Do Balanced Fluids Help Critically Ill Children?  . Rédigé le 28 avril 2022.

Pediatric Emergency Care

Nonutility of Diagnostic Testing in Ambulatory Patients With Supraventricular Tachycardia.
Taylor RA, Thomas R, Lawrence D. | Pediatr Emerg Care. 2022 Mar 1;38(3):e1036-e1040
DOI: https://doi.org/10.1097/pec.0000000000002649
Keywords: Aucun

Original article

Introduction : Supraventricular tachycardia (SVT) is the most common arrhythmia in the pediatric population. Patients often present to the emergency department and undergo extensive diagnostic assessment. The objective of this study is to determine the frequency of diagnostic studies obtained in such patients and to assess clinical significance of these results.

Méthode : A retrospective study was performed from 2011 to 2018 in a single-center ED, including patients 21 years of age or younger presenting with SVT without shock.

Résultats : A total of 40 patients with 92 encounters were included for analysis. The mean age was 8.58 (±5.51) years; 55% female. A total of 67.4% underwent serologic laboratory evaluation, of which 8 (12.9%) had any abnormality. Only one was deemed clinically significant to warrant intervention. Nearly 30% of patients underwent chest radiography, with no clinically significant findings.

Conclusion : Patients undergoing ED management of uncomplicated SVT are likely to undergo laboratory investigation and unlikely to have abnormal studies impacting their care. Given the associated risk of false-positive studies, the discomfort to the patient and parent, and cost of these studies, routine laboratory or radiographic investigation in this population may be unwarranted.

Conclusion (proposition de traduction) : Les patients bénéficiant d'une prise en charge aux urgences pour une TSV non compliquée sont susceptibles de subir des examens de laboratoire et il est peu probable que des résultats anormaux aient un impact sur leurs soins. Compte tenu du risque associé de résultats faussement positives, de l'inconfort pour le patient et ses parents et du coût de ces examens complémentaires, un examen de laboratoire ou radiographique de routine dans cette population peut être injustifié.

Applying the Ottawa Ankle Rules in a Pediatric Emergency Department.
Almeida SI, Rios J, Costa Lima S, Oom P. | Pediatr Emerg Care. 2022 Mar 1;38(3):e1123-e1126
DOI: https://doi.org/10.1097/pec.0000000000002528
Keywords: Aucun

Original article

Introduction : Ankle and midfoot injuries constitute one of the most frequent reasons to visit the pediatric emergency department (ED). The aims of the study were (1) to determine the feasibility of the Ottawa Ankle Rules (OARs) in a pediatric ED and its reliability to safely manage ankle and midfoot injuries and (2) to verify the impact in reducing the number of radiographs, healthcare costs, and time spent in the ED.

Méthode : The prospective study enrolled 90 patients for the control group and 94 for the case group. For the control group, the standard of practice was registered. In the case group, before beginning enrolment, an instruction of how to apply the OARs were given to all clinicians. After that, OARs were applied according to patient complaints. A follow-up call was made for both groups.

Résultats : The mean age of the control group was 11.9 years (standard deviation, 3.267 years), whereas in the case group was 11.3 years (standard deviation, 3.533 years). Demographic and injury characteristics were similar in both groups. A significant statistical difference was verified in the number of radiographs (P = 0.001) with a reduction of 16.7% in the case group. Patients who did not perform radiography, in the case group, spent at least 1 hour less than the ones who did. The OARs have shown a sensitivity of 100% (95% confidence interval, 39.76-100.00) and specificity of 23.33% (95% CI, 15.06-33.43) with a negative predictive value of 100%.

Conclusion : The OARs are an important clinical instrument with a high sensitivity and negative predictive value, which allows clinicians to avoid unnecessary exposure to radiation without missing clinically relevant fractures.

Conclusion (proposition de traduction) : Les règles d'Ottawa pour la cheville sont un instrument clinique important avec une sensibilité élevée et une valeur prédictive négative, qui permet aux cliniciens d'éviter une exposition inutile aux rayonnements sans manquer des fractures cliniquement pertinentes.

Prehospital Emergency Care

Prehospital Intranasal Glucagon for Hypoglycemia.
Haamid A, Christian E, Tataris K, Markul E, Zaidi HQ, Mycyk MB, Weber JM. | Prehosp Emerg Care. 2022 Mar 2:1-4.
DOI: https://doi.org/10.1080/10903127.2022.2045406
Keywords: Aucun

Article

Introduction : Prehospital hypoglycemia is usually treated with oral or intravenous (IV) dextrose in a variety of concentrations. In the absence of vascular access, intramuscular (IM) glucagon is commonly administered. Occupational needle-stick injury remains a significant risk while attempting to obtain vascular access or administer medications intramuscularly in the prehospital setting. We sought to determine if intranasal (IN) glucagon is effective in the prehospital treatment of hypoglycemia.

Méthode : We performed a retrospective analysis of all consecutive cases where recombinant glucagon was administered IN by paramedics from January 1, 2015 through December 31, 2020. Excluded were cases without pre or post administration blood glucose documentation, and cases where another form of treatment for hypoglycemia was administered at any time during the EMS encounter. The primary outcome was clinical response to IN glucagon documented by paramedics; secondary outcomes included pre and post administration blood glucose values.

Résultats : Out of 44 cases that met study inclusion criteria, 14 patients (32%) had substantial improvement, 13 patients (30%) had slight improvement, and 17 patients (38%) had no improvement in mental status after administration of IN glucagon. In cases with substantial improvement (n = 14), the mean pre administration blood glucose was 33.8 mg/dl and the mean post administration blood glucose was 87.1 mg/dl (mean increase 53.3 mg/dl, 95% CI: 21.5 to 85.1). In cases with slight improvement (n = 13), the mean pre administration blood glucose was 23.9 mg/dl and the mean post administration blood glucose was 53.8 mg/dl (mean increase 29.9 mg/dl, 95% CI = 2.9 to 56.9). In case with no improvement (n = 17) the mean pre administration blood glucose was 30.1 mg/dl and the mean post administration glucose was 33.1 mg/dl (mean difference 3.1 mg/dl, 95% CI: -10.1 to 3.9).

Conclusion : Intranasal administration of recombinant glucagon for hypoglycemia resulted in a clinically significant improvement in mental status and a corresponding increase in blood glucose levels in select cases in the prehospital setting.

Conclusion (proposition de traduction) : L'administration intranasale de glucagon recombinant pour l'hypoglycémie a entraîné une amélioration cliniquement significative de l'état mental et une augmentation correspondante de la glycémie dans certains cas en milieu préhospitalier.

Interfacility Transport of Mechanically Ventilated Patients with Suspected COVID-19 in the Prone Position.
Pan A, Peddle M, Auger P, Parfeniuk D, MacDonald RD. | Prehosp Emerg Care. 2022 Mar 2:1-6
DOI: https://doi.org/10.1080/10903127.2022.2036882
Keywords: Aucun

Article

Introduction : Prone positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport.

Méthode : This retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events.

Résultats : From April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO2 < 88%), and 3 (2.4%) were hypotensive (SBP < 90 or MAP < 65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO2/FiO2 ratio was available, the mean (median; range) was 86.7 (81; 47-144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14-176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport.

Conclusion : Patients with severe hypoxemic respiratory failure due to COVID-19 can be safely transported in the prone position by specially trained critical care paramedic crews.

Conclusion (proposition de traduction) : Les patients souffrant d'insuffisance respiratoire hypoxémique sévère due à la COVID-19 peuvent être transportés en toute sécurité en décubitus ventral par des équipes paramédicales de soins intensifs spécialement formées.

Resuscitation

Diagnostic test accuracy of point-of-care ultrasound during cardiopulmonary resuscitation to indicate the etiology of cardiac arrest: A systematic review.
Reynolds JC, Nicholson T, O'Neil B, Drennan IR, Issa M, Welsford M; Advanced Life Support Task Force at the International Liaison Committee on Resuscitation ILCOR. | Resuscitation. 2022 Mar;172:54-63
DOI: https://doi.org/10.1016/j.resuscitation.2022.01.006
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Diagnosis; Diagnostic test accuracy; Echocardiography; Point-of-care ultrasound; Systematic review.

Reviews

Introduction : Point-of-care ultrasound (POCUS) is used in cardiac arrest patients to assess for reversible causes. We aimed to conduct a diagnostic test accuracy systematic review of intra-arrest POCUS to indicate the etiology of cardiac arrest in adults in any setting.

Méthode : This review is registered with PROSPERO (CRD42020205207) and reported according to PRISMA guidelines. We searched Medline, EMBASE, Web of Science, CINAHL, and Cochrane Library on October 6, 2021. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) template. We estimated sensitivity and specificity when feasible and evaluated the certainty of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

Résultats : Of 8,621 search results, 12 observational studies reported 26 combinations of index tests and reference standards to indicate six different etiologies of cardiac arrest. All studies had high risks of bias from subject selection, lack of blinding, reference standards susceptible to confounding, and/or differential verification. One study reported sufficient data to complete contingency tables for sensitivity and specificity of POCUS to identify myocardial infarction, cardiac tamponade, and pulmonary embolism as the etiology of cardiac arrest. Heterogeneity and risk of bias precluded meta-analysis and the certainty of evidence was uniformly very low.

Conclusion :  It is feasible to identify reversible causes of cardiac arrest with POCUS, but the current literature is heterogenous with high risks of bias, wide confidence intervals, and very low certainty of evidence, which render these data difficult to interpret.

Conclusion (proposition de traduction) : Il est possible d'identifier les causes réversibles d'un arrêt cardiaque avec l'échographie au point d'intervention, mais la littérature actuelle est hétérogène avec des risques élevés de biais, de larges intervalles de confiance et une très faible certitude des preuves, ce qui rend ces données difficiles à interpréter.

Cardiorenal function and survival in in-hospital cardiac arrest: A nationwide study of 22,819 cases.
Berglund S, Andreasson A, Rawshani A, Hirlekar G, Lundgren P, Angerås O, Mandalenakis Z, Redfors B, Holm A, Hagberg E, Ricksten SE, Friberg H, Gustafsson L, Dworeck C, Herlitz J, Rawshani A. | Resuscitation. 2022 Mar;172:9-16
DOI: https://doi.org/10.1016/j.resuscitation.2021.12.037  | Télécharger l'article au format  
Keywords: Heart failure; In-hospital cardiac arrest; Kidney function;

Clinical Paper

Introduction : Fonction cardio-rénale et survie en cas d'arrêt cardiaque à l'hôpital : une étude nationale de 22 819 cas

Méthode : We included cases aged ≥ 18 years in the Swedish Cardiopulmonary Resuscitation Registry during 2008 to 2020. The CKD-EPI equation was used to calculate estimated glomerular filtration rate (eGFR). A history of heart failure was defined according to contemporary guideline criteria. Logistic regression was used to study survival. Neurological outcome was assessed using cerebral performance category (CPC).

Résultats : We studied 22,819 patients with IHCA. The 30-day survival was 19.3%, 16.6%, 22.5%, 28.8%, 39.3%, 44.8% and 38.4% in cases with eGFR < 15, 15-29, 30-44, 45-59, 60-89, 90-130 and 130-150 ml/min/1.73 m2, respectively. All eGFR levels below and above 90 ml/min/1.73 m2 were associated with increased mortality. Probability of survival at 30 days was 62% lower in cases with eGFR < 15 ml/min/1.73 m2, compared with normal kidney function. At every level of eGFR, presence of heart failure increased mortality markedly; patients without heart failure displayed higher mortality only at eGFR below 30 ml/min/1.73 m2. Among survivors with eGFR < 15 ml/min/1.73 m2, good neurological outcome was noted in 87.2%. Survival increased in most groups over time, but most for those with eGFR < 15 ml/min/1.73 m2, and least for those with normal eGFR.

Conclusion : All eGFR levels below and above normal range are associated with increased mortality and this association is modified by the presence of heart failure. Neurological outcome is good in the majority of cases, across kidney function levels and survival is increasing.

Conclusion (proposition de traduction) : Tous les taux de filtration glomérulaire estimés inférieurs et supérieurs à la normale sont associés à une mortalité accrue et cette association est modifiée par la présence d'une insuffisance cardiaque. Les résultats neurologiques sont bons dans la majorité des cas, à tous les niveaux de la fonction rénale et la survie augmente.

External validation of Pittsburgh Cardiac Arrest Category illness severity score.
Nassal MMJ, Nichols D, Demasi S, Rittenberger JC, Panchal AR, Kurz MC; UAB Post-Cardiac Arrest Service. | Resuscitation. 2022 Mar;172:32-37
DOI: https://doi.org/10.1016/j.resuscitation.2021.12.022
Keywords: Cardiac arrest; Post-arrest care; Prognostication; Resuscitation.

Clinical paper

Introduction : Early prognostication post-cardiac arrest can help determine appropriate medical management and help evaluate effectiveness of post-arrest interventions. The Pittsburgh Cardiac Arrest Category (PCAC) severity score is a 4-level illness severity score found to strongly predict patient outcomes in both in- (IHCA) and out-of-hospital cardiac arrests (OHCA). We aimed to validate the PCAC severity score in an external cohort of cardiac arrest patients.

Méthode : We retrospectively assigned PCAC scores to both IHCA and OHCA patients treated by our hypothermia team from July 1, 2009 to July 1 2016. Our primary outcome was survival to hospital discharge. Secondary outcomes were favorable functional status defined as favorable discharge disposition (home or acute rehabilitation), discharge Cerebral Performance Category (CPC); and discharge modified Rankin Scale (mRS). We tested the association of PCAC and outcomes using a multivariable adjusted logistic regression model.

Résultats : We included 317 subjects in our model. PCAC was strongly associated with survival I Reference; II adjusted odds ratio (OR) 0.20 95% confidence interval (CI) 0.35-0.66, III (OR 0.14 CI 0.3-0.73, p < 0.05); IV (OR 0.05 CI 0.01-0.24, p < 0.01). PCAC was similarly associated with favorable functional outcomes: favorable discharge disposition II (OR 0.12 CI 0.02-0.68), III (OR 0.19 CI 0.05-0.74, p < 0.05) IV (OR 0.05 CI 0.01-0.22, p < 0.01); favorable CPC score II (OR 0.25 CI 0.06-1.03), III (OR 0.14 CI 0.03-0.57, p < 0.01), IV (OR 0.05 CI 0.01-0.20, p < 0.01) and favorable mRS (OR 0.47 CI (0.33-0.68)).

Conclusion : Early (<6 h post-arrest) PCAC severity scoring strongly predicts patient outcomes from cardiac arrest in both OHCA and IHCA.

Conclusion (proposition de traduction) : Le score de gravité précoce (<6 h après l'arrêt) « Pittsburgh Cardiac Arrest Category » prédit fortement les résultats pour les patients en cas d'arrêt cardiaque, à la fois dans les arrêts cardiaques à l'hôpital et en dehors de l'hôpital.

Commentaire : Pittsburgh Cardiac Arrest Category (PCAC) Tool  .

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Remote real-time supervision of prehospital point-of-care ultrasound: a feasibility study.
Hermann M, Hafner C, Scharner V, Hribersek M, Maleczek M, Schmid A, Schaden E, Willschke H, Hamp T. | Scand J Trauma Resusc Emerg Med. 2022 Mar 24;30(1):23
DOI: https://doi.org/10.1186/s13049-021-00985-0  | Télécharger l'article au format  
Keywords: Anaesthesiology; Diagnostic imaging; Echocardiography; Emergency medicine; Patient safety; Sonography; Telemedicine; Ultrasonics; Ultrasonography; Ultrasound.

Original research

Introduction : Although prehospital point-of-care ultrasound (POCUS) is gaining in importance, its rapid interpretation remains challenging in prehospital emergency situations. The technical development of remote real-time supervision potentially offers the possibility to support emergency medicine providers during prehospital emergency ultrasound. The aim of this study was to assess the feasibility of live data transmission and supervision of prehospital POCUS in an urban environment and so to improve patients' safety.

Méthode : mergency doctors with moderate ultrasound experience performed prehospital POCUS in emergency cases (n = 24) such as trauma, acute dyspnea or cardiac shock using the portable ultrasound device Lumify™. The ultrasound examination was remotely transmitted to an emergency ultrasound expert in the clinic for real-time supervision via a secure video and audio connection. Technical feasibility as well as quality of communication and live stream were analysed.

Résultats : Prehospital POCUS with remote real-time supervision was successfully performed in 17 patients (71%). In 3 cases, the expert was not available on time and in 1 case remote data transmission was not possible due to connection problems. In 3 cases tele-supervision was restricted to video only and no verbal communication was possible via the device itself due to power saving mode of the tablet.

Conclusion : Remote real-time supervision of prehospital POCUS in an urban environment is feasible most of the time with excellent image and communication quality.

Conclusion (proposition de traduction) : La supervision à distance en temps réel de l'échographie préhospitalière au point d'intervention en milieu urbain est réalisable la plupart du temps avec une excellente qualité d'image et de communication.

Shock

Outcome in Elderly Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction.
Ratcovich HL, Josiassen J, Helgestad OKL, Linde L, Jensen LO, Ravn HB, Joshi FR, Engstrøm T, Schmidt H, Hassager C, Møller JE, Holmvang L. | Shock. 2022 Mar 1;57(3):327-335
DOI: https://doi.org/10.1097/shk.0000000000001837
Keywords: Aucun

Clinical Aspect

Introduction : Despite advances in treatment of patients with cardiogenic shock following acute myocardial infarction (AMICS) in-hospital mortality remains around 50%. Outcome varies among patient subsets and the elderly often have a poor a priori prognosis. We sought to investigate outcome among elderly AMICS patients referred to evaluation and treatment at a tertiary university hospital.

Méthode : Current analysis was based on the RETROSHOCK registry comprising consecutive AMICS patients admitted to tertiary care. Patients in the registry were individually identified and validated.

Résultats : Of 1,716 admitted patients, 496 (28.9%) patients were ≥75 years old. Older patients were less likely to be admitted directly to a tertiary centre (59.4% vs. 69.9%, P = 0.003), receive mechanical support devices (i.e., Impella® (8.9% vs. 15.0%, P = 0.003), and undergo revascularization attempt (76.8% vs. 90.2%, P < 0.001). Thirty-day survivors ≥75 years were characterized by having higher left ventricular ejection fraction (30.2% ± 12.5% vs. 26.5% ± 11.8%, P = 0.004) and lower arterial lactate (3.2[2.2-5.2] mmol/L vs. 5.5[3.3-8.2] mmol/L, P < 0.001) at admission. In a multivariable analysis of patients ≥75 years, higher age (HR 1.09, 95% CI 1.05-1.14, P < 0.001), higher heart rate (HR 1.01, 95% CI 1.001-1.014, P = 0.03), and higher lactate (HR 1.11, 95% CI 1.07-1.16, P < 0.001) at admission were associated with an increased risk of 30-day mortality.

Conclusion : Among patients ≥75 years with AMICS referred for tertiary specialized treatment, 30-day mortality was 73.4%. Survivors were characterized by lower arterial lactate and heart rate at admission.

Conclusion (proposition de traduction) : Parmi les patients ≥ 75 ans atteints d'infarctus aigu du myocarde référés pour un traitement spécialisé tertiaire, la mortalité à 30 jours était de 73,4 %. Les survivants étaient caractérisés par une diminution du lactate artériel et de la fréquence cardiaque à l'admission.

Factors Associated With Mortality Among Patients Managed for Large Volume Hemorrhage in a Medical Intensive Care Unit.
Wang X, Li M, Duggal A, Adams G, Hite D. | Shock. 2022 Mar 1;57(3):392-396
DOI: https://doi.org/10.1097/shk.0000000000001913
Keywords: Aucun

Review Article

Introduction : Our goal was to describe resuscitation practices in critically ill medical patients with active hemorrhage requiring large volume resuscitation and identify factors associated with poor outcomes.

Méthode : This was a single center retrospective observational cohort study. Patients admitted to the medical intensive care unit from 2011 to 2017 who received ≥5 units of packed red blood cells (pRBCs) within 24 h were included. Data including volume of blood products and crystalloid administered, baseline sequential organ failure assessment (SOFA) scores, and outcomes were abstracted. Univariate and multivariate analyses were performed to determine clinical factors associated with hospital mortality.

Résultats : Two hundred forty-six patients were identified. Mean volumes of 2,448 mL of pRBCs and 3.9L of crystalloid were transfused over 24 h. Inpatient mortality for the entire cohort was 48%. Multivariable analysis identified factors associated with hospital mortality; higher BMI (OR 1.047, 95% CI 1.013-1.083), higher ratio of fresh frozen plasma (FFP) to pRBCs (OR 2.744, 95% CI 1.1-6.844), and higher baseline SOFA scores (OR 1.3, 95% CI 1.175-1.437).

Conclusion : In a cohort of critically ill medical patients undergoing resuscitation for hemorrhage, higher BMI, increased ratio of FFP to pRBCs, and higher SOFA scores were associated with increased mortality. Further studies are needed to clarify resuscitation practices associated with outcomes in this population.

Conclusion (proposition de traduction) : Dans une cohorte de patients médicaux gravement malades subissant une réanimation pour hémorragie, un IMC plus élevé, un rapport accru entre le plasma frais congelé et les concentrés de globules rouges et des scores SOFA plus élevés étaient associés à une mortalité accrue. D'autres études sont nécessaires pour clarifier les pratiques de réanimation associées aux résultats dans cette population.

Stroke

Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study.
Yaghi S, Shu L, Bakradze E, Salehi Omran S and al. | Stroke. 2022 Mar;53(3):728-738
DOI: https://doi.org/10.1161/strokeaha.121.037541  | Télécharger l'article au format  
Keywords: anticoagulants; contraindications; dabigatran; hemorrhage; venous thrombosis.

Original Contribution

Introduction : A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort.

Méthode : This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups.

Résultats : Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140-720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51-1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22-2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48-1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15-0.82]; P=0.02).

Conclusion : In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

Conclusion (proposition de traduction) : Chez les patients présentant une thrombose veineuse cérébrale, le traitement par anticoagulants oraux directs (AOD) a été associé à des résultats cliniques et radiographiques similaires et à un profil d'innocuité favorable par rapport au traitement par la warfarine. Nos résultats doivent être confirmés par de grandes études prospectives ou randomisées.

Associations of Early Systolic Blood Pressure Control and Outcome After Thrombolysis-Eligible Acute Ischemic Stroke: Results From the ENCHANTED Study.
Wang X, Minhas JS, Moullaali TJ and al; ENCHANTED Investigators. | Stroke. 2022 Mar;53(3):779-787.
DOI: https://doi.org/10.1161/strokeaha.121.034580
Keywords: blood pressure; hypertension; intracranial hemorrhage; ischemic stroke

Original contribution

Introduction : In thrombolysis-eligible patients with acute ischemic stroke, there is uncertainty over the most appropriate systolic blood pressure (SBP) lowering profile that provides an optimal balance of potential benefit (functional recovery) and harm (intracranial hemorrhage). We aimed to determine relationships of SBP parameters and outcomes in thrombolyzed acute ischemic stroke patients.

Méthode : Post hoc analyzes of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study), a partial-factorial trial of thrombolysis-eligible and treated acute ischemic stroke patients with high SBP (150-180 mm Hg) assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) alteplase and intensive (target SBP, 130-140 mm Hg) or guideline-recommended (target SBP <180 mm Hg) treatment. All patients were followed up for functional status and serious adverse events to 90 days. Logistic regression models were used to analyze 3 SBP summary measures postrandomization: attained (mean), variability (SD) in 1-24 hours, and magnitude of reduction in 1 hour. The primary outcome was a favorable shift on the modified Rankin Scale. The key safety outcome was any intracranial hemorrhage.

Résultats : Among 4511 included participants (mean age 67 years, 38% female, 65% Asian) lower attained SBP and smaller SBP variability were associated with favorable shift on the modified Rankin Scale (per 10 mm Hg increase: odds ratio, 0.76 [95% CI, 0.71-0.82]; P<0.001 and 0.86 [95% CI, 0.76-0.98]; P=0.025) respectively, but not for magnitude of SBP reduction (0.98, [0.93-1.04]; P=0.564). Odds of intracranial hemorrhage was associated with higher attained SBP and greater SBP variability (1.18 [1.06-1.31]; P=0.002 and 1.34 [1.11-1.62]; P=0.002) but not with magnitude of SBP reduction (1.05 [0.98-1.14]; P=0.184).

Conclusion : Attaining early and consistent low levels in SBP <140 mm Hg, even as low as 110 to 120 mm Hg, over 24 hours is associated with better outcomes in thrombolyzed acute ischemic stroke patients.

Conclusion (proposition de traduction) : Obtenir des niveaux de pression artérielle bas précoces et constants avec une PAS <140 mmHg, même aussi bas que 110 à 120 mmHg, sur 24 heures est associé à de meilleurs résultats chez les patients victimes d'un AVC ischémique aigu thrombolysé.

Stroke Among Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry.
Shakil SS, Emmons-Bell S, Rutan C, Walchok J, Navi B, Sharma R, Sheth K, Roth GA, Elkind MSV. | Stroke. 2022 Mar;53(3):800-807
DOI: https://doi.org/10.1161/strokeaha.121.035270  | Télécharger l'article au format  
Keywords: COVID-19; cardiovascular diseases; continental population groups; ethnic groups; ischemic stroke

Original contribution

Introduction : Coronavirus disease 2019 (COVID-19) may be associated with increased risk for ischemic stroke. We present prevalence and characteristics of strokes in patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection enrolled in the American Heart Association COVID-19 Cardiovascular Disease Registry.

Méthode : In this quality improvement registry study, we examined demographic, baseline clinical characteristics, and in-hospital outcomes among hospitalized COVID-19 patients. The primary outcomes were ischemic stroke or transient ischemic attack (TIA) and in-hospital death.

Résultats : Among 21 073 patients with COVID-19 admitted at 107 hospitals between January 29, 2020, and November 23, 2020, 160 (0.75%) experienced acute ischemic stroke/TIA (55.3% of all acute strokes) and 129 (0.61%) had other types of stroke. Among nonischemic strokes, there were 44 (15.2%) intracerebral hemorrhages, 33 (11.4%) subarachnoid hemorrhages, 21 (7.3%) epidural/subdural hemorrhages, 2 (0.7%) cerebral venous sinus thromboses, and 24 (8.3%) strokes not otherwise classified. Asians and non-Hispanic Blacks were overrepresented among ischemic stroke/TIA patients compared with their overall representation in the registry, but adjusted odds of stroke did not vary by race. Median time from COVID-19 symptom onset to ischemic stroke was 11.5 days (interquartile range, 17.8); median National Institutes of Health Stroke Scale score was 11 (interquartile range, 17). COVID-19 patients with acute ischemic stroke/TIA had higher prevalence of hypertension, diabetes, and atrial fibrillation compared with those without stroke. Intensive care unit admission and mechanical ventilation were associated with higher odds of acute ischemic stroke/TIA, but older age was not a predictor. In adjusted models, acute ischemic stroke/TIA was not associated with in-hospital mortality.

Conclusion : Ischemic stroke risk did not vary by race. In contrast to the association between older age and death from COVID-19, ischemic stroke risk was the highest among middle-aged adults after adjusting for comorbidities and illness severity, suggesting a potential mechanism for ischemic stroke in COVID-19 independent of age-related atherosclerotic pathways.

Conclusion (proposition de traduction) : Le risque d’accident vasculaire cérébral ischémique n’a pas varié selon la race. Contrairement à l’association entre un âge plus avancé et le décès dans la COVID-19, le risque d’accident vasculaire cérébral ischémique était le plus élevé chez les adultes d’âge moyen après ajustement pour tenir compte des comorbidités et de la gravité de la maladie, ce qui suggère un mécanisme potentiel d’accident vasculaire cérébral ischémique dans la COVID-19 indépendamment des voies athérosclérotiques liées à l’âge.

Low Blood Pressure, Comorbidities, and Ischemic Stroke Mortality in US Veterans.
Aparicio HJ, Tarko LM, Gagnon D, Costa L, Galloway A, Demissie S, Djousse L, Seshadri S, Cho K, Wilson PWF. | Stroke. 2022 Mar;53(3):886-894
DOI: https://doi.org/10.1161/strokeaha.120.033195
Keywords: blood pressure; cerebrovascular disorders; epidemiology; hypertension; mortality

Original contribution

Introduction : Low blood pressure (BP) is associated with higher stroke mortality, although the factors underlying this association have not been fully explored. We investigated prestroke BP and long-term mortality after ischemic stroke in a national sample of US veterans.

Méthode : Using a retrospective cohort study design of veterans hospitalized between 2002 and 2007 with a first ischemic stroke and with ≥1 outpatient BP measurements 1 to 18 months before admission, we defined 6 categories each of average prestroke systolic BP (SBP) and diastolic BP, and 7 categories of pulse pressure. Patients were followed-up to 12 years for primary outcomes of all-cause and cardiovascular mortality. We used Cox models to relate prestroke BP indices to mortality and stratified analyses by the presence of preexisting comorbidities (smoking, myocardial infarction, heart failure, atrial fibrillation/flutter, cancer, and dementia), race and ethnicity.

Résultats : Of 29 690 eligible veterans with stroke (mean±SD age 67±12 years, 98% men, 67% White), 2989 (10%) had average prestroke SBP<120 mm Hg. During a follow-up of 4.1±3.3 years, patients with SBP<120 mm Hg experienced 61% all-cause and 27% cardiovascular mortality. In multivariable analyses, patients with the lowest SBP, lowest diastolic BP, and highest pulse pressure had the highest mortality risk: SBP<120 versus 130 to 139 mm Hg (hazard ratio=1.26 [95% CI, 1.19-1.34]); diastolic BP <60 versus 70 to 79 mm Hg (hazard ratio=1.35 [95% CI, 1.23-1.49]); and pulse pressure ≥90 versus 60 to 69 mm Hg (hazard ratio=1.24 [95% CI, 1.15-1.35]). Patients with average SBP<120 mm Hg and at least one comorbidity (smoking, heart disease, cancer, or dementia) had the highest mortality risk (hazard ratio=1.45 [95% CI, 1.37-1.53]).

Conclusion : Compared with normotension, low prestroke BP was associated with mortality after stroke, particularly among patients with at least one comorbidity.

Conclusion (proposition de traduction) : Par rapport à la normotension, une TA basse avant un AVC était associée à la mortalité après AVC, en particulier chez les patients présentant au moins une comorbidité.

The American Journal of Emergency Medicine

Effect of age on the efficacy of tranexamic acid: An analysis of heterogeneity of treatment effect within the CRASH-2 dataset.
Manoukian MAC, Tancredi DJ, Nishijima DK. | Am J Emerg Med. 2022 Mar;53:37-40
DOI: https://doi.org/10.1016/j.ajem.2021.12.033
Keywords: Geriatric trauma; Hemorrhage; Heterogeneity of treatment affect; Tranexamic acid; Trauma.

Research article

Introduction : Trauma is a major cause of morbidity and mortality in older adults and will become more common as the population ages. Tranexamic acid (TXA) is a lysine analogue frequently used in the setting of significant trauma with hemorrhage. The aim of this study is to investigate the heterogeneity of treatment effect of TXA as it relates to patient age during trauma care.

Méthode : We included patients from the CRASH-2 trial who were randomized within 3 h of injury. Patients were stratified into age groups <26 years, 26 to 35 years, 36 to 45 years, 46 to 55 years, and >55 years. Multiple logistic regression models were utilized to evaluate adjusted odds ratios (OR) with 95% confidence intervals (CI) for mortality. Heterogeneity of treatment effect was evaluated using Akaike and Bayesian information criteria to determine the optimum logistic regression model after which a Wald Chi-square test was utilized to evaluate statistical significance.

Résultats : On univariate analysis, TXA administration decreased mortality within the <26 years cohort (decrease of 2.1%, 95% CI 0.2 to 4.0), 46 to 55 years cohort (decrease 6.7%, 95% CI 2.7 to 10.7), and >55 years cohort (decrease of 5.3%, 95% CI 0.4 to 10.3). On adjusted analysis, when compared to the 36 to 45 years cohort, the <26 year cohort experienced a decreased mortality (OR 0.72, 95% CI 0.62 to 0.85) whereas the >55 year cohort experienced increased mortality (OR 1.8, 95% CI 1.5 to 2.2). Assessment for heterogeneity of treatment effect of TXA administration between groups approached but did not reach statistical significance (p = 0.11).

Conclusion : Mortality related to trauma increases with age, however, there does not appear to be heterogeneity of treatment effect for TXA administration among different age groups.

Conclusion (proposition de traduction) : La mortalité liée aux traumatismes augmente avec l'âge, cependant, il ne semble pas y avoir d'hétérogénéité de l'effet du traitement pour l'administration d'acide tranexamique parmi les différents groupes d'âge.

Adequacy of probabilistic prehospital antibiotic therapy for septic shock.
Jouffroy R, Gilbert B, Hassan A, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. | Am J Emerg Med. 2022 Mar;53:80-85
DOI: https://doi.org/10.1016/j.ajem.2021.12.062
Keywords: Adequacy; Prehospital probabilistic antibiotic therapy; Safety; Septic shock.

Research article

Introduction : Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown.

Méthode : From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed.

Résultats : Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93].

Conclusion : Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

Conclusion (proposition de traduction) : Parmi les chocs septiques pris en charge par une unité de soins intensifs, une antibiothérapie probabiliste préhospitalière est la plupart du temps adéquate et associée à une diminution de la mortalité à J30. D'autres études prospectives sont nécessaires pour confirmer ces résultats et le poids de l'antibiothérapie préhospitalière dans la prise en charge préhospitalière du choc septique.

Emergency department and transport predictors of neurological deterioration in patients with spontaneous intracranial hemorrhage.
Bzhilyanskaya V, Najafali D, Torre OM, Afridi L, Cao T, Panchal B, Albelo F, Karwoski A, Afridi I, Tran QK. | Am J Emerg Med. 2022 Mar;53:154-160
DOI: https://doi.org/10.1016/j.ajem.2022.01.002
Keywords: Blood pressure variability; Emergency department; Interhospital transfer; Intracranial hypertension; Neurological outcomes; Spontaneous intracranial hemorrhage.

Research article

Introduction : Patients with spontaneous intracranial hemorrhage (sICH) and intracranial hypertension are associated with poor outcomes. Blood pressure variability (BPV) and neurological deterioration (ND) are known factors associated with sICH outcomes, but the relationship between BPV and ND in the hyperacute phase remains poorly described. We hypothesized that BPV is associated with ND during patients' initial emergency department (ED) stay and during interhospital transport (IHT) to a tertiary care center.

Méthode : A retrospective study of adult patients with sICH was performed. Patients who were transferred from an ED to a tertiary care center between 01/01/2011 and 09/30/2015 and underwent external ventricular drainage were eligible. The outcome was ND at any time before arrival at a tertiary care center. Classification and Regression Tree (CART) analysis, a machine learning algorithm, was used to assign "relative variable importance" (RVI) for important predictive clinical factors.

Résultats : 153 eligible patients were analyzed. Sixty-five (42%) patients developed ND. Maximum ED systolic blood pressure (ED SBPMax) was most predictive of sICH patients developing ND (RVI = 100%). Other important factors for ND included standard deviation in SBP (SBPSD) during ED stay and IHT, with RVI of 43% and 20%, respectively.

Conclusion : ED SBPMax was the strongest predictive factor of ND, while other BPV components were also significant. Our study found evidence that BPV should be prioritized as it may also increase the risk of ND among patients with sICH who required external ventricular drain placement. Future studies should examine whether fluctuations in BP in an ED or IHT setting are associated with increased risk of worsening outcomes.

Conclusion (proposition de traduction) : La pression artérielle systolique max au service des urgences était le facteur prédictif le plus puissant de détérioration neurologique, tandis que d'autres composantes de la variabilité de la pression artérielle étaient également significatives. Notre étude a trouvé des preuves que la variabilité de la pression artérielle doit être priorisée car elle peut également augmenter le risque de détérioration neurologique chez les patients présentant une hémorragie intracrânienne spontanée nécessitant la mise en place d'un drain ventriculaire externe. Les études futures devraient examiner si les fluctuations de la pression artérielle dans un service d'urgence ou un transport interhospitalier sont associées à un risque accru d'aggravation des résultats.

Commentaire : Pour aller plus loin :
• Des revues récentes proposent de maintenir soit la PAM < 130 mmHg soit la pression artérielle systolique < 160 mmHg. Audibert G, Hoche J, Mertes PM. Quel niveau de pression artérielle moyenne dans l’hémorragie méningée ? MAPAR 2011  .
• Aucune donnée validée de la littérature ne peut proposer de chiffres précis, toutefois la conférence d’experts française conseille de respecter des valeurs de PAS allant jusqu’à 180-200 mmHg. G. Lecardinal G, Jochmans S, Dékadjevi H, Rebillard L, Pamar B, Tazarourte K. Particularités des hémorragies méningées. Urgences 2007  .
• La nimodipine intraveineuse est souvent à l’origine de fluctuations de la pression artérielle, son administration n’est plus recommandée. Losser MR, Payen D. Hémorragie méningée : prise en charge. Réanimation (2007) 16, 463—471  .
▶ Il semble que la pression artérielle systolique doive être maintenue à une valeur inférieure à 160 mmHg et que les variations de pression artérielle, exposant le parenchyme cérébral à une ischémie, ne doivent pas être brutales. Certains auteur proposent de ramener la PAM entre 90 et 100 mm Hg (faible niveau de preuve).
[PPC = PAM - PIC].

Risk of delayed intracranial haemorrhage after an initial negative CT in patients on DOACs with mild traumatic brain injury.
Turcato G, Cipriano A, Zaboli A, Park N, Riccardi A, Santini M, Lerza R, Ricci G, Bonora A, Ghiadoni L. | Am J Emerg Med. 2022 Mar;53:185-189
DOI: https://doi.org/10.1016/j.ajem.2022.01.018
Keywords: Anticoagulants; DOACs; Delayed intracranial haemorrhage; Emergency department; Intracranial haemorrhage; Mild traumatic brain injury; Negative CT; Oral anticoagulant therapy.

Research article

Introduction : Repeat head CT in patients on direct oral anticoagulant therapy (DOACs) with minor traumatic brain injury (MTBI) after an initial CT scan without injury on arrival in the Emergency Department (ED) is a common clinical practice but is not based on clear evidence.
Aim: To assess the incidence of delayed intracranial haemorrhage (ICH) in patients taking DOACs after an initial negative CT and the association of clinical and risk factors presented on patient arrival in the ED.

Méthode : This retrospective multicentre observational study considered patients taking DOACs undergoing repeat CT after a first CT free of injury for the exclusion of delayed ICH after MTBI. Timing between trauma and first CT in the ED and pre- or post-trauma risk factors were analysed to assess a possible association with the risk of delayed ICH.

Résultats : A total of 1426 patients taking DOACs were evaluated in the ED for an MTBI. Of these, 68.3% (916/1426) underwent a repeat CT after an initial negative CT and 24 h of observation, with a rate of delayed ICH of 1.5% (14/916). Risk factors associated with the presence of a delayed ICH were post-traumatic loss of consciousness, post-traumatic amnesia and the presence of a risk factor when the patient presented to the ED within 8 h of the trauma. None of the patients with delayed ICH at 24-h repeat CT required neurosurgery or died within 30 days.

Conclusion : Delayed ICH is an uncommon event at the 24-h control CT and does not affect patient outcome. Studying the timing and characteristics of the trauma may indicate patients who may benefit from more in-depth management.

Conclusion (proposition de traduction) : L'hémorragie intracrânienne retardée est un événement peu fréquent au contrôle scanographique à 24 h et ne modifie pas le devenir du patient. L'étude du moment (timing) et des caractéristiques du traumatisme peuvent suggérer que les patients pourraient nécessiter une prise en charge plus approfondie.

Increased weight in patients with time-sensitive diagnosis is associated with longer prehospital on-scene times.
Supples MW, Vaizer J, Liao M, Faris GW, O'Donnell DP, Glober NK. | Am J Emerg Med. 2022 Mar;53:236-239
DOI: https://doi.org/10.1016/j.ajem.2022.01.022
Keywords: EMS; Obesity; STEMI; Stroke; Time-delay; Trauma.

Research article

Introduction : Obesity is a growing epidemic associated with higher rates of metabolic disease, heart disease and all-cause mortality. Heavier patients may require more advanced resources and specialized equipment. We hypothesize that increasing patient weight will be associated with longer prehospital on-scene times.

Méthode : We reviewed electronic patient care records for patients transported by two urban 9-1-1 emergency medical services (EMS) agencies. We collected age, sex, estimated patient weight, vital signs (systolic blood pressure, heart rate, pulse oximetry), provider impression, method of moving patient to ambulance, and on-scene times. We selected patients with time-sensitive diagnoses of stroke, ST-segment elevation myocardial infarction (STEMI), and trauma and compared on-scene times for patients who weighed above or below 300 pounds. We performed descriptive statistics, Mann-Whitney U tests for continuous variables and Chi-square tests for discrete variables. We constructed a generalized linear model to determine the effect of patient weight adjusted for covariates.

Résultats : For a three-year period (May 1, 2018 to April 30, 2021) 48,203 patients were transported with an EMS impression of stroke, ST-segment elevation myocardial infarction (STEMI), and trauma. 23,654 (49.1%) patients were female, and the median age was 52 (IQR 34-68) years. The median weight was 175.0 (IQR 150.0-205.0) pounds. Patients above a dichotomous weight categorization of 300 pounds experienced a longer median scene time with any time-sensitive diagnosis (12.6 versus 11.9 min p < 0.001), STEMI (16.0 versus 13.1 min, p = 0.014) and blunt trauma (12.6 versus 11.9 min, p < 0.001)). They were more likely to be hypoxic (p < 0.001) and more likely to experience cardiac arrest (p < 0.001). They were less likely to walk to the ambulance (22.1% versus 32.2%, p < 0.001).

Conclusion : Patient weight above 300 pounds was associated with significantly longer on-scene time. These patients were more likely to be hypoxic, sustain a cardiac arrest, and less likely to walk to the ambulance.

Conclusion (proposition de traduction) : Le poids du patient supérieur à 300 livres (136 kg) était associé à un temps sur place significativement plus long. Ces patients étaient plus susceptibles d'être hypoxiques, de subir un arrêt cardiaque et moins susceptibles de marcher jusqu'à l'ambulance.

Emergency medicine updates: Droperidol.
Cisewski D, Long B, Gottlieb M. | Am J Emerg Med. 2022 Mar;53:180-184
DOI: https://doi.org/10.1016/j.ajem.2022.01.011  | Télécharger l'article au format  
Keywords: Agitation; Droperidol; Headache; Nausea; Pain; Prolonged QT; QT prolongation; vertigo.

Research article

Introduction : Droperidol is a butyrophenone that has recently been reintroduced after a United States Food and Drug Administration (US FDA) black box warning in 2001. Evidence demonstrates utility in a variety of clinical conditions.

Méthode : This paper provides evidence-based updates concerning the use of droperidol for the emergency clinician.

Résultats : Droperidol received a black box warning by the US FDA in 2001 due to concerns for QT prolongation and torsades de pointes; however, reevaluation of the available data suggests droperidol is a safe and efficacious medication. It can be used in the emergency department (ED) setting for many conditions, including acute agitation, headaches, vertigo, nausea, and vomiting. Extensive literature supports that the QT-prolonging effects are transient and that the risk of torsades de pointes is rare with doses utilized in the ED. An electrocardiogram does not need to be routinely obtained before droperidol use but should be considered in patients at high risk for QT prolongation.

Conclusion : Current evidence suggests that droperidol is a safe and effective medication for treating nausea and vomiting, headache, vertigo, and agitation in the ED setting.

Conclusion (proposition de traduction) : Les preuves actuelles suggèrent que le dropéridol est un médicament sûr et efficace pour traiter les nausées et les vomissements, les maux de tête, les vertiges et l'agitation dans le cadre de l'urgence.

The Journal of Trauma and Acute Care Surgery

Emergency medical services shock index is the most accurate predictor of patient outcomes after blunt torso trauma.
Bardes JM, Price BS, Adjeroh DA, Doretto G, Wilson A. | J Trauma Acute Care Surg. 2022 Mar 1;92(3):499-503
DOI: https://doi.org/10.1097/ta.0000000000003483
Keywords: Therapeutic/care management, level IV.

2021 AAST POSTER

Introduction : Shock index (SI) and delta shock index (∆SI) predict mortality and blood transfusion in trauma patients. This study aimed to evaluate the predictive ability of SI and ∆SI in a rural environment with prolonged transport times and transfers from critical access hospitals or level IV trauma centers.

Méthode : We completed a retrospective database review at an American College of Surgeons verified level 1 trauma center for 2 years. Adult subjects analyzed sustained torso trauma. Subjects with missing data or severe head trauma were excluded. For analysis, poisson regression and binomial logistic regression were used to study the effect of time in transport and SI/∆SI on resource utilization and outcomes. p < 0.05 was considered significant.

Résultats : Complete data were available on 549 scene patients and 127 transfers. Mean Injury Severity Score was 11 (interquartile range, 9.0) for scene and 13 (interquartile range, 6.5) for transfers. Initial emergency medical services SI was the most significant predictor for blood transfusion and intensive care unit care in both scene and transferred patients (p < 0.0001) compared with trauma center arrival SI or transferring center SI. A negative ∆SI was significantly associated with the need for transfusion and the number of units transfused. Longer transport time also had a significant relationship with increasing intensive care unit length of stay. Cohorts were analyzed separately.

Conclusion : Providers must maintain a high level of clinical suspicion for patients who had an initially elevated SI. Emergency medical services SI was the greatest predictor of injury and need for resources. Enroute SI and ∆SI were less predictive as time from injury increased. This highlights the improvements in en route care but does not eliminate the need for high-level trauma intervention.

Conclusion (proposition de traduction) : Les prestataires doivent maintenir un niveau élevé de suspicion clinique pour les patients dont l'IS était initialement élevé. Au service des urgence, l’IS était le principal facteur prédictif de blessure et de besoin de ressources. Le SI et le ∆SI en route étaient moins prédictifs à mesure que le temps écoulé depuis la blessure augmentait. Cela souligne les améliorations à apporter aux soins en cours de route, mais n’élimine pas la nécessité d’une intervention de haut niveau en traumatologie.

The impact of prehospital time intervals on mortality in moderately and severely injured patients.
Waalwijk JF, van der Sluijs R, Lokerman RD, Fiddelers AAA, Hietbrink F, Leenen LPH, Poeze M, van Heijl M; Pre-hospital Trauma Triage Research Collaborative (PTTRC). | J Trauma Acute Care Surg. 2022 Mar 1;92(3):520-527
DOI: https://doi.org/10.1097/ta.0000000000003380
Keywords: Prognostic and Epidemiologic; level III

INDEPENDENT SUBMISSION

Introduction : Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality.

Méthode : All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association.

Résultats : We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality.

Conclusion : A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality.

Conclusion (proposition de traduction) : Une présence prolongée sur les lieux est associée à la mortalité chez les patients modérément ou gravement blessés, ce qui suggère qu'un temps d'intervention réduit pourrait être favorable pour ces patients. De plus, il a été constaté que le temps de transport n'était pas associé à la mortalité.

Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest.
Benhamed A, Canon V, Mercier E, Heidet M, Gossiome A, Savary D, El Khoury C, Gueugniaud PY, Hubert H, Tazarourte K. | J Trauma Acute Care Surg. 2022 Mar 1;92(3):553-560
DOI: https://doi.org/10.1097/ta.0000000000003474
Keywords: Aucun

INDEPENDENT SUBMISSION

Introduction : Traumatic cardiac arrests (TCAs) are associated with high mortality and the majority of deaths occur at the prehospital scene. The aim of the present study was to assess, in a prehospital physician-led emergency medical system, the factors associated with sustained return of spontaneous circulation (ROSC) in TCA, including advanced life procedures. The secondary objectives were to assess factors associated with 30-day survival in TCA, evaluate neurological recovery in survivors, and describe the frequency of organ donation among patients experiencing a TCA.

Méthode : We conducted a retrospective study of all TCA patients included in the French nationwide cardiac arrest registry from July 2011 to November 2020. Multivariable logistic regression analysis was used to identify factors independently associated with ROSC.

Résultats : A total of 120,045 out-of-hospital cardiac arrests were included in the registry, among which 4,922 TCA were eligible for analysis. Return of spontaneous circulation was sustained on-scene in 21.1% (n = 1,037) patients. Factors significantly associated with sustained ROSC were not-asystolic initial rhythms (pulseless electric activity (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.40-2.35; p < 0.001), shockable rhythm (OR, 1.83; 95% CI, 1.12-2.98; p = 0.016), spontaneous activity (OR, 3.66; 95% CI, 2.70-4.96; p < 0.001), and gasping at the mobile medical team (MMT) arrival (OR, 1.40; 95% CI, 1.02-1.94; p = 0.042). The MMT interventions significantly associated with ROSC were as follows: intravenous fluid resuscitation (OR, 3.19; 95% CI, 2.69-3.78; p < 0.001), packed red cells transfusion (OR, 2.54; 95% CI, 1.84-3.51; p < 0.001), and external hemorrhage control (OR, 1.74; 95% CI, 1.31-2.30; p < 0.001). Among patients who survived (n = 67), neurological outcome at Day 30 was favorable (cerebral performance categories 1-2) in 72.2% cases (n = 39/54) and 1.4% (n = 67/4,855) of deceased patients donated one or more organ.

Conclusion : Sustained ROSC was frequently achieved in patients not in asystole at MMT arrival, and higher ROSC rates were achieved in patients benefiting from specific advanced life support interventions. Organ donation was somewhat possible in TCA patients undergoing on-scene resuscitation.

Conclusion (proposition de traduction) : Un retour à une activité circulatoire spontanée soutenu a été fréquemment observé chez les patients qui n’étaient pas en asystolie à l’arrivée de l’équipe médicale mobile, et des taux plus élevés de retour à une activité circulatoire spontanée ont été observés chez les patients bénéficiant d’interventions médicalisé spécifiques. Le don d’organes était possible chez les patients présentant un arrêt cardiaque traumatique nécessitant une réanimation sur place.

The New England Journal of Medicine

Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults.
Finfer S, Micallef S, Hammond N, Navarra L, Bellomo R, Billot L, Delaney A, Gallagher M, Gattas D, Li Q, Mackle D, Mysore J, Saxena M, Taylor C, Young P, Myburgh J; PLUS Study Investigators; Australian New Zealand Intensive Care Society Clinical Trials Group. | N Engl J Med. 2022 Mar 3;386(9):815-826
DOI: https://doi.org/10.1056/nejmoa2114464
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Whether the use of balanced multielectrolyte solution (BMES) in preference to 0.9% sodium chloride solution (saline) in critically ill patients reduces the risk of acute kidney injury or death is uncertain.

Méthode : In a double-blind, randomized, controlled trial, we assigned critically ill patients to receive BMES (Plasma-Lyte 148) or saline as fluid therapy in the intensive care unit (ICU) for 90 days. The primary outcome was death from any cause within 90 days after randomization. Secondary outcomes were receipt of new renal-replacement therapy and the maximum increase in the creatinine level during ICU stay.

Résultats : A total of 5037 patients were recruited from 53 ICUs in Australia and New Zealand - 2515 patients were assigned to the BMES group and 2522 to the saline group. Death within 90 days after randomization occurred in 530 of 2433 patients (21.8%) in the BMES group and in 530 of 2413 patients (22.0%) in the saline group, for a difference of -0.15 percentage points (95% confidence interval [CI], -3.60 to 3.30; P = 0.90). New renal-replacement therapy was initiated in 306 of 2403 patients (12.7%) in the BMES group and in 310 of 2394 patients (12.9%) in the saline group, for a difference of -0.20 percentage points (95% CI, -2.96 to 2.56). The mean (±SD) maximum increase in serum creatinine level was 0.41±1.06 mg per deciliter (36.6±94.0 μmol per liter) in the BMES group and 0.41±1.02 mg per deciliter (36.1±90.0 μmol per liter) in the saline group, for a difference of 0.01 mg per deciliter (95% CI, -0.05 to 0.06) (0.5 μmol per liter [95% CI, -4.7 to 5.7]). The number of adverse and serious adverse events did not differ meaningfully between the groups.

Conclusion : We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of BMES than with saline.

Conclusion (proposition de traduction) : ous n'avons trouvé aucune preuve que le risque de décès ou d'insuffisance rénale aiguë chez les adultes gravement malades en USI était plus faible avec l'utilisation d'un soluté cristalloïde balancé qu'avec une solution saline.

Use of eFAST in Patients with Injury to the Thorax or Abdomen.
Canelli R, Leo M, Mizelle J, Shrestha GS, Patel N, Ortega R. | N Engl J Med. 2022 Mar 10;386(10):e23
DOI: https://doi.org/10.1056/nejmvcm2107283
Keywords: Aucun

VIDEOS IN CLINICAL MEDICINE

Editorial : This video demonstrates the use of eFAST — or extended focused assessment with sonography for trauma — a point-of-care ultrasound examination performed in patients with a traumatic injury to the thorax or abdomen. eFAST involves obtain- ing images in six focused views to assess for pericardial, intraperitoneal, and pelvic fluid, as well as for hemothorax and pneumothorax.

Conclusion : Examining patients with the use of eFAST — or extended focused assessment with sonography for trauma — requires planning, preparation, and practice. Clear in- stitutional guidelines can maximize the efficiency and accuracy of eFAST exami- nations and help to provide the best possible care for patients with acute trauma.

Conclusion (proposition de traduction) : L'examen eFAST des patients - ou d'une évaluation ciblée étendue avec échographie pour les traumatismes - nécessite de la planification, de la préparation et de la pratique. Des directives institutionnelles claires peuvent maximiser l'efficacité et la précision des examens eFAST et aider à fournir les meilleurs soins possibles aux patients souffrant de traumatismes aigus.

Commentaire : Download Video (MP4)  


Mois de mars 2022