Bibliographie de Médecine d'Urgence

Mois d'avril 2022


Academic Emergency Medicine

Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS).
Capone CA, Emerson B, Sweberg T, Polikoff L, Turner DA, Adu-Darko M, Li S, Glater-Welt LB, Howell J, Brown CA 3rd, Donoghue A, Krawiec C, Shults J, Breuer R, Swain K, Shenoi A, Krishna AS, Al-Subu A, Harwayne-Gidansky I, Biagas KV, Kelly SP, Nuthall G, Panisello J, Napolitano N, Giuliano JS Jr, Emeriaud G, Toedt-Pingel I, Lee A, Page-Goertz C, Kimura D, Kasagi M, D'Mello J, Parsons SJ, Mallory P, Gima M, Bysani GK, Motomura M, Tarquinio KM, Nett S, Ikeyama. | Acad Emerg Med.  2022 Apr;29(4):406-414
DOI: https://doi.org/10.1111/acem.14431
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets.

Méthode : Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED.

Résultats : A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs.

Conclusion : While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.

Conclusion (proposition de traduction) : Bien que les caractéristiques de l'intubation trachéale varient entre les services d'urgence pédiatriques et les unités de soins intensifs, les résultats sont similaires. Un état de choc et une ouverture limitée de la bouche étaient indépendamment associés à des événements indésirables lors de l'intubation trachéale aux urgences.

Commentaire : Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, Lascarrou JB, Szuldrzynski K, Camporota L, Pelosi P, Sorbello M, Higgs A, Greif R, Putensen C, Agvald-Öhman C, Chalkias A, Bokums K, Brewster D, Rossi E, Fumagalli R, Pesenti A, Foti G, Bellani G; INTUBE Study Investigators. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021 Mar 23;325(12):1164-1172. doi: 10.1001/jama.2021.1727  .

Clinical factors associated with significant coronary lesions following out-of-hospital cardiac arrest.
Helfer DR, Helber AR, Ferko AR, Klein DD, Elchediak DS, Deaner TS, Slagle D, White WB, Buckler DG, Mitchell OJL, Fiorilli PN, Isenberg D, Nomura J, Murphy KA, Sigal A, Saif H, Reihart MJ, Vernon TM, Abella BS. | Acad Emerg Med.  2022 Apr;29(4):456-464
DOI: https://doi.org/10.1111/acem.14416
Keywords: cardiac arrest; coronary angiography; coronary artery disease; resuscitation.

Original contribution

Introduction : Out-of-hospital cardiac arrest (OHCA) afflicts >350,000 people annually in the United States. While postarrest coronary angiography (CAG) with percutaneous coronary intervention (PCI) has been associated with improved survival in observational cohorts, substantial uncertainty exists regarding patient selection for postarrest CAG. We tested the hypothesis that symptoms consistent with acute coronary syndrome (ACS), including chest discomfort, prior to OHCAs are associated with significant coronary lesions identified on postarrest CAG.

Méthode : We conducted a multicenter retrospective cohort study among eight regional hospitals. Adult patients who experienced atraumatic OHCA with successful initial resuscitation and subsequent CAG between January 2015 and December 2019 were included. We collected data on prehospital documentation of potential ACS symptoms prior to OHCA as well as clinical factors readily available during postarrest care. The primary outcome in multivariable regression modeling was the presence of significant coronary lesions (defined as >50% stenosis of left main or >75% stenosis of other coronary arteries).

Résultats : Four-hundred patients were included. Median (interquartile range) age was 59 (51-69) years; 31% were female. At least one significant stenosis was found in 62%, of whom 71% received PCI. Clinical factors independently associated with a significant lesion included a history of myocardial infarction (adjusted odds ratio [aOR] = 6.5, [95% confidence interval {CI} = 1.3 to 32.4], p = 0.02), prearrest chest discomfort (aOR = 4.8 [95% CI = 2.1 to 11.8], p ≤ 0.001), ST-segment elevations (aOR = 3.2 [95% CI = 1.7 to 6.3], p < 0.001), and an initial shockable rhythm (aOR = 1.9 [95% CI = 1.0 to 3.4], p = 0.05).

Conclusion : Among survivors of OHCA receiving CAG, history of prearrest chest discomfort was significantly and independently associated with significant coronary artery lesions on postarrest CAG. This suggests that we may be able to use prearrest symptoms to better risk stratify patients following OHCA to decide who will benefit from invasive angiography.

Conclusion (proposition de traduction) : Parmi les survivants d'un arrêt cardiaque en dehors de l'hôpital bénéficiant d'une coronarographie, les antécédents d'inconfort thoracique avant l'arrêt étaient associés de manière significative et indépendante à des lésions coronariennes importantes lors de la coronarographie post-arrêt. Cela suggère que nous pourrions être en mesure d'utiliser les symptômes avant l'arrêt pour mieux stratifier les risques des patients après un arrêt cardiaque en dehors de l'hôpital afin de décider qui bénéficiera de l'angiographie invasive.

Accuracy of presenting symptoms, physical examination, and imaging for diagnosis of ruptured abdominal aortic aneurysm: Systematic review and meta-analysis.
Fernando SM, Tran A, Cheng W, Rochwerg B, Strauss SA, Mutter E, McIsaac DI, Kyeremanteng K, Kubelik D, Jetty P, Nagpal SK, Thiruganasambandamoorthy V, Roberts DJ, Perry JJ. | Acad Emerg Med.  2022 Apr;29(4):486-496
DOI: https://doi.org/10.1111/acem.14475
Keywords: abdominal aortic aneurysm; computed tomography; point-of-care ultrasound.

EVIDENCE-BASED DIAGNOSTIC

Introduction : Ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition, and rapid diagnosis is necessary to facilitate early surgical intervention. We sought to evaluate the accuracy of presenting symptoms, physical examination signs, computed tomography with angiography (CTA), and point-of-care ultrasound (PoCUS) for diagnosis of rAAA.

Méthode : We searched six databases from inception through April 2021. We included studies investigating the accuracy of any of the above tests for diagnosis of rAAA. The primary reference standard used in all studies was intraoperative diagnosis or death from rAAA. Because PoCUS cannot detect rupture, we secondarily assessed its accuracy for the diagnosis of AAA, using the reference standard of intraoperative or CTA diagnosis. We used GRADE to assess certainty in estimates.

Résultats : We included 20 studies (2,077 patients), with 11 of these evaluating signs and symptoms, seven evaluating CTA, and five evaluating PoCUS. Pooled sensitivities of abdominal pain, back pain, and syncope for rAAA were 61.7%, 53.6%, and 27.8%, respectively (low certainty). Pooled sensitivity of hypotension and pulsatile abdominal mass were 30.9% and 47.1%, respectively (low certainty). CTA had a sensitivity of 91.4% and specificity of 93.6% for diagnosis of rAAA (moderate certainty). In our secondary analysis, PoCUS had a sensitivity of 97.8% and specificity of 97.0% for diagnosing AAA in patients suspected of having rAAA (moderate certainty).

Conclusion : Classic clinical symptoms associated with rAAA have poor sensitivity, and their absence does not rule out the condition. CTA has reasonable accuracy, but misses some cases of rAAA. PoCUS is a valuable tool that can help guide the need for urgent transfer to a vascular center in patients suspected of having rAAA.

Conclusion (proposition de traduction) : Les symptômes cliniques classiques associés à la rupture d'un anévrisme de l'aorte abdominale ont une faible sensibilité et leur absence n'exclut pas le diagnostic. L'angioscanner a une précision raisonnable, mais manque certains cas de rupture d'anévrisme de l'aorte abdominale. L'échographie au point de service est un outil précieux qui peut aider à guider la nécessité d'un transfert urgent vers un centre vasculaire chez les patients suspectés d'avoir rompu un anévrisme de l'aorte abdominale.

Acute Medicine & Surgery

Success rate of anterior shoulder dislocation reduction by emergency physicians: a retrospective cohort study.
Hayashi M, Tanizaki S, Nishida N, Shigemi R, Nishiyama C, Tanaka J, Kano K, Azuma H, Sera M, Nagai H, Maeda S, Ishida H. | Acute Med Surg.  2022 Apr 19;9(1):e751
DOI: https://doi.org/10.1002/ams2.751  | Télécharger l'article au format  
Keywords: Anterior shoulder dislocation reduction; emergency department; epidemiology; reduction failure; shoulder injuries.

Original Article

Introduction : Emergency physicians (EPs) often treat anterior shoulder dislocation, but epidemiology of anterior shoulder dislocation in the emergency department of Japan remains unclear. In this study, we clarified the success rate of anterior shoulder reduction performed by EPs.

Méthode : This single-center cohort study included patients with anterior shoulder dislocation for whom the EP performed initial reduction. The period was from January 2006 to March 2021 and we used the electronic medical record data of the tertiary care hospital. Our primary outcome was the success rate of the shoulder reduction performed by EP. The secondary outcome was to compare the success of reduction with the failure of the reduction.

Résultats : In total, 293 eligible patients were identified. Of these patients, 244 were included in this study. The success rate of the shoulder reduction performed by EP was 92.2% (225/244). EPs failed in successfully performing reduction in 19 (7.8%) cases of anterior shoulder dislocations. The failure group was older (P = 0.017), had a higher frequency of fall down in the mechanism of dislocation (P = 0.019), used intravenous analgesics more frequently (P = 0.004), used peripheral nerve blocks more frequently (P = 0.006), and had fewer patients who did not use drugs (P = 0.002). We could not perform statical adjustment because the sample size was small.

Conclusion : The success rate of the shoulder reduction performed by EPs was 92.2%. Older age might be associated with failure of shoulder reduction.

Conclusion (proposition de traduction) : Le taux de réussite de la réduction de l'épaule pratiquée par les médecins urgentistes était de 92,2 %. L'âge avancé peut être associé à l'échec de la réduction de l'épaule.

Comparison between midazolam and propofol in acute phase for ventilated patients with sepsis: a post-hoc analysis of the DESIRE trial.
Miyagawa N, Kawazoe Y, Sato T, Kushimoto S, Miyamoto K, Ohta Y, Morimoto T, Yamamura H; DESIRE Trial Investigators. | Acute Med Surg.  2022 Apr 5;9(1):e746
DOI: https://doi.org/10.1002/ams2.746  | Télécharger l'article au format  
Keywords: Delirium; midazolam; propofol; sedation; sepsis.

https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.746

Introduction : There are few assessments of sedatives during the acute phase under sedation protocols for patients with sepsis. We aimed to compare the influence of different sedation strategies using midazolam and propofol under light sedation on clinical outcomes of ventilated patients with sepsis.

Méthode : This study was a post-hoc analysis of data from the dexmedetomidine for sepsis in the ICU Randomized Evaluation (DESIRE) trial. Patients were divided into propofol and midazolam groups based on continuously used drug, and sedation control between groups compared on day three. We assessed the incidence of delirium, length of ICU stay, number of ventilator-free days within the first 28 days, and mortality after 28 days.

Résultats : The midazolam and propofol groups consisted of 51 and 66 patients, respectively. Both groups had similar characteristics, except for age and emergency surgery. The number of well-controlled sedation patients in the propofol group on day three was significantly higher than that in the midazolam group (odds ratio [OR] 3.9, 95% CI [1.30, 11.7]). The incidence of daily coma and delirium within the initial week was different between groups and increased with midazolam administration (P = 0.0138). The number of Confusion Assessment Method for ICU-positive patients was significantly higher in the midazolam group than in the propofol group (OR 5.71, 95% CI [2.30, 14.2]).

Conclusion : In patients with sepsis required mechanical ventilation, sedation with midazolam based on a light sedation protocol may be associated with inappropriate sedation during the acute phase, with increased coma and delirium as compared to propofol.

Conclusion (proposition de traduction) : Chez les patients présentant un sepsis nécessitant une ventilation mécanique, la sédation au midazolam basée sur un protocole de sédation légère peut être associée à une sédation inappropriée pendant la phase aiguë, avec une augmentation du coma et du délire par rapport au propofol.

Anaesthesia Critical Care & Pain Medicine

Intrahospital trauma flowcharts - Cognitive aids for intrahospital trauma management from the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society of Emergency Medicine (SFMU).
Gauss T, Quintard H, Bijok B, Bouhours G, Clavier T, Cook F, de Courson H, David JS, Duracher-Gout C, Garrigue D, Geeraerts T, Hamada S, Joannes-Boyau O, Jouffroy R, Lamblin A, Langeron O, Lanot P, Lasocki S, Leone M, Mirek S, Muller L, Pasquier P, Prunet B, Perbet S, Raux M, Richards J, Roger C, Roquilly A, Weiss E, Bouzat P, Pottecher J. | Anaesth Crit Care Pain Med.  2022 Apr 22;41(3):101069
DOI: https://doi.org/10.1016/j.accpm.2022.101069
Keywords: Cognitive aid; Damage Control; Guideline; Resuscitation; Shock; Trauma; Traumatic Brain Injury.

Guideline

Editorial : Trauma care is best provided along concise and evidence-based guidelines. Yet despite considerable improvement in trauma outcome over the last ten years, mortality and morbidity remain high and low guideline compliance seems associated with increased mortality. Often conventional guideline formats are too cumbersome and not user-friendly enough to be consulted on scene or in the resuscitation room. Easy-to-use cognitive aids enhance guideline compliance and ultimately improve patient outcome.
For this reason, the present corpus of cognitive aids (CA) for trauma management, trauma flowcharts, provides comprehensive and visual guidelines for trauma clinicians in the intrahospital setting for the first 24–48 h. These flowcharts are structured along a timeline and all essential actions carry a specific time stamp. The flowcharts aspire to be an easy-to-use real-time support for clinicians, as well as to serve as reference for training and education. The flowcharts are the result of a close cooperation of the French Society of Anaesthesia and Intensive Care Medicine (Société française d’anesthésie et de réanimation, SFAR) and the French Society of Emergency Medicine (Société française de médecine d’urgence, SFMU).
The flowcharts cover the following topics:
1) Resuscitation Room Principles Major Trauma
2) Damage Control Principles
3) Clinical, Biological and Radiological Exams
4) Chest Trauma
5) Airway Management
6) Abdominal Trauma
7) Pelvic Trauma
8) Extremity Trauma
9) Traumatic Brain Injury
10) Spine and Medullary Trauma
The flowcharts were developed according to a distinct methodology. Every flowchart was composed by two collaborators along a pre-established template and existing clinical guidelines. All flowcharts were submitted to peer review from a college composed of 42 members from SFAR and the SFMU. After extensive review, the entire college of experts voted on the entire corpus of flowcharts. The vote was performed according to a scale from 1 to 9 (1–3 = no agreement; 4–6 = indetermined, new vote; 7–9 = strong agreement). A flowchart was adopted, if more than 75% of college members expressed a strong agreement. The final version was reviewed and validated by the clinical guideline committee of the French Society of Anaesthesia and Intensive Care Medicine (SFAR).

Conclusion (proposition de traduction) : Retrouver les « Aides cognitives trauma en intrahospitalier »   (dernière mise à jour : 10 janvier 2022) sur le site Internet de la SFAR  .

Anesthesia & Analgesia

Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis.
Carsetti A, Sorbello M, Adrario E, Donati A, Falcetta S. | Anesth Analg.  2022 Apr 1;134(4):740-750
DOI: https://doi.org/10.1213/ane.0000000000005839  | Télécharger l'article au format  
Keywords: Aucun

REVIEW ARTICLES: META-ANALYSIS

Introduction : Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in anesthesia practice. The aim of this systematic review and meta-analysis was to evaluate whether preoperative airway ultrasound can predict difficult direct laryngoscopy in adult patients undergoing elective surgery under general anesthesia.

Méthode : We searched the Medline, Scopus, and Web of Science databases from their inception to December 2020. The population of interest included adults who required tracheal intubation for elective surgery under general anesthesia without clear anatomical abnormalities suggesting difficult laryngoscopy. A bivariate model has been used to assess the accuracy of each ultrasound index test to predict difficult direct laryngoscopy.

Résultats : Fifteen studies have been considered for quantitative analysis of summary receiver operating characteristic (SROC). The sensitivity for distance from skin to epiglottis (DSE), distance from skin to hyoid bone (DSHB), and distance from skin to vocal cords (DSVC) was 0.82 (0.74-0.87), 0.71 (0.58-0.82), and 0.75 (0.62-0.84), respectively. The specificity for DSE, DSHB, and DSVC was 0.79 (0.70-0.87), 0.71 (0.57-0.82), and 0.72 (0.45-0.89), respectively. The area under the curve (AUC) for DSE, DSHB, DSVC, and ratio between the depth of the pre-epiglottic space and the distance from the epiglottis to the vocal cords (Pre-E/E-VC) was 0.87 (0.84-0.90), 0.77 (0.73-0.81), 0.78 (0.74-0.81), and 0.71 (0.67-0.75), respectively. Patients with difficult direct laryngoscopy have higher DSE, DSVC, and DSHB values than patients with easy laryngoscopy, with a mean difference of 0.38 cm (95% confidence interval [CI], 0.17-0.58 cm; P = .0004), 0.18 cm (95% CI, 0.01-0.35 cm; P = .04), and 0.23 cm (95% CI, 0.08-0.39 cm; P = .004), respectively.

Conclusion : Our study demonstrates that airway ultrasound index tests are significantly different between patients with easy versus difficult direct laryngoscopy, and the DSE is the most studied index test in literature to predict difficult direct laryngoscopy. However, it is not currently possible to reach a definitive conclusion. Further studies are needed with better standardization of ultrasound assessment to limit all possible sources of heterogeneity.

Conclusion (proposition de traduction) : Notre étude démontre que les tests d'indice échographique des voies aériennes diffèrent significativement entre les patients ayant une laryngoscopie directe facile et difficile, et la distance entre la peau et l'épiglotte est le test d'indice le plus étudié dans la littérature pour prédire la laryngoscopie directe difficile. Toutefois, il n’est actuellement pas possible de parvenir à une conclusion définitive. D'autres études sont nécessaires avec une meilleure standardisation de l'évaluation échographique pour limiter toutes les sources possibles d'hétérogénéité.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : POCUS for Predicting Difficult Airways  . Rédigé par Jonathan Brewer, le 02 mai 2022.

Annals of Emergency Medicine

Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative.
Donoghue A, O'Connell K, Neubrand T, Myers S, Nishisaki A, Kerrey B. | Ann Emerg Med.  2022 Apr;79(4):333-343
DOI: https://doi.org/10.1016/j.annemergmed.2021.12.014  | Télécharger l'article au format  
Keywords: Aucun

PEDIATRICS/ORIGINAL RESEARCH

Introduction : We sought to describe the tracheal intubation technique across a network of children's hospitals and explore the association between intubation technical adjuncts and first-attempt success as well as between laryngoscopy duration and the incidence of hypoxemia.

Méthode : We conducted a prospective observational study in 4 tertiary pediatric emergency departments of the Videography in Pediatric Resuscitation Collaborative. Children undergoing tracheal intubation captured on video were eligible for inclusion. Data on intubator background, patient characteristics, technical characteristics (eg, use of videolaryngoscopy and apneic oxygenation), and procedural outcomes were obtained through a video review.

Résultats : We obtained complete data on first attempts in 494 patients. The first-attempt success rate was 67%, the median laryngoscopy duration was 35 seconds (interquartile range 25 to 40), and hypoxemia occurred in 15% of the patients. Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia. Attempts in which videolaryngoscopy was used for the entire procedure (compared with direct laryngoscopy for the entire procedure) had a longer duration (the difference between the medians was 6 seconds; 95% confidence interval, 1 to 12 seconds). Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts.

Conclusion : Among children undergoing tracheal intubation in a group of pediatric emergency departments, first-attempt success occurred in 67% of the patients. Videolaryngoscopy use was associated with longer laryngoscopy durations but was not associated with success or the incidence of hypoxemia.

Conclusion (proposition de traduction) : Parmi les enfants bénéficiant d'une intubation trachéale dans un groupe de services d'urgence pédiatriques, le succès au premier essai a été obtenu chez 67 % des patients. L'utilisation de la vidéolaryngoscopie était associée à des durées de laryngoscopie plus longues, mais n'était pas associée au succès ou à l'incidence de l'hypoxémie.

Annals of Emergency Medicine,

Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department.
Dean P, Edmunds K, Shah A, Frey M, Zhang Y, Boyd S, Kerrey BT. | Ann Emerg Med.  2022 Apr;79(4):323-332
DOI: https://doi.org/10.1016/j.annemergmed.2021.11.019
Keywords: Aucun

Pediatrics

Introduction : Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance.

Méthode : We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model.

Résultats : From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90).

Conclusion : We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.

Conclusion (proposition de traduction) : Nous avons trouvé une grande variation dans la façon dont les utilisateurs voyaient l'écran du vidéolaryngoscope pendant les intubations dans un service d'urgence pédiatrique. Nous illustrons l'application de 2 mesures objectives de visualisation d'écran pour quantifier et comprendre comment les cliniciens utilisent réellement la laryngoscopie vidéo.

Archives of Academic Emergency Medicine

Efficacy of Sumatriptan/Placebo versus Sumatriptan/Propofol Combination in Acute Migraine; a Randomized Clinical Trial.
Farahmand Rad R, Zolfaghari Sadrabad A, Jafari M, Ghilian M. | Arch Acad Emerg Med.  2022 Apr 14;10(1):e27
DOI: https://doi.org/10.22037/aaem.v10i1.1510  | Télécharger l'article au format  
Keywords: Migraine disorders; headache; pain management; propofol; sumatriptan.

Original/Research Article

Introduction : Migraine headaches can cause severe pain for patients and lead them to multiple visits to the emergency department (ED). This study aimed to evaluate the efficacy of propofol + sumatriptan combination in comparison with sumatriptan alone in the management of acute migraine headaches.

Méthode : This triple-blind clinical trial involved patients who referred to two emergency departments with acute migraine headaches. Patients were randomly assigned to control (sumatriptan and placebo) or intervention (propofol and sumatriptan) groups for comparison of the efficacy and side effects of treatment.

Résultats : In this study, 60 patients were included whose mean age was 31±8.8 years, and headaches were more common among women. After 30 and 60 minutes from the beginning of treatment, the mean pain score reduction in the intervention group was significantly greater than that in the control group (p=0.012, p=0.024). In addition, the rate of chest tightness in the control group was significantly higher than the intervention group. The absolute risk reduction of adverse events (Chest tightness, Bradycardia, hypotension, and etc.), in patients with acute migraine headache taking propofol and sumatriptan treatment, was 32.18% (95% CI: 8.02 - 56.35).

Conclusion : This study supports the use of propofol for treatment of acute migraine headaches and shows that combining sumatriptan with propofol is more effective in relieving migraine headaches and the associated symptoms than using sumatriptan alone. However, more studies with longer follow-ups are still needed.

Conclusion (proposition de traduction) : Cette étude suggère l'utilisation du propofol pour le traitement des migraines aiguës et montre que l'association du sumatriptan au propofol est plus efficace pour soulager les migraines et les symptômes associés que l'utilisation du sumatriptan seul. Cependant, d'autres études avec des suivis plus longs sont encore nécessaires.

BMC Emergency Medicine

Admission vital signs as predictors of COVID-19 mortality: a retrospective cross-sectional study.
Ikram AS, Pillay S. | BMC Emerg Med.  2022 Apr 29;22(1):68
DOI: https://doi.org/10.1186/s12873-022-00631-7  | Télécharger l'article au format  
Keywords: Age; Blood pressure; COVID-19; Glucose; Heart rate; Mortality; Oxygen saturation; Respiratory rate; Temperature; Vital signs.

Research

Introduction : COVID-19 remains a major healthcare concern. Vital signs are routinely measured on admission and may provide an early, cost-effective indicator of outcome - more so in developing countries where such data is scarce. We sought to describe the association between six routinely measured admission vital signs and COVID-19 mortality, and secondarily to derive potential applications for resource-limited settings.

Méthode : Retrospective analysis of consecutive patients admitted to King Edward VIII Hospital, South Africa, with COVID-19 during June-September 2020 was undertaken. The sample was subdivided into survivors and non-survivors and comparisons made in terms of demographics and admission vital signs. Univariate and multivariate analysis of predictor variables identified associations with in-hospital mortality, with the resulting multivariate regression model evaluated for its predictive ability with receiver operating characteristic (ROC) curve analysis.

Résultats : The 236 participants enrolled comprised 153(77.54%) survivors and 53(22.46%) non-survivors. Most participants were Black African(87.71%) and female(59.75%) with a mean age of 53.08(16.96) years. The non-survivor group demonstrated a significantly lower median/mean for admission oxygen saturation (%) [87(78-95) vs. 96(90-98)] and diastolic BP (mmHg) [70.79(14.66) vs. 76.3(12.07)], and higher median for admission respiratory rate (breaths/minute) [24(20-28) vs. 20(20-23)] and glucose (mmol/l) [10.2(6.95-16.25) vs. 7.4(5.5-9.8)]. Age, oxygen saturation, respiratory rate, glucose and diastolic BP were found to be significantly associated with mortality on univariate analysis. A log rank test revealed significantly lower survival rates in patients with an admission oxygen saturation < 90% compared with ≥90% (p = 0.001). Multivariate logistic regression revealed a significant relationship between age and oxygen saturation with in-hospital mortality (OR 1.047; 95% CI 1.016-1.080; p = 0.003 and OR 0.922; 95% CI 0.880-0.965; p = 0.001 respectively). A ROC curve analysis generated an area under the curve (AUC) of 0.778 (p < 0.001) when evaluating the predictive ability of oxygen saturation, respiratory rate, glucose and diastolic BP for in-hospital death. This improved to an AUC of 0.832 (p < 0.001) with the inclusion of age.

Conclusion : A multivariate regression model comprising admission oxygen saturation, respiratory rate, glucose and diastolic BP (with/without age) demonstrated promising predictive capacity, and may provide a cost-effective means for early prognostication of patients admitted with COVID-19 in resource-limited settings.

Conclusion (proposition de traduction) : Un modèle de régression multivariée comprenant la saturation en oxygène à l'admission, la fréquence respiratoire, le glucose et la TA diastolique (avec/sans âge) a démontré une capacité prédictive prometteuse et pourrait fournir un moyen rentable pour le pronostic précoce des patients admis avec COVID-19 dans des contextes à ressources limitées .

Chest

Lung Response to a Higher Positive End-Expiratory Pressure in Mechanically Ventilated Patients With COVID-19.
Protti A, Santini A, Pennati F, Chiurazzi C, Cressoni M, Ferrari M, Iapichino GE, Carenzo L, Lanza E, Picardo G, Caironi P, Aliverti A, Cecconi M. | Chest.  2022 Apr;161(4):979-988
DOI: https://doi.org/10.1016/j.chest.2021.10.012  | Télécharger l'article au format  
Keywords: acute respiratory distress syndrome; coronavirus disease 2019; mechanical ventilation; positive end-expiratory pressure.

Critical Care: Original Research

Introduction : International guidelines suggest using a higher (> 10 cm H2O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe ARDS due to COVID-19. However, even if oxygenation generally improves with a higher PEEP, compliance, and Paco2 frequently do not, as if recruitment was small.
Research question: Is the potential for lung recruitment small in patients with early ARDS due to COVID-19?

Méthode : Forty patients with ARDS due to COVID-19 were studied in the supine position within 3 days of endotracheal intubation. They all underwent a PEEP trial, in which oxygenation, compliance, and Paco2 were measured with 5, 10, and 15 cm H2O of PEEP, and all other ventilatory settings unchanged. Twenty underwent a whole-lung static CT scan at 5 and 45 cm H2O, and the other 20 at 5 and 15 cm H2O of airway pressure. Recruitment and hyperinflation were defined as a decrease in the volume of the non-aerated (density above -100 HU) and an increase in the volume of the over-aerated (density below -900 HU) lung compartments, respectively.

Résultats : From 5 to 15 cm H2O, oxygenation improved in 36 (90%) patients but compliance only in 11 (28%) and Paco2 only in 14 (35%). From 5 to 45 cm H2O, recruitment was 351 (161-462) mL and hyperinflation 465 (220-681) mL. From 5 to 15 cm H2O, recruitment was 168 (110-202) mL and hyperinflation 121 (63-270) mL. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them.

Conclusion : Patients with early ARDS due to COVID-19, ventilated in the supine position, present with a large potential for lung recruitment. Even so, their compliance and Paco2 do not generally improve with a higher PEEP, possibly because of hyperinflation.

Conclusion (proposition de traduction) : Les patients présentant un SDRA précoce dû à la COVID-19, ventilés en décubitus dorsal, présentent un fort potentiel de recrutement pulmonaire. Même ainsi, leur compliance et Paco2 ne s'améliorent généralement pas avec une PEP plus élevée, peut-être à cause de l'hyperinflation.

Complications of Critical COVID-19: Diagnostic and Therapeutic Considerations for the Mechanically Ventilated Patient.
Maslove DM, Sibley S, Boyd JG, Goligher EC, Munshi L, Bogoch II, Rochwerg B. | Chest.  2022 Apr;161(4):989-998
DOI: https://doi.org/10.1016/j.chest.2021.10.011  | Télécharger l'article au format  
Keywords: ARDS; COVID-19; ICU; complications; critical care; mechanical ventilation.

CHEST Reviews

Editorial : Patients admitted to the ICU with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated patient with COVID-19 who shows persistent or worsening signs of critical illness, and we offer an approach to treating this complex but common scenario.

Conclusion : Patients with severe COVID-19 admitted to the ICU are at high risk for prolonged periods of mechanical ventilation. This translates to a long period at risk for complications. Clinical management can be fraught with challenges and frustration, as setbacks are common, and mortality remains high. Patients with COVID-19 may be at enhanced risk of the usual complications associated with prolonged critical illness but face additional risks specific to COVID-19 itself. Many of the potential complications—including VILI, VTE, and secondary or latent infection—may be difficult to disentangle from the underlying condition. Physicians must therefore maintain a high degree of suspicion, and pursue timely investigation and treatment as indicated in patients who either fail to improve or worsen despite optimal management.

Conclusion (proposition de traduction) : Les patients présentant une COVID-19 sévère admis aux soins intensifs sont à haut risque pour des périodes prolongées de ventilation mécanique. Cela se traduit par une longue période à risque de complications. La prise en charge clinique peut être semée d'embûches et de frustrations, car les revers sont fréquents et la mortalité reste élevée. Les patients présentant une COVID-19 peuvent être exposés à un risque accru de complications habituelles associées à une maladie grave prolongée, mais font face à des risques supplémentaires spécifiques à la COVID-19 lui-même. Bon nombre des complications potentielles, y compris les lésions pulmonaires induites par la ventilation, les thrombophlébites veineuses et les infections secondaires ou latentes, peuvent être difficiles à dissocier de la condition sous-jacente. Les médecins doivent donc maintenir un degré élevé de suspicion et poursuivre les investigations et le traitement en temps opportun, selon les indications, chez les patients dont l'état ne s'améliore pas ou s'aggrave malgré une prise en charge optimale.

Cochrane Database of Systematic Reviews

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation.
Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. | Cochrane Database Syst Rev.  2022 Apr 4;4(4):CD011136
DOI: https://doi.org/10.1002/14651858.cd011136.pub3  | Télécharger l'article au format  
Keywords: Aucun

Intervention

Introduction : Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016.
Objectives: To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings.

Méthode : We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches.
Selection criteria: We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs.
Data collection and analysis: We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation.

Résultats : We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit. We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation..

Conclusion : VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.

Conclusion (proposition de traduction) : Les vidéolaryngoscopes de toutes les conceptions réduisent probablement les taux d'échec d'intubation et permettent des taux plus élevés de succès de l'intubation dès la première tentative avec une vision glottique améliorée. Les vidéolaryngoscopes de type Macintosh avec canal guide pour la sonde d’intubation réduisent probablement les taux d'événements hypoxémiques, tandis que les vidéolaryngoscopes hyperangulés (ndlr : permettant d’optimiser l’exposition glottique) réduisent probablement les taux d'intubation œsophagienne. Nous concluons que la vidéolaryngoscopie fournit probablement un profil de risque plus sûr par rapport à la laryngoscopie directe pour tous les adultes nécessitant une intubation trachéale.

Critical Care

Early prolonged prone position in noninvasively ventilated patients with SARS-CoV-2-related moderate-to-severe hypoxemic respiratory failure: clinical outcomes and mechanisms for treatment response in the PRO-NIV study.
Musso G, Taliano C, Molinaro F, Fonti C, Veliaj D, Torti D, Paschetta E, Castagna E, Carbone G, Laudari L, Aseglio C, Zocca E, Chioni S, Giannone LC, Arabia F, Deiana C, Benato FM, Druetta M, Campagnola G, Borsari M, Mucci M, Rubatto T, Peyronel M, Tirabassi G. | Crit Care.  2022 Apr 29;26(1):118
DOI: https://doi.org/10.1186/s13054-022-03937-x  | Télécharger l'article au format  
Keywords: Corrected minute ventilation; Dead space; Lung ultrasound; Noninvasive ventilation; Ventilatory ratio.

RESEARCH

Introduction : Whether prone position (PP) improves clinical outcomes in COVID-19 pneumonia treated with noninvasive ventilation (NIV) is unknown. We evaluated the effect of early PP on 28-day NIV failure, intubation and death in noninvasively ventilated patients with moderate-to-severe acute hypoxemic respiratory failure due to COVID-19 pneumonia and explored physiological mechanisms underlying treatment response.

Méthode : In this controlled non-randomized trial, 81 consecutive prospectively enrolled patients with COVID-19 pneumonia and moderate-to-severe (paO2/FiO2 ratio < 200) acute hypoxemic respiratory failure treated with early PP + NIV during Dec 2020-May 2021were compared with 162 consecutive patients with COVID-19 pneumonia matched for age, mortality risk, severity of illness and paO2/FiO2 ratio at admission, treated with conventional (supine) NIV during Apr 2020-Dec 2020 at HUMANITAS Gradenigo Subintensive Care Unit, after propensity score adjustment for multiple baseline and treatment-related variables to limit confounding. Lung ultrasonography (LUS) was performed at baseline and at day 5. Ventilatory parameters, physiological dead space indices (DSIs) and circulating inflammatory and procoagulative biomarkers were monitored during the initial 7 days.

Résultats : In the intention-to-treat analysis. NIV failure occurred in 14 (17%) of PP patients versus 70 (43%) of controls [HR = 0.32, 95% CI 0.21-0.50; p < 0.0001]; intubation in 8 (11%) of PP patients versus 44 (30%) of controls [HR = 0.31, 95% CI 0.18-0.55; p = 0.0012], death in 10 (12%) of PP patients versus 59 (36%) of controls [HR = 0.27, 95% CI 0.17-0.44; p < 0.0001]. The effect remained significant within different categories of severity of hypoxemia (paO2/FiO2 < 100 or paO2/FiO2 100-199 at admission). Adverse events were rare and evenly distributed. Compared with controls, PP therapy was associated with improved oxygenation and DSIs, reduced global LUS severity indices largely through enhanced reaeration of dorso-lateral lung regions, and an earlier decline in inflammatory markers and D-dimer. In multivariate analysis, day 1 CO2 response outperformed O2 response as a predictor of LUS changes, NIV failure, intubation and death.

Conclusion : Early prolonged PP is safe and is associated with lower NIV failure, intubation and death rates in noninvasively ventilated patients with COVID-19-related moderate-to-severe hypoxemic respiratory failure. Early dead space reduction and reaeration of dorso-lateral lung regions predicted clinical outcomes in our study population.

Conclusion (proposition de traduction) : Le décubitus ventral prolongé précoce est sûre et est associée à des taux d'échec de ventilation non invasive, d'intubation et de décès plus faibles chez les patients ventilés de manière non invasive atteints d'insuffisance respiratoire hypoxémique modérée à sévère liée à la COVID-19. La réduction précoce de l'espace mort et le recrutement des régions pulmonaires dorso-latérales ont prédit les résultats cliniques dans notre population d'étude.

Transcranial Doppler as a screening test to exclude intracranial hypertension in brain-injured patients: the IMPRESSIT-2 prospective multicenter international study.
Rasulo FA, Calza S, Robba C, Taccone FS, Biasucci DG, Badenes R, Piva S, Savo D, Citerio G, Dibu JR, Curto F, Merciadri M, Gritti P, Fassini P, Park S, Lamperti M, Bouzat P, Malacarne P, Chieregato A, Bertuetti R, Aspide R, Cantoni A, McCredie V, Guadrini L, Latronico N. | Crit Care.  2022 Apr 15;26(1):110
DOI: https://doi.org/10.1186/s13054-022-03978-2  | Télécharger l'article au format  
Keywords: Brain injury; Intracranial hypertension; Intracranial pressure; Noninvasive monitoring.

RESEARCH

Introduction : Alternative noninvasive methods capable of excluding intracranial hypertension through use of transcranial Doppler (ICPtcd) in situations where invasive methods cannot be used or are not available would be useful during the management of acutely brain-injured patients. The objective of this study was to determine whether ICPtcd can be considered a reliable screening test compared to the reference standard method, invasive ICP monitoring (ICPi), in excluding the presence of intracranial hypertension.

Méthode : This was a prospective, international, multicenter, unblinded, diagnostic accuracy study comparing the index test (ICPtcd) with a reference standard (ICPi), defined as the best available method for establishing the presence or absence of the condition of interest (i.e., intracranial hypertension). Acute brain-injured patients pertaining to one of four categories: traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) or ischemic stroke (IS) requiring ICPi monitoring, were enrolled in 16 international intensive care units. ICPi measurements (reference test) were compared to simultaneous ICPtcd measurements (index test) at three different timepoints: before, immediately after and 2 to 3 h following ICPi catheter insertion. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated at three different ICPi thresholds (> 20, > 22 and > 25 mmHg) to assess ICPtcd as a bedside real-practice screening method. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of ICPtcd.

Résultats : Two hundred and sixty-two patients were recruited for final analysis. Intracranial hypertension (> 22 mmHg) occurred in 87 patients (33.2%). The total number of paired comparisons between ICPtcd and ICPi was 687. The NPV was elevated (ICP > 20 mmHg = 91.3%, > 22 mmHg = 95.6%, > 25 mmHg = 98.6%), indicating high discriminant accuracy of ICPtcd in excluding intracranial hypertension. Concordance correlation between ICPtcd and ICPi was 33.3% (95% CI 25.6-40.5%), and Bland-Altman showed a mean bias of -3.3 mmHg. The optimal ICPtcd threshold for ruling out intracranial hypertension was 20.5 mmHg, corresponding to a sensitivity of 70% (95% CI 40.7-92.6%) and a specificity of 72% (95% CI 51.9-94.0%) with an AUC of 76% (95% CI 65.6-85.5%).

Conclusion : ICPtcd has a high NPV in ruling out intracranial hypertension and may be useful to clinicians in situations where invasive methods cannot be used or not available.

Conclusion (proposition de traduction) : L'hypertension intracrânienne mesurée par doppler transcrânien a une valeur prédictive négative élevée pour exclure l'hypertension intracrânienne et peut être utile aux cliniciens dans les situations où les méthodes invasives ne peuvent pas être utilisées ou ne sont pas disponibles.

Commentaire :  Une fois l'indication de surveillance de l'hypertension intracrânienne (ICPtcd) décidée, l'application de la méthode invasive (gold standard) est évaluée :
Si NON (surveillance invasive de l'hypertension intracrânienne impossible) pour la présence d'une ou plusieurs des raisons fournies, hypertension intracrânienne par l'utilisation du Doppler transcrânien associée à l'imagerie cérébrale doit être réalisée. * Le résultat ne doit pas avoir un effet dissuasif sur le transfert vers un hôpital doté d'un centre de neurochirurgie ou pour effectuer d'autres études d'imagerie cérébrale, mais l'hypertension intracrânienne par l'utilisation du Doppler transcrânien doit être utilisée comme un complément capable de fournir des informations précieuses au clinicien ;
si OUI (surveillance invasive de l'hypertension intracrânienne possible), alors un trou de trépan et l'insertion d'un cathéter dans le parenchyme cérébral doivent être effectués. * Cependant, l'échographie cérébrale avec Doppler transcrânien peut être utile pour obtenir des informations de substitution concernant l'hémodynamique cérébrale grâce à l'évaluation de la vitesse du flux sanguin cérébral.

High-flow nasal cannula versus conventional oxygen therapy in acute COPD exacerbation with mild hypercapnia: a multicenter randomized controlled trial.
Xia J, Gu S, Lei W, Zhang J, Wei H, Liu C, Zhang H, Lu R, Zhang L, Jiang M, Hu C, Cheng Z, Wei C, Chen Y, Lu F, Chen M, Bi H, Liu H, Yan C, Teng H, Yang Y, Liang C, Ge Y, Hou P, Liu J, Gao W, Zhang Y, Feng Y, Tao C, Huang X, Pan P, Luo H, Yun C, Zhan Q. | Crit Care.  2022 Apr 15;26(1):109
DOI: https://doi.org/10.1186/s13054-022-03973-7  | Télécharger l'article au format  
Keywords: Chronic obstructive; High-flow nasal cannula; Hypercapnia; Pulmonary disease; Respiratory insufficiency; Respiratory support.

Research

Introduction : High-flow nasal cannula (HFNC) can improve ventilatory function in patients with acute COPD exacerbation. However, its effect on clinical outcomes remains uncertain.

Méthode : This randomized controlled trial was conducted from July 2017 to December 2020 in 16 tertiary hospitals in China. Patients with acute COPD exacerbation with mild hypercapnia (pH ≥ 7.35 and arterial partial pressure of carbon dioxide > 45 mmHg) were randomly assigned to either HFNC or conventional oxygen therapy. The primary outcome was the proportion of patients who met the criteria for intubation during hospitalization. Secondary outcomes included treatment failure (intolerance and need for non-invasive or invasive ventilation), length of hospital stay, hospital cost, mortality, and readmission at day 90.

Résultats : Among 337 randomized patients (median age, 70.0 years; 280 men [83.1%]; median pH 7.399; arterial partial pressure of carbon dioxide 51 mmHg), 330 completed the trial. 4/158 patients on HFNC and 1/172 patient on conventional oxygen therapy met the criteria for intubation (P = 0.198). Patients progressed to NPPV in both groups were comparable (15 [9.5%] in the HFNC group vs. 22 [12.8%] in the conventional oxygen therapy group; P = 0.343). Compared with conventional oxygen therapy, HFNC yielded a significantly longer median length of hospital stay (9.0 [interquartile range, 7.0-13.0] vs. 8.0 [interquartile range, 7.0-11.0] days) and a higher median hospital cost (approximately $2298 [interquartile range, $1613-$3782] vs. $2005 [interquartile range, $1439-$2968]). There were no significant differences in other secondary outcomes between groups.

Conclusion : In this multi-center randomized controlled study, HFNC compared to conventional oxygen therapy did not reduce need for intubation among acute COPD exacerbation patients with mild hypercapnia. The future studies should focus on patients with acute COPD exacerbation with respiratory acidosis (pH < 7.35). However, because the primary outcome rate was well below expected, the study was underpowered to show a meaningful difference between the two treatment groups.

Conclusion (proposition de traduction) : Dans cette étude contrôlée randomisée multicentrique, l'oxygénothérapie nasale à haut débit par rapport à l'oxygénothérapie conventionnelle n'a pas réduit le besoin d'intubation chez les patients atteints d'exacerbation aiguë de la BPCO avec une légère hypercapnie. Les futures études devraient porter sur les patients présentant une exacerbation aiguë de BPCO avec acidose respiratoire (pH < 7,35). Cependant, comme le taux de résultat principal était bien inférieur aux attentes, l'étude n'avait pas la puissance suffisante pour montrer une différence significative entre les deux groupes de traitement.

Emergencias

Emergency department prescription of sinus rhythm maintenance therapy for patients treated for atrial fibrillation: a secondary analysis of the HERMES-AF study.
Fernández-Simón A, Martín A, Suero C, Sánchez J, Varona M, Sánchez S, Cancio M, Carbajosa J, Tamargo J, Del Arco C, Medrano FJ, Coll-Vinent B; En representación de los investigadores del estudio HERMES-AF. | Emergencias.  2022 Apr;34(2):111-118
DOI: NC  | Télécharger l'article au format  
Keywords: Atrial fibrillation; Sinus rhythm maintenance; Emergency health services; Cardiac remodeling; Upstream therapy; Antiarrhythmic agents.

Original article

Introduction : The maintenance of sinus rhythm by means of antiarrhythmic drugs and/or upstream therapy to counter cardiac remodeling is fundamental to the management of atrial fibrillation (AF). This study aimed to analyze this approach and its appropriateness in the setting of hospital emergency departments.

Méthode : Secondary analysis of data from the multicenter observational cross-sectional HERMES-AF study carried out in 124 hospitals representative of the Spanish national health service in 2011. Included were consecutive patients with AF restored to sinus rhythm who were discharged home from emergency care.

Résultats : A total of 449 patients were included; 204 (45.4%) were already on sinus rhythm maintenance therapy. Of the 245 remaining patients, 107 (43.67%) were prescribed maintenance treatment in the emergency department, as follows: 41, an antiarrhythmic drug; 19, upstream therapy; and 49, both treatments. The selection of an antiarrhythmic drug did not follow guideline recommendations in 10 patients (11.8%). Antiarrhythmic drug prescription was associated with having had a prior episode of AF (odds ratio [OR], 2.024; 95% CI, 1.196-3.424; P = .009); a heart rate of more than 110 beats/min (OR, 2.147; 95% CI, 1.034-4.456, P = 0.40); and prescription of anticoagulation on discharge (OR, 1.862; 95% CI, 1.094-3.170; P = .022). Upstream therapy prescription was associated only with a heart rate over 110 beats/min (OR, 2.187; 95% CI, 1.005-4.757; P = .018). In total, 311 patients (69.23%) were discharged from the emergency department with sinus rhythm maintenance therapy: 87 with an antiarrhythmic drug, 117 with an upstream therapy, and 107 with both.

Conclusion : Treatment to prevent the recurrence of AF is underprescribed in emergency departments. Increasing such prescription and ensuring the appropriateness of antiarrhythmic therapy prescribed are points emergency departments can improve in the interest of better sinus rhythm maintenance.

Conclusion (proposition de traduction) : Les traitements visant à prévenir la récidive de la fibrillation atriale sont insuffisamment prescrits dans les services d'urgence. Augmenter cette prescription et s'assurer de la pertinence du traitement antiarythmique prescrit sont des points que les services d'urgence peuvent améliorer dans l'intérêt d'un meilleur maintien du rythme sinusal.

Emergency Medicine Australasia

Conservative management of traumatic pneumothoraces: A retrospective cohort study.
Gerhardy BC, Liebenberg P, Simpson G. | Emerg Med Australas.  2022 Apr;34(2):194-198
DOI: https://doi.org/10.1111/1742-6723.13846
Keywords: conservative; pneumothorax; trauma.

Original Research

Introduction : Traumatic pneumothoraces (T-PTXs) are traditionally managed with an intercostal catheter (ICC), despite little evidence for this. Success with conservative management of primary spontaneous PTX has been demonstrated, and our ED has adopted a conservative approach where safe for all PTX.

Méthode : We reviewed all T-PTXs at our institution over a 7-year period to assess outcomes of those conservatively managed and compare with those who received an ICC. A total of 144 cases were identified, 65 managed conservatively and 79 invasively. Each was individually reviewed and variables including demographics, aetiology, smoking/lung disease history, T-PTX size (apical interpleural distance and hemithorax percentage), length of stay, Revised Trauma Score, Injury Severity Score and delayed intervention/complications were recorded. Chi-squared, Z-score, Mann-Whitney U and t-tests were used for analysis.

Résultats : The mean apical interpleural distance was 26.8 mm (95% confidence interval [CI] 22.1-29.7 mm) in the conservative group and 49.1 mm (95% CI 41.2-57.0 mm) in the ICC group (P < 0.05 for difference between groups). Mean T-PTX percentage 25.9% (95% CI 22.1-29.7%) in the conservative group versus 45.9% (95% CI 39.7-50.5%) in the ICC group (P < 0.05 for difference between two groups) and mean Revised Trauma Score 7.4 (conservative) versus 6.8 (invasive) (P < 0.05). No conservatively managed patient required a delayed intervention for their T-PTX, and 2 of 79 (3%) patients in the ICC group had a complication (one infection, one haemothorax).

Conclusion : Our data support conservative management of selected T-PTXs and shows a need for a prospective randomised trial to further examine this intervention.

Conclusion (proposition de traduction) : Nos données confirment le bien-fondé du traitement conservateur de certains pneumothorax traumatiques et montrent la nécessité d'un essai prospectif randomisé pour examiner plus avant cette intervention.

Mapping haemodynamic changes with rapid sequence induction agents in the emergency department.
Freeman J, Alkhouri H, Knipp R, Fogg T, Gillett M. | Emerg Med Australas.  2022 Apr;34(2):237-243
DOI: https://doi.org/10.1111/1742-6723.13867
Keywords: airway management; anaesthesia; emergency department; induction agent; rapid sequence induction.

Original Research

Introduction : Patients intubated in the ED are at an increased risk of post-intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction.

Méthode : This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre- and post-intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre- and post-intubation was the primary measure of haemodynamic stability.

Résultats : From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre-intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose-dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9.

Conclusion : Propofol was associated with post-intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post-intubation hypotension.

Conclusion (proposition de traduction) : Le propofol a été associé à une hypotension après l'intubation et il est recommandé aux cliniciens d'envisager l'utilisation de la dose efficace la plus faible pour réduire ce risque. En raison de sa stabilité hémodynamique supposée, les patients ayant reçu de la kétamine étaient plus susceptibles d'avoir un shock index plus élevé ; cependant, il y avait également une association avec l'hypotension après l'intubation.

Emergency Medicine International

Underuse of Epinephrine for the Treatment of Anaphylaxis in the Prehospital Setting.
Dami F, Enggist R, Comte D, Pasquier M. | Emerg Med Int.  2022 Apr 15;2022:5752970
DOI: https://doi.org/10.1155/2022/5752970  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Introduction : Anaphylaxis is a life-threatening reaction. Its key management is rapid diagnosis and prompt administration of intramuscular epinephrine. There are many barriers to epinephrine use.
Objective: To assess the performance of dispatchers at suspecting anaphylaxis, proposing epinephrine treatment, helping find an epinephrine autoinjector (EAI) and using it.

Méthode : This is a retrospective study. Calls classified as "anaphylaxis" or "allergy" were included, and voice recordings were reviewed. Clinical, environmental, and operational variables were collected. Anaphylaxis was suspected if sudden dyspnoea, abdominal symptoms (vomiting, abdominal pain, or diarrhoea), dizziness, or loss of consciousness were present.

Résultats : The dispatch handled 120,618 dispatch calls. Dispatchers suspected 611 (0.5%) cases of allergy. Among those, 437 (72%) were deemed consistent with anaphylaxis: 65 patients received epinephrine prior to the dispatcher's advice, and dispatchers proposed the use of an EAI to 141 patients (38%). An EAI was available in 45 situations. The proposition was accepted on 18 cases and performed in 16 cases. The median time from the EAI being in hand and the injection was 50 seconds.

Conclusion : Trained dispatchers are able to suspect anaphylaxis, decide when to treat and provide guidance on using an EAI, although their performance can be improved. There is a need for easier access to EAIs in public places.

Conclusion (proposition de traduction) : Les régulateurs formés sont capables de suspecter une anaphylaxie, de décider quand la traiter et de fournir des conseils sur l'utilisation d'un auto-injecteur d'épinéphrine, bien que leur performance puisse être améliorée. Il est nécessaire de faciliter l'accès aux auto-injecteurs d'épinéphrine dans les lieux publics.

Emergency Medicine Journal

Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis.
Turner JS, Hunter BR, Haseltine ID, Motzkus CA, DeLuna HM, Cooper DD, Ellender TJ, Sarmiento EJ, Menard LM, Kirschner JM. | Emerg Med J.  2022 Apr 7:emermed-2021-211968
DOI: https://doi.org/10.1136/emermed-2021-211968
Keywords: airway

Systematic review

Introduction : Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation.

Méthode : A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach.

Résultats : A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes.

Conclusion : This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.

Conclusion (proposition de traduction) : Cette revue systématique et cette méta-analyse n'ont trouvé aucune preuve de bénéfice ou d'inconvénient avec le positionnement du patient incliné par rapport au décubitus dorsal pendant l'intubation endotrachéale dans n'importe quel contexte.

Geriatric clinical screening tool for cervical spine injury after ground-level falls.
Engelbart J, Zhou P, Johnson J, Lilienthal M, Zhou Y, Ten-Eyck P, Galet C, Skeete D. | 2022 Apr;39(4):301-307.  Emerg Med J
DOI: https://doi.org/10.1136/emermed-2020-210693
Keywords: clinical assessment; fractures and dislocations; geriatrics; imaging; research; trauma.

TRAUMA

Introduction : A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI.

Méthode : The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set.

Résultats : Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%).

Conclusion : Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.

Conclusion (proposition de traduction) : La sensibilité de la ligne des épineuses, le déficit neurologique focal et les signes de traumatisme crânien/facial étaient significatifs dans cette population âgée. L'absence des trois variables indique une probabilité plus faible de blessure du rachis cervical chez les patients ≥ 65 ans. De futures études observationnelles sont justifiées pour valider prospectivement ce modèle.

Emergency management of older people with cervical spine injuries: an expert practice review.
Benchetrit S, Blackham J, Braude P, Halliday R, Shipway D, Williams A, Carlton E. | Emerg Med J.  2022 Apr;39(4):331-336
DOI: https://doi.org/10.1136/emermed-2020-211002
Keywords: accidental falls; emergency department management; frailty; spine and pelvis; trauma.

PRACTICE REVIEW

Editorial : Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.

Conclusion : C-spine injuries are common, particularly in older people, with a lack of well-evidenced recommendations on their emergency management. Falls from standing height are closely associated with advancing age and are already the most common cause of injuries meeting major trauma criteria. EDs must adapt to ensure the specific management needs of this patient group are met with pragmatic evidence-based practice.
While spinal clearance scoring systems have been validated in wider adult trauma, there is little evidence to support their use in the older patients. A liberal use of radiology is recommended to ensure occult injuries are not missed. Plain radiography is insuffi- ciently sensitive to exclude fractures and CT imaging should be the first-line imaging modality. In patients presenting with abnormal neurology, MRI should be considered even where CT does not reveal injury. Hard collars in pre-diagnosis immobilisation are not recommended in older people, and if necessary, soft pads and tape should be used to maximise comfort. Ongoing management can be complex and should account for patient-specific factors, such as frailty, comorbidity, prognosis and quality of life. A multidisci- plinary approach involving spinal surgeons, trauma geriatricians and dedicated therapists are needed to engage in careful shared decision-making with patients and their carers to best achieve optimal outcomes.

Conclusion (proposition de traduction) : Les blessures à la colonne vertébrale C sont courantes, en particulier chez les personnes âgées, avec un manque de recommandations bien documentées sur leur gestion aux urgences. Les chutes de leur hauteur sont étroitement associées à l'avancée en âge et sont déjà la cause la plus fréquente de blessures répondant aux critères de traumatisme majeur. Les services d'urgence doivent s'adapter pour s'assurer que les besoins de gestion spécifiques de ce groupe de patients sont satisfaits par une pratique pragmatique fondée sur des preuves.
Bien que les systèmes de scoring des atteintes cervicales aient été validés dans des traumatismes chez l'adultes plus larges, il existe peu de preuves pour soutenir leur utilisation chez les patients plus âgés. Une utilisation libérale de la radiologie est recommandée pour s'assurer que les blessures occultes ne soient pas manquées. La radiographie simple est insuffisamment sensible pour exclure les fractures et l'imagerie par tomodensitométrie devrait être la modalité d'imagerie de première intention. Chez les patients présentant des anomalies neurologiques, l'IRM doit être envisagée même si la TDM ne révèle pas de lésion. Les colliers rigides en immobilisation pré-diagnostic ne sont pas recommandés chez les personnes âgées et, si nécessaire, des coussinets souples et du ruban adhésif doivent être utilisés pour maximiser le confort. La prise en charge continue peut être complexe et doit tenir compte de facteurs spécifiques liés au patient, tels que la fragilité, les comorbidités, le pronostic et la qualité de vie. Une approche multidisciplinaire impliquant des chirurgiens de la colonne vertébrale, des gériatres traumatologues et des thérapeutes dédiés est nécessaire pour s'engager dans une prise de décision partagée prudente avec les patients et leurs soignants afin d'obtenir des résultats optimaux.

Emergency Radiology

Retrospective analysis of the application of CT scan in the emergency department to screen clinically asymptomatic COVID-19 before hospital admission.
Volpicelli G, Fraccalini T, Barba M, Fischetto C, Maggiani G, Veltri A, Cardinale L. | Emerg Radiol.  2022 Apr;29(2):235-241
DOI: https://doi.org/10.1007/s10140-022-02016-6  | Télécharger l'article au format  
Keywords: COVID-19 pandemic; Chest imaging; Thoracic CT scan; Thoracic imaging.

ORIGINAL ARTICLE

Introduction : The necessity to identify and isolate COVID-19 patients to avoid intrahospital cross infections is particularly felt as a challenge. Clinically occult SARS-CoV-2 infection among patients admitted to the hospital is always considered a risk during the pandemic. The aim of our study is to describe the application of CT scan to reveal unexpected COVID-19 in patients needing hospital admission.

Méthode : In our emergency department, we prospectively enrolled adult patients needing hospital admission, without symptoms suspected of COVID-19, and showing negative reverse transcriptase-polymerase chain reaction (RT-PCR) swab test. CT scan was performed to diagnose clinically occult COVID-19 pneumonia. All the exams were read and discussed retrospectively by two expert radiologists and assigned to one of 4 exclusive diagnoses: typical (typCT), indeterminate (indCT), atypical (atyCT), negative (negCT). The clinical characteristics and final diagnoses were described and compared with the results of CT scans.

Résultats : From May 25 to August 18, 2020, we prospectively enrolled 197 patients. They showed 122 negCT, 52 atyCT, 22 indCT, and 1 typCT. Based on the CT imaging, the prevalence of suspected clinically occult COVID-19 pneumonia was 11.6% (23 patients). None had confirmation of SARS-CoV-2 infection after the hospital stay. Nineteen patients had negative serial RT-PCR while in 4 cases, the infection was excluded by clinical follow-up or appearance of positivity of RT-PCR after months.

Conclusion : Our descriptive analysis confirms that CT scan cannot be considered a valid tool to screen clinically occult COVID-19, when the asymptomatic patients need hospitalization for other conditions. Application of personnel protections and distancing among patients remains the best strategies to limit the possibility of intrahospital cross-infections.

Conclusion (proposition de traduction) : Notre analyse descriptive confirme que la tomodensitométrie ne peut pas être considérée comme un outil valable pour dépister la COVID-19 cliniquement asymptomatique, lorsque ces patients doivent être hospitalisés pour d'autres causes. L'application de protections individuelles et la distanciation entre les patients restent les meilleures stratégies pour limiter la possibilité d'infections croisées intrahospitalières.

Vascular findings in CTA body and extremity of critically ill COVID-19 patients: commonly encountered vascular complications with review of literature.
Lee EE, Gong AJ, Gawande RS, Fishman EK, Vadvala HV. | Emerg Radiol.  2022 Apr;29(2):263-279
DOI: https://doi.org/10.1007/s10140-021-02013-1  | Télécharger l'article au format  
Keywords: COVID-19; CT angiography of body and extremity; Critically ill patients; Vascular findings.

REVIEW ARTICLE

Editorial : The purpose of our review is to discuss the role of CT angiography (CTA) in evaluating a variety of vascular complications in critically ill COVID-19 patients. The COVID-19 pandemic continues to be a worldwide health threat. While COVID-19 pneumonia is the most common and well-recognized presentation of COVID-19, severely ill hospitalized patients often present with extrapulmonary systemic findings. Vascular complications occur not only due to known viral-induced vasculopathy, coagulopathy, and related "cytokine storm," but also due to anticoagulation medication used during hospitalization. There is a paucity of articles describing extrapulmonary vascular findings, especially in critically ill COVID-19 patients. In our article, we discuss commonly encountered vascular imaging findings in the body (chest, abdomen, and pelvis) and extremities, the importance of early radiological detection, and the role of CTA in the management of critically ill COVID-19 patients.

Conclusion : Vascular complications including both thromboembolism in the setting of hypercoagulability and bleeding in the setting of prophylactic anticoagulation are clinically significant concerns for critically ill COVID-19 patients. Commonly affected regions are the pulmonary artery, GI tract, kidney, hepatobiliary organs, extremity vessels, and aorta. Thus, the decision to initiate anticoagulation must be weighed against concern for bleeding risk, and patients should be carefully monitored for possible hemorrhage. It is important that all radiologists and clinicians are aware of the vascular (thromboembolic and hemorrhagic) complications on CTA body and extremity of COVID-19 patients in order to provide timely diagnosis and guide appropriate management.

Conclusion (proposition de traduction) : Les complications vasculaires, y compris la phlébite dans le cadre de l'hypercoagulabilité et les saignements dans le cadre de l'anticoagulation prophylactique, sont des préoccupations cliniques importantes pour les patients COVID-19 de réanimation. Les régions couramment touchées sont l'artère pulmonaire, le tractus gastro-intestinal, les reins, les organes hépatobiliaires, les vaisseaux des extrémités et l'aorte. Ainsi, la décision d'initier une anticoagulation doit être pesée par rapport au risque de saignement, et les patients doivent être étroitement surveillés pour une éventuelle hémorragie. Il est important que tous les radiologues et cliniciens soient conscients des complications vasculaires (thromboemboliques et hémorragiques) découverts à l'angioscanner sur le corps et les extrémités des patients COVID-19 afin de fournir un diagnostic rapide et de guider une prise en charge appropriée.

A multicenter evaluation of the accuracy of prehospital eFAST by a physician-staffed helicopter emergency medical service.
Partyka C, Coggins A, Bliss J, Burns B, Fiorentino M, Goorkiz P, Miller M. | Emerg Radiol.  2022 Apr;29(2):299-306
DOI: https://doi.org/10.1007/s10140-021-02002-4
Keywords: Emergency medical services; Focused assessment with sonography for trauma; Injury; Trauma; Ultrasonography.

Original Article

Introduction : The purpose of this study is to report the relative accuracy of prehospital extended focused assessment with sonography in trauma (eFAST) examinations performed by HEMS physicians.

Méthode : Trauma patients who received prehospital eFAST by HEMS clinicians between January 2013 and December 2017 were reviewed. The clinician's interpretations of these ultrasounds were compared to gold standard references of CT imaging or operating room findings. The outcomes measured include the calculated accuracy of eFAST for detecting intraperitoneal free fluid (IPFF), pneumothorax, hemothorax, and pericardial fluid compared to available gold standard results.

Résultats : Of the 411 patients with adequate data for comparison, the median age was 39.5 years with 73% male and 98% sustaining blunt force trauma. For the detection of IPFF, eFAST had a sensitivity of 25% (95% CI 16-36%) and specificity of 96% (95% CI 93-98%). Sensitivities and specificities were calculated for pneumothorax (38% and 96% respectively), hemothorax (17% and 97% respectively), and pericardial effusion (17% and 100% respectively). These results did not change significantly when reassessed with several sensitivity analyses.

Conclusion : Prehospital eFAST is reliable for detecting the presence of intraperitoneal free fluid. This finding should inform receiving trauma teams to prepare for early definitive care in these patients. The low sensitivities across all components of the eFAST highlight the importance of cautiously interpreting negative studies while prompting the need for further studies.

Conclusion (proposition de traduction) : L'eFAST réalisé en préhospitalier est fiable pour détecter la présence de liquide libre intrapéritonéal. Cette constatation devrait aider les équipes de traumatologie à se préparer aux soins définitifs précoces chez ces patients. La faible sensibilité de toutes les composantes de l’eFAST fait ressortir l’importance d’interpréter avec prudence les études négatives tout en suscitant la nécessité de mener d’autres études.

Commentaire : FAST et eFAST (extended focused assessement with sonography for trauma)
L’exploration du FAST s’intéresse à la cavité péritonéale, à la cavité péricardique et aux cavités pleurales à la recherche de liquide libre. Quatre vues sont généralement suffisantes : péricardique, péri- hépatique, périsplénique et pelvienne. Le eFAST ajoute l’exploration antérieure du thorax à la recherche d’un pneumothorax.

Traitement chirurgical définitif versus Damage Control

Increased relative risk of delayed hemorrhage in patients taking anticoagulant/antiplatelet medications with concurrent aspirin therapy: implications for clinical practice based on 3-year retrospective analysis in a large health system.
Chang W, Yin D, Li C, Weston B, Sohn A, Wanamaker C, Kulzer M, Tragon T, Spearman M, Eisenmenger L, Goldberg M. | Emerg Radiol.  2022 Apr;29(2):353-358
DOI: https://doi.org/10.1007/s10140-021-02003-3  | Télécharger l'article au format  
Keywords: Anticoagulation; Antiplatelet; Aspirin; Computational tomography; Cost-effectiveness; Delayed hemorrhage; Emergency department; Intracranial hemorrhage; Trauma.

ORIGINAL ARTICLE

Introduction : The incidence of delayed posttraumatic intracranial hemorrhage (DH) in patients on anticoagulant (AC) and antiplatelet (AP) medications, especially with concurrent aspirin therapy, is not well established, with studies reporting disparate results with between 1-10% risk of DH and 0-3% mortality. The purpose of this 3-year retrospective study is to evaluate the true risk of DH in patients on AP/AC medications with or without concurrent aspirin therapy.

Méthode : One thousand forty-six patients taking AP and AC medications presenting to network emergency departments with head trauma who had repeat CT to evaluate for DH were included in the study. Repeat examinations were typically performed within 24 h (average follow-up time was 21 h and 99% were within 3 days). Mean time to DH was 20 h. All positive studies were reviewed by two board-certified neuroradiologists. Patients were excluded from the study if hemorrhage was retrospectively identified on the initial examination. Cases were reclassified as negative if hemorrhage on the follow-up examination was thought to be not present or artifactual. Cases were considered positive if the initial examination was negative and the follow-up examination demonstrated new hemorrhage.

Résultats : Overall, there was 1.91% incidence (20 patients) of DH and 0.3% overall mortality (3 patients). The group of patients taking warfarin or AP agents demonstrated a significantly higher rate of DH (3.2% compared to 0.9%) and higher mortality (0.9% compared to 0.0%) compared to the DOAC group (p < 0.01). The risk of DH in patients taking AC or AP agents with aspirin (13/20 cases) was significantly higher (RR 3.8, p < 0.01) than that of patients taking AC or AP alone (7/20 cases).

Conclusion : The risk of DH was significantly higher in patients taking aspirin in addition to AC/AP medications. Repeat imaging should be obtained for trauma patients taking AC/AP agents with concurrent aspirin. The rate of DH was also significantly higher in patients taking warfarin or AP agents when compared to patients taking DOACs. Repeat examination should be strongly considered on patients taking warfarin or AP agents without aspirin. Given the relatively low risk of DH in patients taking DOACs alone, repeat imaging could be reserved for patients with external signs of trauma or dangerous mechanism of injury.

Conclusion (proposition de traduction) : Le risque d'hémorragie intracrânienne post-traumatique retardée était significativement plus élevé chez les patients prenant de l'aspirine en plus des médicaments anticoagulants/antiplaquettaires. Une imagerie répétée doit être réalisée pour les patients traumatisés prenant des traitement anticoagulants/antiplaquettaires associés à l'aspirine en même temps. Le taux d'hémorragie intracrânienne post-traumatique retardée était également significativement plus élevé chez les patients prenant de la warfarine ou des antiagrégants plaquettaires par rapport aux patients prenant des AOD. Un nouvel examen doit être fortement envisagé chez les patients prenant de la warfarine ou des antiagrégants plaquettaires sans aspirine. Compte tenu du risque relativement faible d'hémorragie intracrânienne post-traumatique retardée chez les patients prenant des AOD seuls, la répétition de l'imagerie pourrait être réservée aux patients présentant des signes externes de traumatisme ou un mécanisme de blessure dangereux.

Accidental or intentional ingestion of toothbrushes: experience with 8 adult patients.
Ghahremani GG, Richman KM. | Emerg Radiol.  2022 Apr;29(2):377-382
DOI: https://doi.org/10.1007/s10140-021-02009-x  | Télécharger l'article au format  
Keywords: Computed tomography; Gastrointestinal foreign body; Radiography; Toothbrush ingestion.

ORIGINAL ARTICLE

Introduction : Ingestion of a toothbrush is an unusual event but may occur either accident or by intent. Radiological examinations play a crucial role in determining the exact location of the object within the gastrointestinal tract and in planning for its removal by endoscopic or surgical intervention.

Méthode : Medical and radiological records of 8 patients who had swallowed the broken heads or entire toothbrush were retrospectively reviewed. This series included 4 men and 4 women, ranging in age from 21 to 57 years (mean: 34 years).

Résultats : Radiographs and computed tomography of the abdomen demonstrated the ingested toothbrushes within the stomach in 3, lodged in the duodenum in 1, and entrapped in various parts of the colon in 4 patients. They were removed by laparotomy in 3, laparoscopy in 2, colonoscopy in 2, and upper gastrointestinal endoscopy in 1 patient. There were no perforations or associated complications, and all patients had uneventful recoveries.

Conclusion : Ingested toothbrushes can be easily identified on radiological studies because of the radiopaque wires holding the nylon bristles. The plastic parts of it, however, are only visible on computed tomography. All cases would require endoscopic or surgical removal of the retained toothbrushes because spontaneous passage per rectum does not occur.

Conclusion (proposition de traduction) : Les brosses à dents ingérées peuvent être facilement identifiées lors d'études radiologiques en raison des fils radio-opaques retenant les poils en nylon. Les parties en plastique de celui-ci, cependant, ne sont visibles que sur la tomodensitométrie. Tous les cas nécessiteraient le retrait endoscopique ou chirurgical des brosses à dents retenues car il n'y a pas de passage spontané par le rectum.

European Journal of Emergency Medicine

The performance of COBRA, a decision rule to predict the need for intensive care interventions in intentional drug overdose.
Wiersma T, van den Oever HLA, van Hout FJHA, Twijnstra MJ, Mauritz GJ, van 't Riet E, Jansman FGA. | Eur J Emerg Med.  2022 Apr 1;29(2):126-133
DOI: https://doi.org/10.1097/mej.0000000000000877
Keywords: Aucun

Original Article

Introduction : COBRA was developed as a decision rule to predict which patients visiting the emergency department (ED) following intentional drug overdose will not require intensive care unit (ICU) interventions. COBRA uses parameters from five vital systems (cardiac conduction, oxygenation, blood pressure, respiration, and awareness) that are readily available in the ED. COBRA recommends against ICU admission when all these parameters are normal.
Objective: The primary aim of this study was to determine the negative predictive value (NPV) of COBRA in predicting ICU interventions. Secondary outcomes were the sensitivity, specificity and positive predictive value (PPV), and the observation time required for a reliable prediction.

Méthode : Observational cohort study.
Settings and participants: Patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function were included, and data necessary to complete the decision rule was collected. The attending physician in the ED made the actual admission decision, on the basis of clinical judgement. COBRA was measured 0, 3 and 6 h after arrival at the ED.
Outcome measures: Need for ICU interventions (treatment of convulsion; defibrillation; mechanical or noninvasive ventilation; intravenous administration of vasopressive agents, antiarrhythmics, atropine, calcium, magnesium or sedation; continuous hemofiltration or administration of antagonist/antidote and fluid resuscitation).

Résultats : Of 230 new cases (144 unique patients), 59 were immediately referred to the psychiatric services and/or sent home by the attending physician, 27 went to a regular ward, and 144 were admitted to the ICU. Of these 144 cases, 40 required one or more ICU interventions. By the time the first parameters were collected, the NPV of COBRA was 95.6%. After 3 h of observation, NPV was 100%, while sensitivity, specificity and PPV were 100, 61.1 and 35.1%, respectively. None of these values improved by prolonging the observation time to 6 h.

Conclusion : In patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function, the COBRA decision rule showed good performances in predicting the need for intensive care interventions, with a NPV of 100% after 3 h of observation.

Conclusion (proposition de traduction) : Chez les patients ayant une intoxication volontaire avec des médicaments ayant des effets aigus potentiels sur la fonction neurologique, circulatoire ou ventilatoire, la règle de décision COBRA a montré de bonnes performances pour prédire la nécessité d'une hospitalisation en soins intensifs, avec une VPN de 100 % après 3 h d'observation.

Commentaire :  Le patient peut nécessiter une hospitalisation en réanimation si, au moins un critère, est présent.

European Journal of Trauma and Emergency Surgery

How effective are different models of pelvic binders: results of a study using a Pelvic Emergency Simulator.
Schweigkofler U, Wincheringer D, Holstein J, Fritz T, Hoffmann R, Pohlemann T, Herath SC. | Eur J Trauma Emerg Surg.  2022 Apr;48(2):847-855
DOI: https://doi.org/10.1007/s00068-020-01406-0
Keywords: Pelvic binder; Pelvic emergency trainer; Pelvic ring fracture.

Original Article

Introduction : The application of pelvic binders in the preclinical and early clinical phase is advisable to avoid or treat C-problems in unstable and potential bleeding pelvic ring fractures, even if the clinical effectivity is not completely proved. The use for pathologies in the posterior pelvic ring is still debatable.
Questions/purposes: We determined if there is a difference in achievable compression in the dorsal pelvic ring depending on position and pelvic binder model. Can this effect be tested with a simplified artificial model?

Méthode : We simulated a Tile type C fracture within the established pelvic emergency trainer and measured in a test series the effectivity of reduction with a non-invasive stabilization technique using 3 different pelvic binders.

Résultats : Any therapeutic effect of a pelvic binder with compression to the posterior pelvic ring requires at first a reduction maneuver. While the compression effect in the symphysis depends only on positioning of the binder, in the posterior pelvic ring, the result varies with the used model. The achievable pressure in the SI joint with a pelvic binder is only 20-25% (33.5-47 N) compared to the C-Clamp values (156 N).

Conclusion : The use of pelvic binders for non-invasive pelvic ring stabilization, even with a posterior pathology, could be proven in a simplified fracture model. A proper fracture reduction and an adequate device positioning influence the effectiveness.

Conclusion (proposition de traduction) : L'utilisation de ceintures pelviennes pour la stabilisation non invasive de l'anneau pelvien, même avec une pathologie postérieure, a pu être prouvée dans un modèle simplifié de fracture. Une bonne réduction de la fracture et un positionnement adéquat du dispositif influencent l'efficacité.

Commentaire :  1 a Entraîneur d'urgence pelvienne avec réglage de mesure.
1 b Montage expérimental avec entraînement pelvien et ceinture pelvienne en cours d'utilisation

Reliability of capillary refill time for evaluation of tissue perfusion in simulated vascular occluded limbs.
Monteerarat Y, Limthongthang R, Laohaprasitiporn P, Vathana T. | Eur J Trauma Emerg Surg.  2022 Apr;48(2):1231-1237
DOI: https://doi.org/10.1007/s00068-020-01594-9
Keywords: Arterial occlusion; Capillary refill time; Cutoff point; Finger pulp; Reliability.

Original Article

Introduction : No standardized execution or evidence demonstrates the area of the digit giving the most accurate capillary refill time (CRT). This study investigated the reliability and validity of CRT, and the relative merits of areas where the test could be performed.

Méthode : In all, 127 healthy volunteers were assessed for normal CRT at the fingernail, lateral paronychia, and proximal and distal pulps of the index finger. The predictive validity of the CRT for the diagnosis of compromised vascular perfusion was also investigated on 24 subjects, using an inflated tourniquet. Three raters assessed interobserver reliability.

Résultats : The mean fingernail, lateral paronychia, proximal pulp, and distal pulp CRTs were 1.93, 1.78, 1.70, and 1.57 s, respectively. The tourniquet and non-tourniquet results demonstrated significant mean differences; however, the fingernail showed a subtle difference (1.22 s) compared with the proximal pulp (4.46 s). The CRT interobserver reliability was fair at the fingernail (intraclass correlation coefficient [ICC] = 0.51), but very poor in occluded limbs (ICC = 0.13). At the lateral paronychia and finger pulp, the interobserver reliability was reasonable (ICC = 0.75-0.81 [non-tourniquet] vs 0.62-0.68 [tourniquet]). In a receiver-operating characteristic curve analysis, the proximal pulp demonstrated better discrimination (area under the curve = 0.93, 95% CI 0.89-0.97, p < 0.0001); the best cutoff point was calculated to be 3 s at the proximal pulp.

Conclusion : CRT use at appropriate areas is reliable. The most dependable site is the finger pulp, and the proposed cutoff is 3 s.

Conclusion (proposition de traduction) : L'utilisation du temps de recoloration cutanée dans les zones appropriées est fiable. Le site le plus fiable est la pulpe des doigts et le seuil proposé est de 3 s.

Commentaire :  Zone de test du temps de recoloration cutanée (1 = ongle ; 2 = pli latéral de l'ongle ; 3 = pulpe proximale [site le plus fiable sur la base des résultats de l'étude présentée ici]) ; 4 = pulpe distale)

Le TRC se mesure en décubitus dorsal, sur l’index (ou le majeur ou l’annulaire), le membre supérieur au niveau du cœur. Une pression modérée est appliquée par le pouce et l’index de l’observateur durant cinq secondes avant de mesurer le temps nécessaire à la pulpe pour retrouver sa couleur initiale, trois mesures devant être moyennées. Un retard de recoloration de la peau est dû à une diminution de sa perfusion, expliquant la corrélation entre un TRC « normal », « ralenti » ou « très lent » et un choc « absent », « faible à modéré » ou « sévère ». (in: Lakhala K, Ehrmannb S, Boulainc T. Couleur et température de la peau dans l’insuffisance circulatoire aiguë. Réanimation (2009) 18, 261—266  ).

European Respiratory Journal

ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure.
Oczkowski S, Ergan B, Bos L, Chatwin M, Ferrer M, Gregoretti C, Heunks L, Frat JP, Longhini F, Nava S, Navalesi P, Ozsancak Uğurlu A, Pisani L, Renda T, Thille AW, Winck JC, Windisch W, Tonia T, Boyd J, Sotgiu G, Scala R. | Eur Respir J.  2022 Apr 14;59(4):2101574
DOI: https://doi.org/10.1183/13993003.01574-2021  | Télécharger l'article au format  
Keywords: Aucun

ERS guidelines

Introduction : High-flow nasal cannula (HFNC) has become a frequently used noninvasive form of respiratory support in acute settings; however, evidence supporting its use has only recently emerged. These guidelines provide evidence-based recommendations for the use of HFNC alongside other noninvasive forms of respiratory support in adults with acute respiratory failure (ARF).

Méthode : The European Respiratory Society task force panel included expert clinicians and methodologists in pulmonology and intensive care medicine. The task force used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methods to summarise evidence and develop clinical recommendations for the use of HFNC alongside conventional oxygen therapy (COT) and noninvasive ventilation (NIV) for the management of adults in acute settings with ARF.

Résultats : The task force developed eight conditional recommendations, suggesting the use of 1) HFNC over COT in hypoxaemic ARF; 2) HFNC over NIV in hypoxaemic ARF; 3) HFNC over COT during breaks from NIV; 4) either HFNC or COT in post-operative patients at low risk of pulmonary complications; 5) either HFNC or NIV in post-operative patients at high risk of pulmonary complications; 6) HFNC over COT in nonsurgical patients at low risk of extubation failure; 7) NIV over HFNC for patients at high risk of extubation failure unless there are relative or absolute contraindications to NIV; and 8) trialling NIV prior to use of HFNC in patients with COPD and hypercapnic ARF.

Conclusion : HFNC is a valuable intervention in adults with ARF. These conditional recommendations can assist clinicians in choosing the most appropriate form of noninvasive respiratory support to provide to patients in different acute settings.

Conclusion (proposition de traduction) : La canule nasale à haut débit d’oxygène est une intervention précieuse chez les adultes souffrant d'insuffisance respiratoire aiguë. Ces recommandations conditionnelles peuvent aider les cliniciens à choisir la forme la plus appropriée d'assistance respiratoire non invasive à fournir aux patients dans différents contextes aigus.

Intensive Care Medicine

Ten questions ICU specialists should address when managing cardiogenic acute pulmonary oedema.
Aissaoui N, Hamzaoui O, Price S. | Intensive Care Med.  2022 Apr;48(4):482-485
DOI: https://doi.org/10.1007/s00134-022-06639-8
Keywords:

What's New in Intensive Care

Editorial : Acute pulmonary oedema (APE) is one of the most com- mon causes of unscheduled hospital admissions among patients 65 years old or older, with up to half being critically ill. APE is associated with a high mortality and rate of re-hospitalisation. Whilst in-hospital mortal- ity ranges from 4 to 10%, the readmission rate for APE increases with time after discharge, ranging from 15% at 1 month to 45–50% at 6 months. One in three APE patients dies within 1 year. In this document we outline 10 key questions ICU specialists should address when managing APE.

Commentaire :  A Mécanismes pathogéniques, B caractéristiques cliniques, C prise en charge.
Traitement recommandé par la boîte verte. La boîte bleue a besoin de plus de données. Traitement de la boîte rouge qui ne doivent pas être effectuées. Pression capillaire pulmonaire PCWP, fréquence respiratoire RR, veine jugulaire JV, électrocardiogramme ECG, procalcitonine PCT, hormone thyroïdienne TSH. † Ventilation non invasive : pression positive continue (CIPAP) ou ventilation assistée par pression positive en fin d'expiration

Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review.
Hoedemaekers CWE, Westhall E, Kamps MJA, Taccone FS, Poole D, Meijer FJA, Antonelli M, Hirsch KG, Soar J, Nolan JP, Cronberg T. | Intensive Care Med.  2022 Apr;48(4):389-413
DOI: https://doi.org/10.1007/s00134-022-06618-z  | Télécharger l'article au format  
Keywords: Cardiac arrest; Clinical examination; Coma; Computed tomography; Diffusion magnetic resonance imaging; Electroencephalogram; Neuron specific enolase; Prognosis; Somatosensory evoked potentials.

Systematic Review

Introduction : To assess the ability of clinical examination, blood biomarkers, electrophysiology or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict good neurological outcome, defined as no, mild, or moderate disability (CPC 1-2 or mRS 0-3) at discharge from intensive care unit or later, in comatose adult survivors from cardiac arrest (CA).

Méthode : PubMed, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were searched. Sensitivity and specificity for good outcome were calculated for each predictor. The risk of bias was assessed using the QUIPS tool.

Résultats : A total of 37 studies were included. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. A withdrawal or localisation motor response to pain immediately or at 72-96 h after ROSC, normal blood values of neuron-specific enolase (NSE) at 24 h-72 h after ROSC, a short-latency somatosensory evoked potentials (SSEPs) N20 wave amplitude > 4 µV or a continuous background without discharges on electroencephalogram (EEG) within 72 h from ROSC, and absent diffusion restriction in the cortex or deep grey matter on MRI on days 2-7 after ROSC predicted good neurological outcome with more than 80% specificity and a sensitivity above 40% in most studies. Most studies had moderate or high risk of bias.

Conclusion : In comatose cardiac arrest survivors, clinical, biomarker, electrophysiology, and imaging studies identified patients destined to a good neurological outcome with high specificity within the first week after cardiac arrest (CA).

Conclusion (proposition de traduction) : Chez les survivants d'un arrêt cardiaque comateux, des études cliniques, de biomarqueurs, d'électrophysiologie et d'imagerie ont identifié des patients destinés à un bon résultat neurologique avec une spécificité élevée au cours de la première semaine après un arrêt cardiaque (AC).

Commentaire : Chez les patients adultes qui sont dans le coma après reprise d'activité circulatoire spontanée (RACS), les indices suivants prédisent un bon résultat neurologique (absence ou incapacité neurologique légère à modérée) avec > 80 % de spécificité et > 40 % de sensibilité dans la plupart des études :
• une réponse motrice de retrait ou de localisation à la douleur immédiatement ou 72 à 96 h après ROSC ;
• valeurs sanguines normales de l'énolase spécifique des neurones (NSE) 24 h à 72 h après ROSC ;
• une amplitude d'onde N20 de potentiels évoqués somatosensoriels à courte latence (SSEPs) > 4 μV ou un fond continu sans décharges sur l'électroencéphalogramme (EEG) dans les 72 h du ROSC ;
• absence de restriction de diffusion dans le cortex ou la matière grise profonde sur l'imagerie pondérée en diffusion (DWI) de l'imagerie par résonance magnétique cérébrale les jours 2 à 7 après RACS La plupart des études présentaient un risque modéré ou élevé de biais, principalement dû à la sélection ou à la confusion.

Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review.
Hoedemaekers CWE, Westhall E, Kamps MJA, Taccone FS, Poole D, Meijer FJA, Antonelli M, Hirsch KG, Soar J, Nolan JP, Cronberg T. | Intensive Care Med.  2022 Apr;48(4):389-413
DOI: https://doi.org/10.1007/s00134-022-06618-z  | Télécharger l'article au format  
Keywords: Cardiac arrest; Clinical examination; Coma; Computed tomography; Diffusion magnetic resonance imaging; Electroencephalogram; Neuron specific enolase; Prognosis; Somatosensory evoked potentials.

Systematic Review

Introduction : To assess the ability of clinical examination, blood biomarkers, electrophysiology or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict good neurological outcome, defined as no, mild, or moderate disability (CPC 1-2 or mRS 0-3) at discharge from intensive care unit or later, in comatose adult survivors from cardiac arrest (CA).

Méthode : PubMed, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were searched. Sensitivity and specificity for good outcome were calculated for each predictor. The risk of bias was assessed using the QUIPS tool.

Résultats : A total of 37 studies were included. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. A withdrawal or localisation motor response to pain immediately or at 72-96 h after ROSC, normal blood values of neuron-specific enolase (NSE) at 24 h-72 h after ROSC, a short-latency somatosensory evoked potentials (SSEPs) N20 wave amplitude > 4 µV or a continuous background without discharges on electroencephalogram (EEG) within 72 h from ROSC, and absent diffusion restriction in the cortex or deep grey matter on MRI on days 2-7 after ROSC predicted good neurological outcome with more than 80% specificity and a sensitivity above 40% in most studies. Most studies had moderate or high risk of bias.

Conclusion : In comatose cardiac arrest survivors, clinical, biomarker, electrophysiology, and imaging studies identified patients destined to a good neurological outcome with high specificity within the first week after cardiac arrest (CA).

Conclusion (proposition de traduction) : Chez les survivants d'un arrêt cardiaque comateux, des études cliniques, de biomarqueurs, d'électrophysiologie et d'imagerie ont identifié des patients destinés à un bon résultat neurologique avec une spécificité élevée au cours de la première semaine après un arrêt cardiaque (AC).

Commentaire : Chez les patients adultes qui sont dans le coma après reprise d'activité circulatoire spontanée (RACS), les indices suivants prédisent un bon résultat neurologique (absence ou incapacité neurologique légère à modérée) avec > 80 % de spécificité et > 40 % de sensibilité dans la plupart des études :
• une réponse motrice de retrait ou de localisation à la douleur immédiatement ou 72 à 96 h après ROSC ;
• valeurs sanguines normales de l'énolase spécifique des neurones (NSE) 24 h à 72 h après ROSC ;
• une amplitude d'onde N20 de potentiels évoqués somatosensoriels à courte latence (SSEPs) > 4 μV ou un fond continu sans décharges sur l'électroencéphalogramme (EEG) dans les 72 h du ROSC ;
• absence de restriction de diffusion dans le cortex ou la matière grise profonde sur l'imagerie pondérée en diffusion (DWI) de l'imagerie par résonance magnétique cérébrale les jours 2 à 7 après RACS.
La plupart des études présentaient un risque modéré ou élevé de biais, principalement dû à la sélection ou à la confusion.

Internal and Emergency Medicine

Overdiagnosis in the emergency department: a sharper focus.
Vigna M, Vigna C, Lang ES. | Intern Emerg Med.  2022 Apr;17(3):629-633
DOI: https://doi.org/10.1007/s11739-022-02952-8
Keywords: Ethics; Low-value care; Overdiagnosis; Overtreatment; Overuse; Shared decision-making.

IM-Point of view

Editorial : Overdiagnosis occurs when a person's symptoms or life experiences are given a diagnostic label that ultimately causes them more harm than good. We describe the complex drivers of overdiagnosis spanning five interconnected domains, which can lead to numerous negative impacts on patients. Emergency physicians are often tasked with making timely clinical assessments, decisions, and diagnoses that can unintentionally result in overdiagnosis. Three pertinent areas related to overdiagnosis in Emergency Medicine: anaphylaxis, subsegmental pulmonary embolism, and low-risk chest pain are discussed. For a broader perspective, insight on overdiagnosis from medical students and a patient advisor are presented. The perspectives illustrated are meant to spark reflection on: the ethics of labeling a person with a diagnosis, current clinical practices, the limitations of medical education, and patient care and communication in the context of overdiagnosis in the Emergency Department.

Conclusion : We believe that issues pertaining to overdiagnosis should be included in patient counselling during disposition discussions at the bedside in the ED. This may involve sending more patients back to their family physicians with diagnostic uncertainty as opposed to defaulting to additional testing and specialty referrals from the ED. These suggestions are made with the intent of reducing the harms of overdiagnosis and to highlight the importance of informed consent. It is our hope that physicians will reflect on our perspectives and use this as an opportunity to advance future research in overdiagnosis.

Conclusion (proposition de traduction) : Nous croyons que les questions relatives au surdiagnostic devraient être incluses dans le conseil aux patients lors des discussions sur la décision partagées avec le patient dans le services des urgences. Cela pourrait impliquer le retour d’un plus grand nombre de patients vers leur médecin de famille avec une incertitude diagnostique plutôt que de les soumettre à des examens supplémentaires et à des transferts vers des spécialistes consultants du service d’urgence. Ces suggestions visent à réduire les méfaits d’un surdiagnostic et à souligner l’importance du consentement éclairé. Nous espérons que les médecins réfléchiront à nos perspectives et profiteront de cette occasion pour faire progresser la recherche sur le surdiagnostic.

PaO2/FiO2 ratio forecasts COVID-19 patients’ outcome regardless of age: a cross-sectional, monocentric study.
Sinatti G, Santini SJ, Tarantino G, Picchi G, Cosimini B, Ranfone F, Casano N, Zingaropoli MA, Iapadre N, Bianconi S, Armiento A, Carducci P, Ciardi MR, Mastroianni CM, Grimaldi A, Balsano C. | Intern Emerg Med.  2022 Apr;17(3):665-673
DOI: https://doi.org/10.1007/s11739-021-02840-7  | Télécharger l'article au format  
Keywords: Atypical pneumonia; COVID-19; PaO2/FiO2 ratio; Pandemic; SARS-CoV-2.

IM - ORIGINAL

Editorial : We studied the predictive value of the PaO2/FiO2 ratio for classifying COVID-19-positive patients who will develop severe clinical outcomes. One hundred fifty patients were recruited and categorized into two distinct populations ("A" and "B"), according to the indications given by the World Health Organization. Patients belonging the population "A" presented with mild disease not requiring oxygen support, whereas population "B" presented with a severe disease needing oxygen support. The AUC curve of PaO2/FiO2 in the discovery cohort was 0.838 (95% CI 0.771-0.908). The optimal cut-off value for distinguishing population "A" from the "B" one, calculated by Youden's index, with sensitivity of 71.79% and specificity 85.25%, LR+4.866, LR-0.339, was < 274 mmHg. The AUC in the validation cohort of 170 patients overlapped the previous one, i.e., 0.826 (95% CI 0.760-0.891). PaO2/FiO2 ratio < 274 mmHg was a good predictive index test to forecast the development of a severe respiratory failure in SARS-CoV-2-infected patients. Moreover, our work highlights that PaO2/FiO2 ratio, compared to inflammatory scores (hs-CRP, NLR, PLR and LDH) indicated to be useful in clinical managements, results to be the most reliable parameter to identify patients who require closer respiratory monitoring and more aggressive supportive therapies.

Conclusion : Could our results fill existing gaps in the field that had not been previously exposed? We aimed to give to clinicians a way to discriminate SARS-CoV-2-positive patients with dif- ferent fate. We intentionally categorized our cohort in “low” (population “A”) or “high” (population “B”)-risk patients in such a way that clinicians could make decisions quickly based on local or regional conditions and opportune thera- peutic approaches. In fact, we consider of great importance the access to good clinical and supportive care for providing a more or less aggressive care whereby the patient’s out- comes might be optimized. Moreover, although the PaO2/FiO2 ratio is simple and easily available, it has a suboptimal power in categorizing patients with ARDS.

Conclusion (proposition de traduction) : Nos résultats pourraient-ils combler les lacunes existantes dans le domaine qui n'avaient pas été exposées auparavant ? Notre objectif était de donner aux cliniciens un moyen de discriminer les patients positifs au SRAS-CoV-2 avec une évolution différente. Nous avons intentionnellement classé notre cohorte en patients à risque « faible » (population « A ») ou « élevé » (population « B ») de manière à ce que les cliniciens puissent prendre des décisions rapidement en fonction des conditions locales ou régionales et des approches thérapeutiques opportunes. En fait, nous considérons comme très important l'accès à de bons soins cliniques et de soutien pour fournir des soins plus ou moins agressifs permettant d'optimiser les résultats du patient. De plus, bien que le rapport PaO2/FiO2 soit simple et facilement disponible, il a un pouvoir sous-optimal dans la catégorisation des patients présentant un SDRA.

Prognostic factors for late death in septic shock survivors: a multi-center, prospective, registry-based observational study.
Kim SM, Ryoo SM, Shin TG, Park YS, Jo YH, Lim TH, Chung SP, Choi SH, Suh GJ, Kim WY; Korean Shock Society (KoSS) Investigators. | Intern Emerg Med.  2022 Apr;17(3):865-871.
DOI: https://doi.org/10.1007/s11739-021-02847-0  | Télécharger l'article au format  
Keywords: Chronic medical disease; Long-term mortality; Post-acute period; Sepsis; Septic shock.

EM - ORIGINAL

Editorial : Septic shock patients who survive past the acute period are associated with an increased risk of long-term mortality. However, factors for predicting late death remain unclear. We aimed to investigate the prognostic factors associated with late mortality in septic shock patients with 28-day survival after admission. This retrospective observational study used a prospective, multi-center registry of septic shock patients between October 2015 and December 2019 involving 12 emergency departments (EDs) from the Korean Shock Society. Adult septic shock patients visiting the ED with 28-day survival after admission were included. Among 4624 septic shock patients, 3588 (77.6%) who survived past day 28 were analyzed. The 90-day mortality rate was 14.2%. Non-survivors were older (66.8 vs. 68.9 years; p = 0.032) and had higher lactate levels (3.7 vs. 4.0 mmol/L; p = 0.028) than survivors. Pulmonary and hepatobiliary infections and a history of malignancy (27.7 vs. 57.5%; p < 0.001) were more frequent in the non-survivor group than in the survivor group. Independent risk factors for late death on multivariate regression analysis were age; malignancy; and hemoglobin, blood urea nitrogen, and albumin levels. The length of intensive care unit stay and Sequential Organ Failure Assessment score were independently associated with late death. Approximately, one-seventh of septic shock patients who survived past day 28 of admission died by day 90. Physicians must pay attention to survivors with these risk factors during the post-acute period as they have an increased mortality risk.

Conclusion : Septic shock patients are at risk of mortality after the acute phase of the disease. This study found that among septic shock patients who survived past day 28, about one-seventh of the patients died by day 90. Physicians must pay attention to sepsis survivors during the post-acute period as they have an increased risk of mortality.

Conclusion (proposition de traduction) : Les patients en choc septique sont à risque de mortalité après la phase aiguë de la maladie. Cette étude a révélé que parmi les patients en choc septique qui ont survécu après le 28e jour, environ un septième des patients sont décédés au 90e jour. Les médecins doivent prêter attention aux survivants de la septicémie pendant la période post-aiguë car ils ont un risque accru de mortalité.

Emergency Department capacity to initiate thromboprophylaxis in patients with atrial fibrillation and thrombotic risk after discharge: URGFAICS cohort analysis.
Yuguero O, Cabello I, Arranz M, Guzman JA, Moreno A, Frances P, Santos J, Esquerrà A, Zarauza A, Mòdol JM, Jacob J. | Intern Emerg Med.  2022 Apr;17(3):873-881
DOI: https://doi.org/10.1007/s11739-021-02864-z  | Télécharger l'article au format  
Keywords: Atrial fibrillation; Emergency medicine; Stroke; Thromboprophylaxis.

EM - ORIGINAL

Editorial : Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in the general population. Stroke prevention is one of the leading management objectives in the treatment of AF patients. The variables associated with the non-initiation of thromboprophylaxis in patients with thrombotic risk consulting for an episode of AF in Emergency Departments (ED) were investigated. This was a multipurpose, analytical, non-interventionist, multicenter Spanish study with a prospective 30-day follow-up. All patients ≥ 18 years of age consulting to the ED for the casual finding of AF in an electrocardiogram (ECG) performed 12 h prior to the consultation or with symptoms related to AF were enrolled from September 1, 2016 to February 28, 2017. Patients not previously received thromboprophylaxis were selected. Multivariate analysis was performed to calculate the odds ratio (OR) and the 95% confidence interval (CI). A total of 634 patients, not received thromboprophylaxis and at high thrombotic risk, were included. Of these, 251 (39.6%) did not receive thromboprophylaxis at ED discharge. In the multivariate analysis, non-initiation of anticoagulation at discharge from the ED was mostly related to cognitive impairment (OR 3.95; (95% CI 2.02-7.72), cancer history (OR 2.12; (95%CI 1.18-3.81), AF duration < 48 h (OR 2.49; (95% CI 1.48-4.21) and patients with re-establishment of sinus rhythm (OR 3.65; (95% CI 1.47-9.06). Reinforcement of the use of CHA2DS2-VASC as a stroke risk scale and empowerment of ED physicians is a must to improve this gap in care.

Conclusion : In summary, we found that about 40% of non-anticoagulated atrial fibrillation patients with stroke risk did not received anticoagulation at ED discharge. The likelihood of not receiving anticoagulation at ED discharge was related to cognitive impairment, a history of cancer and patients in whom sinus rhythm was reestablished. These situations do not justify not initiating the anticoagulation therapy in the ED. Reinforcement of the use of CHA2DS2-VASC as a stroke risk scale and empowerment of ED physicians are necessary to improve this gap of care.

Conclusion (proposition de traduction) : En résumé, nous avons constaté qu'environ 40 % des patients présentant une fibrillation atriale non anticoagulés présentant un risque d'AVC n'avaient pas reçu d'anticoagulation à leur sortie des urgences. La probabilité de ne pas recevoir d'anticoagulation à la sortie des urgences était liée à une déficience cognitive, à des antécédents de cancer et aux patients chez qui le rythme sinusal avait été rétabli. Ces situations ne justifient pas de ne pas débuter le traitement anticoagulant aux urgences. Le renforcement de l'utilisation du CHA2DS2-VASC comme échelle de risque d'AVC et l'autonomisation des médecins des urgences sont nécessaires pour combler cette lacune dans les soins.

International Journal of Emergency Medicine

Bradykinin-induced angioedema in the emergency department.
Hébert J, Boursiquot JN, Chapdelaine H, Laramée B, Desjardins M, Gagnon R, Payette N, Lepeshkina O, Vincent M. | Int J Emerg Med.  2022 Mar 26;15(1):15
DOI: https://doi.org/10.1186/s12245-022-00408-6  | Télécharger l'article au format  
Keywords: Angioedema; Bradykinin; Emergency; Histamine.

Review

Introduction : Acute airway angioedema commonly occurs through two distinct mechanisms: histamine- and bradykinin-dependent. Although they respond to distinct treatments, these two potentially life-threatening states present similarly. Poor recognition of the bradykinin-dependent pathway leads to treatment errors in the emergency department (ED), despite the availability of multiple pharmacologic options for hereditary angioedema (HAE) and other forms of bradykinin-induced angioedema. Here, we consider the pathophysiology and clinical features of bradykinin-induced angioedema, and we present a systematic literature review exploring the effectiveness of the available therapies for managing such cases.

Méthode : PubMed searches using 'emergency', 'bradykinin' and various therapeutic product names identified studies reporting the efficacy of treatments for bradykinin-induced angioedema in the ED setting. In all, 22 studies met prespecified criteria and are analysed here.

Résultats : Whereas histamine-induced angioedema has a faster onset and often presents with urticaria, bradykinin-induced angioedema is slower in onset, with greater incidence of abdominal symptoms. Acute airway angioedema in the ED should initially be treated with anaphylactic protocols, focusing on airway management and treatment with epinephrine, antihistamine and systemic steroids. Bradykinin-induced angioedema should be considered if this standard treatment is not effective, despite proper dosing and regard of beta-adrenergic blockade. Therapeutics currently approved for HAE appear as promising options for this and other forms of bradykinin-induced angioedema encountered in the ED.

Conclusion : Diagnostic algorithms of bradykinin-induced angioedema should be followed in the ED, with early use of approved therapies to improve patient outcomes.

Conclusion (proposition de traduction) : Les algorithmes de diagnostic de l'angiœdème bradykinique idoivent être suivis au service des urgences, avec une utilisation précoce des traitements approuvées pour améliorer les résultats des patients.

Commentaire : Javaud N, F. Adnet F, Fain O. Angiœdème bradykinique et médecine d’urgence : vers une optimisation des stratégies de prise en charge. Réanimation (2016) 25:400-407  .

Journal of Intensive Care Medicine

Associations of Vasopressor Requirements With Echocardiographic Parameters After Out-of-Hospital Cardiac Arrest.
Tabi M, Burstein BJ, Anavekar NS, Kashani KB, Jentzer JC. | J Intensive Care Med.  2022 Apr;37(4):518-527
DOI: https://doi.org/10.1177/0885066621998936
Keywords: cardiac arrest; echocardiography; hemodynamics; shock; systolic dysfunction; vasopressor.

Original Research

Introduction : Post-arrest hypotension is common after out of hospital cardiac arrest (OHCA) and many patients resuscitated after OHCA will require vasopressors. We sought to determine the associations between echocardiographic parameters and vasopressor requirements in OHCA patients.

Méthode : We retrospectively analyzed adult patients with OHCA treated with targeted temperature management between December 2005 and September 2016 who underwent a transthoracic echocardiogram (TTE). Categorical variables were compared using 2-tailed Fisher's exact and Pearson's correlation coefficients and variance (r2) values were used to assess relationships between continuous variables.

Résultats : Among 217 included patients, the mean age was 62 ± 12 years, including 74% males. The arrest was witnessed in 90%, the initial rhythm was shockable in 88%, and 58% received bystander CPR. At the time of TTE, 41% of patients were receiving vasopressors; this group of patients was older, had greater severity of illness, higher inpatient mortality and left ventricular ejection fraction (LVEF) was modestly lower (36.8 ± 17.1% vs. 41.4 ± 16.4%, P = 0.04). Stroke volume, cardiac power output and left ventricular stroke work index correlated with number of vasopressors (Pearson r -0.24 to -0.34, all P < 0.002), but the correlation with LVEF was weak (Pearson r -0.13, P = 0.06).

Conclusion : In patients after OHCA, left ventricular systolic dysfunction was associated with the need for vasopressors, and Doppler TTE hemodynamic parameters had higher correlation coefficients compared with vasopressor requirements than LVEF. This emphasizes the complex nature of shock after OHCA, including pathophysiologic processes not captured by TTE assessment alone.

Conclusion (proposition de traduction) : Chez les patients après un arrêt cardiaque en dehors de l'hôpital, la dysfonction systolique ventriculaire gauche était associée au besoin de vasopresseurs, et les paramètres hémodynamiques de l'échodoppler transthoracique avaient des coefficients de corrélation plus élevés par rapport aux besoins en vasopresseurs que la fraction d'éjection ventriculaire gauche. Cela met l'accent sur la nature complexe du choc après un arrêt cardiaque en dehors de l'hôpital, y compris les processus physiopathologiques non saisis par la seule évaluation de l'échocardiogramme transthoracique.

Journal of the American Medical Association

Antiseizure Medications for Adults With Epilepsy: A Review.
Kanner AM, Bicchi MM. | JAMA.  2022 Apr 5;327(13):1269-1281
DOI: https://doi.org/10.1001/jama.2022.3880
Keywords: Aucun

Review

Introduction : Epilepsy affects approximately 65 million people worldwide. Persistent seizures are associated with a 20% to 40% risk of bodily injuries (eg, fractures, burns, concussions) over 12-month follow-up. The primary goal of epilepsy treatment is to eliminate seizures while minimizing adverse effects of antiseizure drugs (ASDs).

Méthode : An epileptic seizure is defined as a sudden occurrence of transient signs and symptoms caused by abnormal and excessive or synchronous neuronal activity in the brain. Focal and generalized epilepsy are the 2 most frequent types of epilepsy; diagnosis is based on the type of seizures. There are 26 US Food and Drug Administration-approved medications for epilepsy, of which 24 have similar antiseizure efficacy for focal epilepsy and 9 have similar efficacy for generalized epilepsy. The decision to initiate an ASD should be individualized, but should be strongly considered after 2 unprovoked seizures or after 1 unprovoked seizure that occurred during sleep and/or in the presence of epileptiform activity on an electroencephalogram and/or in the presence of a structural lesion on the brain magnetic resonance imaging. The ASDs must be selected based on the seizure and epilepsy types, the epilepsy syndrome, and the adverse effects associated with the drug. For focal epilepsy, oxcarbazepine and lamotrigine are first-line therapy, while levetiracetam can be also considered if there is no history of psychiatric disorder. For generalized epilepsy, the selection of the ASD is based on the type of epilepsy syndrome and the patient's sex, age, and psychiatric history. Seizure freedom is achieved in approximately 60% to 70% of all patients. A total of 25% to 50% of patients also experience neurologic, psychiatric, cognitive, or medical disorders, such as mood, anxiety, and attention deficit disorders and migraines. For these patients, selecting an ASD should consider the presence of these disorders and concomitant use of medications to treat them. ASDs with cytochrome P450 enzyme-inducing properties (eg, carbamazepine, phenytoin) may worsen comorbid coronary and cerebrovascular disease by causing hyperlipidemia and accelerating the metabolism of concomitant drugs used for their treatment. They can also facilitate the development of osteopenia and osteoporosis.

Conclusion : Epilepsy affects approximately 65 million people worldwide and is associated with increased rates of bodily injuries and mortality when not optimally treated. For focal and generalized epilepsy, selection of ASDs should consider the seizure and epilepsy types and epilepsy syndrome, as well as the patient's age and sex, comorbidities, and potential drug interactions.

Conclusion (proposition de traduction) : L'épilepsie touche environ 65 millions de personnes dans le monde et est associée à des taux accrus de blessures corporelles et de mortalité lorsqu'elle n'est pas traitée de manière optimale. Pour l'épilepsie focale et généralisée, la sélection des anticonvulsivants doit tenir compte des types de crises et d'épilepsie et du syndrome épileptique, ainsi que de l'âge et du sexe du patient, des comorbidités et des interactions médicamenteuses potentielles.

Pediatric Emergency Care

Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model.
Yauger YJ, Johnson MD, Mark J, Le T, Woodruff T, Silvey S, Revis J, Blouin D, O'Sullivan J, Brady K, Hensler JG, Johnson D. | Pediatr Emerg Care.  2022 Apr 1;38(4):e1166-e1172
DOI: https://doi.org/10.1097/pec.0000000000002127
Keywords: Aucun

Original article

Introduction : We compared the efficacy of tibial intraosseous (TIO) administration of epinephrine in a pediatric normovolemic versus hypovolemic cardiac arrest model to determine the incidence of return of spontaneous circulation (ROSC) and plasma epinephrine concentrations over time.

Méthode : This experimental study evaluated the pharmacokinetics of epinephrine and/or incidence of ROSC after TIO administration in either a normovolemic or hypovolemic pediatric swine model.

Résultats : All subjects in the TIO normovolemia cardiac arrest group experienced ROSC after TIO administration of epinephrine. In contrast, subjects experiencing hypovolemia and cardiac arrest were significantly less likely to experience ROSC when epinephrine was administered TIO versus intravenous (TIO hypovolemia: 14% [1/7] vs IV hypovolemia: 71% [5/7]; P = 0.031). The TIO hypovolemia group exhibited significantly lower plasma epinephrine concentrations versus IV hypovolemia at 60, 90, 120, and 150 seconds (P < 0.05). Although the maximum concentration of plasma epinephrine was similar, the TIO hypovolemia group exhibited significantly slower time to maximum concentration times versus TIO normovolemia subjects (P = 0.004).

Conclusion : Tibial intraosseous administration of epinephrine reliably facilitated ROSC among normovolemic cardiac arrest pediatric patients, which is consistent with published reports. However, TIO administration of epinephrine was ineffective in restoring ROSC among subjects experiencing hypovolemia and cardiac arrest. Tibial intraosseous-administered epinephrine during hypovolemia and cardiac arrest may have resulted in a potential sequestration of epinephrine in the tibia. Central or peripheral intravascular access attempts should not be abandoned after successful TIO placement in the resuscitation of patients experiencing concurrent hypovolemia and cardiac arrest.

Conclusion (proposition de traduction) : L'administration intraosseuse tibiale d'adrénaline a facilité de manière fiable le retour à une activité circulatoire spontanée chez les patients pédiatriques en arrêt cardiaque normovolémique, ce qui est conforme aux rapports publiés. Cependant, l'administration intra-osseuse tibiale d'adrénaline n'a pas réussi à restaurer le rretour à une activité circulatoire spontanée chez les sujets souffrant d'hypovolémie et d'arrêt cardiaque. L'adrénaline administrée par voie intraosseuse tibiale pendant l'hypovolémie et l'arrêt cardiaque peut avoir entraîné une séquestration potentielle d'adrénaline dans le tibia. Les tentatives d'accès intravasculaire central ou périphérique ne doivent pas être abandonnées après une mise en place intra-osseuse tibiale réussie dans la réanimation de patients présentant simultanément une hypovolémie et un arrêt cardiaque.

Prehospital Emergency Care

Emergency Medical Services Responder Manual Ventilation Performance.
Ni SA, Carpenter RS, Walker JR 3rd, Holley J, Brady MF. | Prehosp Emerg Care.  2022 Apr 20:1-8
DOI: https://doi.org/10.1080/10903127.2022.2066234
Keywords: Biodevice; EMS; Pulmonary; Resuscitation; Transport; Ventilation.

Article

Introduction : Manual ventilation is a basic skill that every emergency medical services (EMS) responder is expected to perform proficiently. Improper manual ventilation may result in significant morbidity; however, there is no feedback mechanism or method of control for the volume, pressure, or frequency during manual ventilation. In this study, we aimed to quantify the volume and peak pressures of manually delivered breaths using a simulated lung.

Méthode : One hundred ninety-nine volunteer EMS responders from the EMS World Expo 2019 and EMS Today 2020 participated in this study. Each volunteer manually ventilated a simulated lung using a bag-valve-mask (BVM) for 18 breaths. Descriptive statistics were computed for peak pressures (Ppeak) and tidal volumes (VT), and a multivariable linear regression was conducted to determine whether there was an independent correlation between Ppeak or VT and seven different variables.

Résultats : Both Ppeak and VT delivered by EMS responders had a high level of variability; 82.9% of clinicians delivered at least one breath exceeding the recommended safety thresholds; and 98.0% delivered at least one breath that was inadequate or excessive. Our results showed no likely clinical significant role of sex, hand size, frequency of use, or years of experience in determining Ppeak and VT. Tidal volumes were significantly higher in males (p < 0.001), those using two-hand manual ventilation (p < 0.001), shorter hand length (p = 0.013), higher confidence (p < 0.001), and more years of experience (p < 0.001). Peak pressures were significantly higher in those using two-hand manual ventilation (p < 0.001), wider hand width (p = 0.004), higher confidence (p < 0.001), less frequent use of the BVM per month (p < 0.001), more experience (p < 0.001).

Conclusion : Our study demonstrated large variability of VT and Ppeak within and, to a lesser degree, between clinicians. Of the seven variables that might have affected tidal volume or peak pressures, only the use of two hands versus one hand had a potentially clinically significant effect. Our study identifies a clear need for BVM improvement to ensure every practitioner can deliver breaths at appropriate volumes and safe pressures.

Conclusion (proposition de traduction) : Notre étude a démontré une grande variabilité de VT et Ppeak au sein et, dans une moindre mesure, entre les cliniciens. Parmi les sept variables susceptibles d'avoir affecté le volume courant ou les pics de pression, seule l'utilisation des deux mains par rapport à une main a eu un effet potentiellement significatif sur le plan clinique. Notre étude identifie un besoin clair d'amélioration de la ventilation au ballon autoremplisseur à valve unidirectionnelle pour s'assurer que chaque praticien peut délivrer des ventilations à des volumes appropriés et à des pressions sûres.

Association between Mode of Transport and Patient Outcomes in the Emergency Department following Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Study.
Sanguanwit P, Sutthisuwan K, Phattharapornjaroen P, Phontabtim M, Mankong Y. | Prehosp Emerg Care.  2022 Apr 12:1-9
DOI: https://doi.org/10.1080/10903127.2022.2058131
Keywords: Aucun

Article

Introduction : Out-of-hospital cardiac arrest (OHCA) remains a health problem worldwide, carrying a high mortality rate. Comparison of emergency department (ED) return of spontaneous circulation (ROSC) after OHCA in relation to emergency medical services (EMS) and non-EMS modes of transportation to the hospital was conducted to assess the impact points of the EMS system in Thailand.

Méthode : This retrospective observational study enrolled all OHCA patients who visited the ED of Ramathibodi Hospital, a tertiary university hospital in Bangkok, between January 1, 2008, and May 31, 2020. Patients were differentiated into EMS and non-EMS groups according to mode of transportation to the ED. Patients' characteristics and comorbidities, witnessed arrests, bystander chest compression, initial rhythm, and resuscitation treatment were documented. ED-sustained ROSC, ED survival, 30-day survival, and 30-day survival with good cerebral performance category (CPC) scores were monitored and recorded. Multivariate logistic analyses were performed to assess factors influencing clinical outcomes.

Résultats : A total of 339 patients were enrolled, 117 (34.51%) of whom were in the EMS transport group. There were no differences between the EMS and non-EMS groups in ED-sustained ROSC (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.58-1.70; P = 0.98), or ED survival (aOR, 0.99; 95% CI, 0.57-1.71; P = 0.97). There were also no differences in 30-day survival or 30-day survival with good CPC score between the two groups.

Conclusion : In our cohort data of OHCA, ED-sustained ROSC and ED survival outcomes were not superior in the EMS transportation group. Evidence to show that EMS transportation affected 30-day survival and 30-day good CPC score was also lacking. Thus, public promotion of Thailand's EMS system is advocated with a simultaneous improvement of EMS response to enhance OHCA outcomes.

Conclusion (proposition de traduction) : Dans nos données de cohorte sur les arrêts cardiaques en dehors de l'hôpital, le retour à une activité circulatoire spontanée au service des urgences et les résultats de survie au service des urgences n'étaient pas supérieurs dans le groupe de transport des services médicaux d'urgence. Il manquait également des preuves montrant que le transport des services médicaux d'urgence affectait la survie à 30 jours et le score de la catégorie de bonnes performances cérébrales à 30 jours. Ainsi, la promotion publique du système d'urgence thaïlandais est préconisée avec une amélioration simultanée de la réponse des services médicaux d'urgence pour améliorer les résultats des arrêts cardiaques en dehors de l'hôpital.

Resuscitation

Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest.
Cohen AL, Li T, Becker LB, Owens C, Singh N, Gold A, Nelson MJ, Jafari D, Haddad G, Nello AV, Rolston DM; Northwell Health Biostatistics Unit. | Resuscitation.  2022 Apr;173:156-165
DOI: https://doi.org/10.1016/j.resuscitation.2022.01.030  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Doppler ultrasound; Pulse detection.

CLINICAL PAPER

Introduction : Our primary objective was to assess the accuracy of Doppler ultrasound versus manual palpation in detecting any pulse with an arterial line waveform in cardiac arrest. Secondarily, we sought to determine whether peak systolic velocity (PSV) on Doppler ultrasound could detect a pulse with a systolic blood pressure (SBP) ≥ 60 mmHg.

Méthode : We conducted a prospective, cross-sectional, diagnostic accuracy study on a convenience sample of adult, Emergency Department (ED) cardiac arrest patients. All patients had a femoral arterial line. During a pulse check, manual pulse detection, PSV and Doppler ultrasound clips, and SBP were recorded. A receiver operator characteristic curve analysis was performed to determine the optimal cut-off of PSV associated with a SBP ≥ 60 mmHg. Accuracy of manual palpation and Doppler ultrasound for detection of any pulse and SBP ≥ 60 mmHg were compared with McNemar's test.

Résultats : 54 patients and 213 pulse checks were analysed. Doppler ultrasound demonstrated higher accuracy than manual palpation (95.3% vs. 54.0%; p < 0.001) for detection of any pulse. Correlation between PSV and SBP was strong (Spearman correlation coefficient = 0.89; p < 0.001). The optimal cut-off value of PSV associated with a SBP ≥ 60 mmHg was 20 cm/s (area under the curve = 0.975). To detect SBP ≥ 60 mmHg, accuracy of a PSV ≥ 20 cm/s was higher than manual palpation (91.4% vs. 66.2%; p < 0.001).

Conclusion : Among ED cardiac arrest patients, femoral artery Doppler ultrasound was more accurate than manual palpation for detecting any pulse. When using a PSV ≥ 20 cm/s, Doppler ultrasound was also more accurate for detecting a SBP ≥ 60 mmHg.

Conclusion (proposition de traduction) : Parmi les patients en arrêt cardiaque aux urgences, l'échodoppler de l'artère fémorale était plus précise que la palpation manuelle pour détecter tout les pouls. Lors de l'utilisation d'une vitesse systolique maximale ≥ 20 cm/s, l'échodoppler était également plus précise pour détecter une pression artérielle systolique ≥ 60 mmHg.

Long-term prognosis and causes of death among survivors after out-of-hospital cardiac arrest: A population-based longitudinal study.
Cho Y, Oh J, Shin JH, Kim BS, Park JK, Lee JH, Kim JH, Park M. | Resuscitation.  2022 Apr;173:31-38
DOI: https://doi.org/10.1016/j.resuscitation.2022.02.005
Keywords: Causes of death; Long-term mortality; Out-of-hospital cardiac arrest; Survivors.

Clinical Paper

Introduction : We aimed to identify the long-term prognosis and causes of death of out-of-hospital cardiac arrest (OHCA) survivors.

Méthode : Using claims data from the National Health Insurance Service (NHIS) database, we included 4937 OHCA patients (aged ≥ 18 years) who were hospitalized between January 2005 and December 2015 and had survived for 30 days or more. The endpoints were long-term mortality and causes of death. Subgroup analyses were performed based on whether cardiac procedures were performed, and risk factors associated with cardiac and noncardiac deaths were identified.

Résultats : We followed 4937 OHCA patients for a median of 3.3 years and up to 14 years of follow-up. The all-cause 1-, 3-, 5-, and 10-year cumulative mortality were 35.2%, 46.5%, 52.3%, and 62.7%, respectively. Regarding the 1130 OHCA survivors who had undergone cardiac procedures, the all-cause 1-, 3-, 5-, and 10-year cumulative mortality were 10.7%, 16.9%, 21.4%, and 30.6%, respectively. More patients (56.2%) died from noncardiovascular causes than from cardiovascular causes (43.8%) among the 2738 total patients who had died. The proportion of patients with cardiac death was significantly higher in the patient group with a cardiac procedure than in the group without a cardiac procedure (49.6% vs. 31.7%; P value < 0.001). A higher Charlson comorbidity index (CCI) was associated with an increased risk of cardiac mortality in the cardiac procedure group.

Conclusion : The long-term mortality among OHCA survivors remains high, particularly within the first year. Individual characteristics are crucial for the follow-up of OHCA survivors and may help improve their long-term prognosis.

Conclusion (proposition de traduction) : La mortalité à long terme chez les survivants d'un arrêt cardiaque en dehors de l'hôpital reste élevée, en particulier au cours de la première année. Les caractéristiques individuelles sont cruciales pour le suivi des survivants d'un arrêt cardiaque en dehors de l'hôpital et peuvent contribuer à améliorer leur pronostic à long terme.

The association between alcohol intake shortly before arrest and survival outcomes of out-of-hospital cardiac arrest.
Choi DH, Ro YS, Kim KH, Park JH, Jeong J, Hong KJ, Song KJ, Shin SD. | Resuscitation.  2022 Apr;173:39-46
DOI: https://doi.org/10.1016/j.resuscitation.2022.02.006
Keywords: Alcohol; Heart disease; Out-of-hospital cardiac arrest.

Clinical paper

Introduction : Alcohol intake is one of the triggers of out-of-hospital cardiac arrest (OHCA) and is associated with survival outcomes due to its relationship with cardiovascular conditions such as variant angina and arrhythmias. The aim of this study was to evaluate the association between alcohol intake shortly before cardiac arrest and survival outcomes after OHCA.

Méthode : This observational study was conducted using a nationwide OHCA registry database in Korea. All adult OHCA patients with presumed cardiac etiology from 2016 to 2019 were analyzed. The primary outcome was survival to hospital discharge. Secondary outcomes included coronary angiography (CAG), percutaneous coronary intervention (PCI), and implantable cardioverter-defibrillator (ICD) implantation. Groups with and without alcohol intake shortly before cardiac arrest were compared using propensity score matching and conditional logistic regression analysis.

Résultats : Among the study population of 83,087, 1,777 (2.1%) patients consumed alcohol shortly before OHCA. In the propensity score-matched population, the group with alcohol intake showed significantly higher odds of survival to hospital discharge compared to the group without alcohol intake (OR (95% CI): 1.33 (1.15-1.53)). The odds of receiving CAG without PCI and ICD implantation were significantly higher in the group with alcohol intake compared to the group without alcohol intake (OR (95% CI): 1.60 (1.34-1.92) and 1.74 (1.28-2.37), respectively), while the odds of receiving CAG with PCI were significantly lower (OR (95% CI): 0.75 (0.59-0.95)).

Conclusion : In OHCA patients with presumed cardiac etiology, alcohol intake shortly before arrest was associated with higher odds of survival outcomes.

Conclusion (proposition de traduction) : Dans les résultats des patients en arrêt cardiaque en dehors de l'hôpital avec une étiologie cardiaque présumée, la consommation d'alcool peu de temps avant l'arrêt cardiaque était associée à des chances plus élevées de survie.

Sex-related disparities in the in-hospital management of patients with out-of-hospital cardiac arrest.
Song J, Ahn S, Kim J, Cho H, Moon S, Choi SH, Park JH. | Resuscitation.  2022 Apr;173:47-55
DOI: https://doi.org/10.1016/j.resuscitation.2022.02.003  | Télécharger l'article au format  
Keywords: In-hospital management; Out-of-hospital cardiac arrest; Sex; Survival.

Clinical paper

Introduction : We investigated sex-related differences in the in-hospital management of patients with out-of-hospital cardiac arrest (OHCA).

Méthode : We retrospectively analyzed prospectively collected data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry, a prospective, multicenter OHCA registry. We enrolled adult patients with OHCA between October 2015 and June 2020. The primary outcomes were coronary angiography (CAG), percutaneous coronary intervention (PCI), targeted temperature management (TTM), and extracorporeal membrane oxygenation (ECMO) performed in the hospital. Propensity score matching (PSM) was performed to minimize differences in baseline demographics and characteristics.

Résultats : Among 12,321 patients in the KoCARC registry, we analyzed 8,177 with OHCA. PSM yielded 5,564 matched patients (2,782 women and men, respectively). In the unmatched cohort, women were less likely to undergo CAG, PCI, TTM, and ECMO. In the PSM cohort, women were less likely to undergo CAG and PCI (6.4% vs. 9.1%, p < 0.001 and 1.9% vs. 3.7%, p < 0.001). The duration of cardiopulmonary resuscitation was shorter in women (19 vs. 20 min, p < 0.001). TTM, ECMO use, and survival outcomes did not differ significantly between sexes. The subgroup analysis according to age showed that among patients aged < 65 years, women were less likely than men to undergo CAG and PCI (12.7% vs. 19.2%, p < 0.001 and 2.3% vs. 8.1%, p < 0.001).

Conclusion : In the PSM cohort, women with OHCA underwent CAG and PCI less frequently than men, regardless of the initial rhythm. However, these sex-related differences narrowed with increasing age. Further studies are needed to confirm the sex-related disparities in the in-hospital management of patients with OHCA.

Conclusion (proposition de traduction) : Dans la cohorte d'appariement par score de propension, les femmes ayant subi un arrêt cardiaque extra-hospitalier ont subi une coronarographie et une intervention coronarienne percutanée moins fréquemment que les hommes, quel que soit le rythme initial. Cependant, ces différences liées au sexe diminuent avec l'âge. D'autres études sont nécessaires pour confirmer les disparités liées au sexe dans la prise en charge hospitalière des patients victimes d'un arrêt cardiaque extra-hospitalier.

Very long-term survivors of in-hospital and out-of-hospital cardiac arrest show considerable impairment of daily life.
Schnaubelt S, Mayr FB, Losert H, Domanovits H, Sulzgruber P, Holzer M, Sterz F, Uray T. | Resuscitation.  2022 Apr;173:192-200
DOI: https://doi.org/10.1016/j.resuscitation.2022.01.023  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Long-term survival; Neurological outcome; Prognostication.

Clinical paper

Introduction : Reliable data on long-term outcomes after cardiac arrest (CA) remain scarce. Identifying factors persistently impacting the quality of life after CA is crucial to improve long-term outcomes.

Méthode : Adult in- and out-of-hospital CA patients surviving to hospital discharge between 1996 and 2015 were retrospectively included. We classified survivors in stages of survival time and assessed long-term survival and quality of life by contacting patients via a standardized telephone questionnaire including the modified Rankin Scale (mRS).

Résultats : Of 4,234 patients, 1,573 (37.2%) survived to hospital discharge. Among those, 693(44.1%) were alive at the time of the interview. We obtained interviews in 178 patients at a survival time of 7.8 (4.2-12.6) years. Younger age, female gender, and shorter duration of initial hospitalization and coma were associated with long-term survival. Conversely, higher median age at time of CA predicted poor outcome (mRS ≥ 3) and impaired quality of daily life. Around 25% declared being impaired in mobility, with female gender and higher age being predictors. Impairment in personal care and hygiene was stated in 11.8%, and activities of daily life such as shopping troubled 33.1%. Chronic pain impairing daily life was reported in 47.2% of cases, and lower socioeconomic status was suggestive of unfavourable outcome.

Conclusion : Very long-term survivors showed considerable impairment of quality of life in terms of reduced mobility, self-care, or chronic pain. Higher age at time of CA and lower socioeconomic status showed worse outcomes. A more personalized screening of survivors for risk factors and long-term support are suggested.

Conclusion (proposition de traduction) : Les survivants à très long terme ont montré une altération considérable de la qualité de vie en termes de mobilité réduite, de soins personnels ou de douleur chronique. Un âge plus élevé au moment de l'arrêt cardiaque et un statut socio-économique inférieur ont montré de moins bons résultats. Un dépistage plus personnalisé des survivants pour les facteurs de risque et un soutien à long terme sont suggérés.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Fluid resuscitation with balanced crystalloids versus normal saline in critically ill patients: a systematic review and meta-analysis.
Dong WH, Yan WQ, Song X, et al. | Scand J Trauma Resusc Emerg Med.  2022;30(28):1-10
DOI: https://doi.org/10.1186/s13049-022-01015-3  | Télécharger l'article au format  
Keywords: Balanced crystalloids; Saline; Intensive care unit; Meta‐analysis; Trial sequential analysis

Original research

Introduction : Intravenous fluids are used commonly for almost all intensive care unit (ICU) patients, especially for patients in need of resuscitation. The selection and use of resuscitation fluids may affect the outcomes of patients; however, the optimal resuscitative fluid remains controversial.

Méthode : We systematically searched PubMed, Embase, and CENTRAL. Studies comparing balanced crystalloids and normal saline in ICU patients were selected. We used the Cochrane Collaboration tool to assess the risk of bias in studies. The primary outcome was mortality at the longest follow-up. Secondary outcomes included the incidence of acute kidney injury (AKI) and new renal replacement therapy (RRT).

Résultats : A total of 35,456 patients from eight studies were included. There was no significant difference between balanced crystalloid solutions and saline in mortality (risk ratio [RR]: 0.96; 95% confidence interval [CI]:0.92–1.01). The subgroup analysis with traumatic brain injury (TBI) showed lower mortality in patients receiving normal saline (RR:1.25; 95% CI 1.02–1.54). However, in patients with non-TBI, balanced crystalloid solutions achieved lower mortality than normal saline (RR: 0.94; 95% CI 0.90–0.99). There was no significant difference in moderate to severe AKI (RR: 0.96; 95% CI 0.90–1.01) or new RRT (RR: 0.94; 95% CI 0.84–1.04).

Conclusion : Compared with normal saline, balanced crystalloids may not improve the outcomes of mortality, the incidence of AKI, and the use of RRT for critically ill patients. However, balanced crystalloids reduce the risk of death in patients with non-TBI but increase the risk of death in those with TBI. Large-scale rigorous randomized trials with better designs are needed, especially for specific patient populations.

Conclusion (proposition de traduction) : Par rapport à une solution cristalloïde normale, les cristalloïdes balancés peuvent ne pas améliorer les résultats de la mortalité, l'incidence des lésions rénales aiguës et l'utilisation du traitement de l'insuffisance rénale chez les patients de réanimation. Cependant, les cristalloïdes balancés réduisent le risque de décès chez les patients atteints de lésions cérébrales non traumatiques, mais augmentent le risque de décès chez ceux atteints de lésions cérébrales traumatiques. Des essais randomisés rigoureux à grande échelle avec de meilleures conceptions sont nécessaires, en particulier pour des populations de patients spécifiques.

Commentaire : Consulter la RFE commune SFAR - SFMU de 2021 :
Choix du soluté pour le remplissage vasculaire en situation critique  .

Stroke

Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns.
Minhas JS, Moullaali TJ, Rinkel GJE, Anderson CS. | Stroke.  2022 Apr;53(4):1065-1073
DOI: https://doi.org/10.1161/strokeaha.121.036139
Keywords: blood pressure; cerebral hemorrhage; hypertension; perfusion; subarachnoid hemorrhage.

Focused Updates: Blood Pressure

Editorial : Blood pressure (BP) elevations often complicate the management of intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage, the most serious forms of acute stroke. Despite consensus on potential benefits of BP lowering in the acute phase of intracerebral hemorrhage, controversies persist over the timing, mechanisms, and approaches to treatment. BP control is even more complex for subarachnoid hemorrhage, where there are rationales for both BP lowering and elevation in reducing the risks of rebleeding and delayed cerebral ischemia, respectively. Efforts to disentangle the evidence has involved detailed exploration of individual patient data from clinical trials through meta-analysis to determine strength and direction of BP change in relation to key outcomes in intracerebral hemorrhage, and which likely also apply to subarachnoid hemorrhage. A wealth of hemodynamic data provides insights into pathophysiological interrelationships of BP and cerebral blood flow. This focused update provides an overview of current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation and perfusion, to facilitate clinical practice recommendations and future research.

Conclusion : This focused update has outlined the current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation, and perfusion. We summarize several clinical research priorities in ICH and SAH (Table). Specifically, the emergence of PaCO2 change as an important modifier of response to intervention (BP lowering) and prognostic marker may allow ultra-acute data on systemic and cerebral hemodynamics in ICH to be obtained, particularly pre- and post-BP agent delivery. Given the overlap in clinical questions, pathophysiology and complications across these 2 subtypes of hemorrhagic stroke, we call for greater international and cross-disciplinary capacity-building collaborations between ICH and SAH researchers. There is potential value in further IPD meta-analyses of RCT data to understand differences in ICH associated with SAH, and vice versa, but also in using novel platform registries with nested RCTs that can address multiple research questions within a common infrastructure. Although less ideal for assessing effectiveness, the use of propensity-score matching and artificial intelligence methodologies of large prospective cohort datasets can allow an assessment of all aspects of patient management. Lastly, by considering the pathophysiological overlap between ICH and SAH, we may better understand the potential benefits of pharmacological agents in both contexts rather than isolation (eg, is there a role for nimodipine in ICH?).

Conclusion (proposition de traduction) : Cette mise à jour ciblée présente les données probantes actuelles, les lacunes dans les connaissances et les concepts émergents sur l’hémodynamique systémique, l’autorégulation cérébrale et la perfusion. Nous résumons plusieurs priorités de recherche clinique sur l’hémorragie intracérébrale et l’hémorragie sous-arachnoïdienne. Plus précisément, l’émergence de la modification de la PaCO2 en tant que modificateur important de la réponse à l’intervention (ici, baisse de la pression artérielle) et comme marqueur pronostique qui pourrait permettre d’obtenir des données ultra-aiguës sur l’hémodynamique systémique et cérébrale en cas d’hémorragie intracérébrale, particulièrement avant et après l’administration d'un antihypertenseur. Étant donné le chevauchement des questions cliniques, de la physiopathologie et des complications de ces deux sous-types d’AVC hémorragique, nous appelons les chercheurs en hémorragie intracérébrale et en hémorragie sous-arachnoïdienne à de plus grandes collaborations internationales et interdisciplinaires de renforcement des capacités entre les chercheurs. Il pourrait être utile d’effectuer d’autres méta-analyses de données individuelles sur les participants des essais contrôlés randomisés pour comprendre les différences dans l’hémorragie intracérébrale associée à l’hémorragie sous-arachnoïdienne, et vice versa, mais aussi d’utiliser de nouveaux registres de plateformes comportant des essais contrôlés randomisés imbriqués qui peuvent répondre à de multiples questions de recherche au sein d’une infrastructure commune. Bien qu’elle soit moins idéale pour évaluer l’efficacité, l’utilisation de méthodes d’appariement des scores de propension et d’intelligence artificielle de vastes ensembles de données de cohortes prospectives peut permettre d’évaluer tous les aspects de la prise en charge des patients. Enfin, en considérant le chevauchement physiopathologique entre l’hémorragie intracérébrale et l’hémorragie sous-arachnoïdienne, nous pouvons mieux comprendre les avantages potentiels des agents pharmacologiques dans les deux contextes plutôt que de manière isolée (par exemple, la nimodipine a-t-elle un rôle dans l’hémorragie intracérébrale ?).

Blood Pressure Management for Ischemic Stroke in the First 24 Hours.
Bath PM, Song L, Silva GS, Mistry E, Petersen N, Tsivgoulis G, Mazighi M, Bang OY, Sandset EC. | Stroke.  2022 Apr;53(4):1074-1084
DOI: https://doi.org/10.1161/strokeaha.121.036143
Keywords: antihypertensive agents; blood platelets; blood pressure; brain ischemia; humans.

Focused Updates: Blood Pressure

Editorial : High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality. The conundrum then arises on whether to lower BP to improve outcome or whether this will worsen cerebral perfusion due to aberrant cerebral autoregulation. A number of large trials of BP lowering have failed to change outcome whether treatment was started prehospital in the community or hospital. Hence, nuances on how to manage high BP are likely, including whether different interventions are needed for different causes, the type and timing of the drug, how quickly BP is lowered, and the collateral effects of the drug, including on cerebral perfusion and platelets. Specific scenarios are also important, including when to lower BP before, during, and after intravenous thrombolysis and endovascular therapy/thrombectomy, when it may be necessary to raise BP, and when antihypertensive drugs taken before stroke should be restarted. This narrative review addresses these and other questions. Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.

Conclusion : In summary, the management of high BP in acute ischemic stroke remains unclear. Unlike for intracerebral hemorrhage, no medium-sized or large trials in ischemic stroke have been positive, and several have been negative (as opposed to neutral). Although further large trials are ongoing, we have to prepare ourselves for the result that changing BP may have no overall benefit. However, specific subgroups of patients may need to have BP lowered (eg, before or after thrombolysis), left alone, or elevated.

Conclusion (proposition de traduction) : En résumé, la prise en charge de l'hypertension artérielle dans les AVC ischémiques aigus reste floue. Contrairement à l'hémorragie intracérébrale, aucun essai de taille moyenne ou grande sur l'AVC ischémique n'a été positif, et plusieurs ont été négatifs (par opposition à neutres). Bien que d'autres essais à grande échelle soient en cours, nous devons nous préparer au résultat selon lequel la modification de la pression artérielle pourrait n'avoir aucun avantage global. Cependant, des sous-groupes spécifiques de patients peuvent avoir besoin d'avoir une pression artérielle abaissée (par exemple, avant ou après la thrombolyse), laissée seule ou élevée.

Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage.
Qureshi AI, Huang W, Lobanova I, Chandrasekaran PN, Hanley DF, Hsu CY, Martin RH, Steiner T, Suarez JI, Yamamoto H, Toyoda K. | Stroke.  2022 Apr;53(4):1226-1234
DOI: https://doi.org/10.1161/strokeaha.121.034928
Keywords: death; diabetes; hyperglycemia; multivariate analysis; odds ratio.

Original Contribution

Introduction : We evaluated the effect of persistent hyperglycemia on outcomes in 1000 patients with intracerebral hemorrhage enrolled within 4.5 hours of symptom onset.

Méthode : We defined moderate and severe hyperglycemia based on serum glucose levels ≥140 mg/dL-<180 and ≥180 mg/dL, respectively, measured at baseline, 24, 48, and 72 hours. Persistent hyperglycemia was defined by 2 consecutive (24 hours apart) serum glucose levels. We evaluated the relationship between moderate and severe hyperglycemia and death or disability (defined by modified Rankin Scale score of 4-6) at 90 days in the overall cohort and in groups defined by preexisting diabetes.

Résultats : In the multivariate analysis, both moderate (odds ratio, 1.8 [95% CI, 1.1-2.8]) and severe (odds ratio, 1.8 [95% CI, 1.2-2.7]) hyperglycemia were associated with higher 90-day death or disability after adjusting for Glasgow Coma Scale score, hematoma volume, presence or absence of intraventricular hemorrhage, hyperlipidemia, cigarette smoking, and hypertension (no interaction between hyperglycemia and preexisting diabetes, P=0.996). Among the patients without preexisting diabetes, both moderate (odds ratio, 1.8 [95% CI, 1.0-3.2]) and severe (odds ratio, 2.0 [95% CI, 1.1-3.7]) hyperglycemia were associated with 90-day death or disability after adjusting for above mentioned potential confounders. Among the patients with preexisting diabetes, moderate and severe hyperglycemia were not associated with 90-day death or disability.

Conclusion : Persistent hyperglycemia, either moderate or severe, increased the risk of death or disability in nondiabetic patients with intracerebral hemorrhage.

Conclusion (proposition de traduction) : L'hyperglycémie persistante, modérée ou sévère, a augmenté le risque de décès ou d'invalidité chez les patients non diabétiques présentant une hémorragie intracérébrale.

The American Journal of Emergency Medicine

Dynamic changes in electrocardiographic findings between initial and follow-up electrocardiography: The role of the T/QRS ratio.
Choi Y, Lee JH. | Am J Emerg Med.  2022 Apr;54:8-14
DOI: https://doi.org/10.1016/j.ajem.2022.01.033  | Télécharger l'article au format  
Keywords: Acute coronary syndrome; Acute heart failure; Coronary angiography; Electrocardiography.

Original Contribution

Introduction : Dynamic changes in electrocardiographic findings between initial and follow-up electrocardiograms (ECGs) have rarely been studied for disease severity and differential diagnosis in non-ST elevation acute coronary syndrome. We aimed to determine whether the changes in staple variables on ECG can assist in distinguishing between neuropsychiatric or gastrointestinal disorders (mild non-ischemic disorders), heart failure, and NSTE-ACS (non-ST elevation acute coronary syndrome).

Méthode : This retrospective study enrolled 1279 patients who presented with ischemic symptoms; were diagnosed with NSTE-ACS, acute heart failure, and mild disorders; and underwent echocardiography and coronary angiography. After performing propensity matching of the ECG follow-up interval, 184 patients with symptom onset within 48 h were included and analyzed.

Résultats : As a discriminator for NSTE-ACS, the maximum change in the T/QRS ratio in two contiguous leads was superior to the maximum change in ST segment depression, T wave inversion, and ST/T ratio. ECGs of patients with NSTE-ACS and heart failure showed a tendency to increase and decrease the T/QRS ratio change, respectively. Compared with regional wall motion abnormality, the change in troponin I/h and the maximum change in ST segment depression and T-wave inversion, the most deviated T/QRS ratio change from 1 (>1.5 or < 0.5) in two contiguous leads was the most significant discriminator for disease severity and differential diagnosis (standardized β = 0.545, p < 0.001).

Conclusion : The maximum changes in the T/QRS ratio in two contiguous leads can assist in distinguishing disease severity and acute mimicking disease such as acute heart failure in patients with suspected ACS.

Conclusion (proposition de traduction) : Les variations maximales dans le rapport T/QRS de deux dérivations contiguës peuvent aider à distinguer la gravité de la maladie et mimer une maladie aiguë telle que l'insuffisance cardiaque aiguë chez les patients suspects de SCA.

Commentaire :  Le panneau A représente une modification accrue du rapport T/QRS (gauche, initial ; droite, suivi). Le panneau B représente une diminution du changement du rapport T/QRS (gauche, initial ; droite, suivi).

Chest compression release velocity: An independent determinant of end-tidal carbon dioxide in out-of-hospital cardiac arrest.
De Roos E, Vanwulpen M, Hachimi-Idrissi S. | Am J Emerg Med.  2022 Apr;54:71-75
DOI: https://doi.org/10.1016/j.ajem.2022.01.053
Keywords: Cardiopulmonary resuscitation; Chest compression release velocity; ETCO2; Out-of-hospital cardiac arrest.

Original contribution

Introduction : Chest compression (CC) depth, CC rate and ventilatory rate (VR) are known to have an impact on end-tidal carbon dioxide (ETCO2) values. Chest compression release velocity (CCRV) is increasingly acknowledged as a novel metric in cardiopulmonary resuscitation (CPR). The objective of this study was to analyze whether CCRV would have any effect on ETCO2 values.

Méthode : In out-of-hospital cardiac arrests (OHCA), effects of CC depth, CC rate, CCRV and VR on ETCO2 were analyzed through linear mixed effect models. A stratification was made on a CCRV of 300, 400 and 500 mm/s. In these categories, mean ETCO2 values were corrected for CC depth and compared through a one-way ANOVA.

Résultats : A 10 mm increase in CC depth was associated with a 1.5 mmHg increase in ETCO2 (p < 0.001), a 100 mm/s increase in CCRV with a 0.8 mmHg increase (p = 0.010) and a 5 breaths per minute increase in VR with a 2.0 mmHg decrease (p < 0.001). CC depth was strongly correlated with CCRV (Pearson's r = 0.709, p < 0.001). After adjusting for CC depth, ETCO2 was on average 6.5 mmHg higher at a CCRV of 500 than at 400 mm/s (p = 0.005) and 5.3 mmHg higher than at 300 mm/s (p = 0.033).

Conclusion : In OHCA patients, higher CCRV values resulted in higher ETCO2 values. This effect is independent of CC depth, despite the strong correlation between CCRV and CC depth.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque en dehors de l'hôpital, des valeurs de vitesse de relâchement de la compression thoracique plus élevées ont entraîné des valeurs d'ETCO2 plus élevées. Cet effet est indépendant de la profondeur de compression thoracique, malgré la forte corrélation entre la vitesse de relâchement de la compression thoracique et la profondeur de compression thoracique.

Retromolar intubation with video intubating stylet in difficult airway: A randomized crossover manikin study.
Chen YY, Lin JC, Tsai MJ, Cheng KY. | Am J Emerg Med.  2022 Apr;54:212-220.
DOI: https://doi.org/10.1016/j.ajem.2022.02.008  | Télécharger l'article au format  
Keywords: Difficult airway; First attempt success; Manikin; Retromolar; Video intubation stylet.

Original article

Introduction : Difficult airway situations, such as trismus and neck rigidity, may prohibit standard midline orotracheal intubation. An alternative route of intubation from the retromolar space using a fiberoptic scope or rigid intubation stylet has been reported. There is no study investigating the applicability of retromolar intubation using a video intubating stylet. This study comparatively analyzed difficult airway management using a video intubating stylet in the retromolar and standard midline approaches.

Méthode : A randomized crossover manikin study was conducted between January 2021 and June 2021 at a tertiary teaching hospital. Thirty-six emergency medicine residents and attending physicians were enrolled, and all participated in an educational course regarding video intubating stylet in standard midline and retromolar approaches. Then, they performed both intubation approaches in a randomized order on a manikin seven times with different airway settings each time. The duration of successful intubation, first attempt success rate, overall success rate, number of attempts, and self-reported difficulty were recorded and compared.

Résultats : Thirty-six emergency physicians were included in the study. Compared with the standard midline approach, the use of the retromolar approach significantly reduced the duration of successful intubation in difficult airway scenarios such as limited mouth opening and neck rigidity with (44.77 [28.58-63.65] vs. 120 [93.86-120] s, p < 0.001) and without tongue edema (31.5 [22.57-57.74] vs. 44.72 [36.23-65.34] s, p = 0.012). Furthermore, the retromolar approach increased the first attempt success rate in scenarios of limited mouth opening and neck rigidity with (91.67% vs. 16.67%, p < 0.001) and without (97.22% vs. 72.22%, p = 0.012) tongue edema. The self-reported difficulty was also significantly lower with the retromolar approach than with the standard approach in the above two scenarios.

Conclusion : The retromolar approach for intubation using a video intubating stylet may be a promising choice for selected patients with a combination of difficult airway features such as limited mouth opening, neck rigidity, and edematous tongue.

Conclusion (proposition de traduction) : L'abord rétromolaire pour l'intubation à l'aide d'un stylet d'intubation vidéo peut être un choix utile chez des patients présentant une combinaison de critères d'intubation difficile telles qu'une ouverture de bouche limitée, l'absence de mobilité cervicale et une macroglossie.

Commentaire : Intubation rétromolaire par fibre optique flexible   (video YouTube).
Ici, technique avec un fibroscope.

Early initiation of norepinephrine in patients with septic shock: A propensity score-based analysis.
Xu F, Zhong R, Shi S, Zeng Y, Tang Z. | Am J Emerg Med.  2022 Apr;54:287-296
DOI: https://doi.org/10.1016/j.ajem.2022.01.063  | Télécharger l'article au format  
Keywords: Norepinephrine; Propensity score; Shock septic; Survival rate; Time factors.

Original contribution

Introduction : The use of vasopressors is vital in septic shock. However, the optimal timing of treatment remains unclear. Therefore, we aimed to explore the impact of early norepinephrine initiation on the survival of patients with septic shock.

Méthode : We selected 4253 patients from the Medical Information Mart for Intensive Care IV database between 2008 and 2019. The primary outcome was 28-day mortality. Propensity score matching (PSM) was applied to minimize between-group imbalances, and a restricted mean survival time was used to quantify the beneficial impact of early norepinephrine treatment on survival. Sensitivity analyses were conducted to test the robustness of the study results in multiple cohorts.

Résultats : In the PSM cohort, 2862 patients were equally assigned to early (receiving norepinephrine within the first 3 h) and delayed (> 3 h) norepinephrine initiation groups. Patients in the early norepinephrine initiation group received significantly less fluid therapy (0 vs. 79 mL/kg), had lower 28-day mortality (30.0% vs. 37.8%), longer survival days (21.89 vs. 20.37 days), shorter duration of intensive care unit (4.9 vs. 7.2 days) and hospital stays (12.4 vs. 13.6 days), shorter duration of supportive norepinephrine and invasive mechanical ventilation, lower incidence of organ failure progression (64.4% vs. 79.2%) within 24 h after shock onset, and higher mean arterial pressure within 6 and 24 h after shock onset than patients in the delayed norepinephrine initiation group (p < 0.05).

Conclusion : Norepinephrine initiation within the first 3 h, regardless of preload dependency, was associated with longer survival time and shorter duration of supportive norepinephrine and invasive mechanical ventilation and may delay or partially reverse rapid onset organ failure.

Conclusion (proposition de traduction) : L'initiation de la noradrénaline dans les 3 premières heures, quelle que soit la pré-charge dépendance, était associée à une durée de survie plus longue et à une durée plus courte de dépendance à la noradrénaline et de ventilation mécanique invasive et peut retarder ou inverser partiellement une défaillance d'organe d'apparition rapide.

The Journal of Emergency Medicine

Results of Reduction of Dislocated Prosthetic Hips in the Emergency Department.
Blokland A, Van Den Akker V, Van Der Poort C, Somford M, Holkenborg J. | J Emerg Med.  2022 Apr;62(4):462-467
DOI: https://doi.org/10.1016/j.jemermed.2021.10.029  | Télécharger l'article au format  
Keywords: arthroplasty; emergency department; hip; procedural sedation and analgesia; reduction.

Original Contribution

Introduction : Dislocation of total hip arthroplasty (dTHA) is a commonly encountered complication in the emergency department (ED). Several studies have been conducted that describe the overall success rate after reduction in the ED, however, all were small in sample size.
Objectives: The aim of the study was to assess the success rate of reduction of dTHA by emergency physicians in the ED under procedural sedation (PSA).

Méthode : Patients who presented to the ED with a dislocated prosthetic hip were eligible for inclusion. We performed a retrospective cohort study assessing success rate. Secondary parameters included time to reduction, discharge rate from the ED, and complication rate.

Résultats : There were 305 patients analyzed. Of these, 31 were excluded due to hemi-arthroplasty and 25 because they went primarily for reduction in the operating room. In total, 249 patients were included. Of 249 attempted reductions in the ED, 230 (92%, 95% confidence interval [CI] 89-96%) were successful. Seventy-one cases (28.5%, 95% CI 22.9-34.2%) were discharged from the ED after successful reduction. Six cases (2.4%, 95% CI 0.2-2.6%) experienced complications related to PSA and three cases (1.2%, 95% CI 0.5-4.3%) experienced complications related to reduction.

Conclusion : Reduction of a dTHA can be performed safely in the ED under PSA by emergency physicians with a high rate of success.

Conclusion (proposition de traduction) : La réduction d'une luxation de prothèse totale de hanche peut être réalisée en toute sécurité dans le service des urgences sous sédation procédurale par des médecins urgentistes avec un taux de réussite élevé.

Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician.
Pelletier J, Gottlieb M, Long B, Perkins JC Jr.. | J Emerg Med.  2022 Apr;62(4):480-491
DOI: https://doi.org/10.1016/j.jemermed.2021.12.012  | Télécharger l'article au format  
Keywords: Fournier gangrene; LRINEC; necrotizing fasciitis; necrotizing soft tissue infections; pyomyositis.

Clinical Review

Introduction : Skin and soft tissue infections are common emergency department (ED) presentations. These infections cover a wide spectrum of disease, from simple cellulitis to necrotizing fasciitis. Despite the commonality, a subset of skin and soft tissue infections known as necrotizing soft tissue infections (NSTIs) can cause significant morbidity and mortality.
Objective: This review evaluates the current evidence regarding the presentation, evaluation, and management of NSTI from the ED perspective.

Discussion : NSTIs are commonly missed diagnoses. History and physical examination findings are inconsistent, and the risk factors for this high mortality disease are common amongst ED populations. Laboratory evaluation and the Laboratory Risk in Necrotizing Fasciitis (LRINEC) score is helpful but is insufficient to rule out the disease. Imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging are highly sensitive and specific, but may delay definitive management. The gold standard for diagnosis includes surgical exploration. Surgical intervention and empiric broad-spectrum antibiotic coverage are the foundations of treatment. Adjuvant therapies including hyperbaric oxygen and intravenous immunoglobulin have not yet been proven to be beneficial or to improve outcome.

Conclusion : NSTIs are associated with significant morbidity and mortality. Knowledge of the history, examination, evaluation, and management is vital for emergency clinicians.

Conclusion (proposition de traduction) : Les fasciites nécrosantes sont associées à une morbidité et une mortalité importantes. La connaissance de l'histoire, de la clinique, de l'évaluation et de la prise en charge est essentielle pour les cliniciens d'urgence.

Commentaire : Quelques articles sur le sujet :
• Prise en charge des infections cutanées bactériennes courantes. Recommandations pour la pratique clinique. HAS Février 2019  .
• Lorne E, Sinna R, Mahjoub Y. Fasciites nécrosantes. MAPAR 2016  .

Artificial Intelligence in Emergency Medicine: Benefits, Risks, and Recommendations.
Vearrier L, Derse AR, Basford JB, Larkin GL, Moskop JC. | J Emerg Med.  2022 Apr;62(4):492-499
DOI: https://doi.org/10.1016/j.jemermed.2022.01.001  | Télécharger l'article au format  
Keywords: artificial intelligence; big data; bioethics; emergency medicine; humanism; information technology; machine learning; physician-patient relations.

Computers in Emergency Medicine

Introduction : Artificial intelligence (AI) can be described as the use of computers to perform tasks that formerly required human cognition. The American Medical Association prefers the term 'augmented intelligence' over 'artificial intelligence' to emphasize the assistive role of computers in enhancing physician skills as opposed to replacing them. The integration of AI into emergency medicine, and clinical practice at large, has increased in recent years, and that trend is likely to continue.

Discussion : AI has demonstrated substantial potential benefit for physicians and patients. These benefits are transforming the therapeutic relationship from the traditional physician-patient dyad into a triadic doctor-patient-machine relationship. New AI technologies, however, require careful vetting, legal standards, patient safeguards, and provider education. Emergency physicians (EPs) should recognize the limits and risks of AI as well as its potential benefits.

Conclusion : EPs must learn to partner with, not capitulate to, AI. AI has proven to be superior to, or on a par with, certain physician skills, such as interpreting radiographs and making diagnoses based on visual cues, such as skin cancer. AI can provide cognitive assistance, but EPs must interpret AI results within the clinical context of individual patients. They must also advocate for patient confidentiality, professional liability coverage, and the essential role of specialty-trained EPs.

Conclusion (proposition de traduction) : Les urgentistes doivent apprendre à s'associer à l'intelligence artificielle, et non à capituler. L'intelligence artificielle s'est avérée supérieure ou égale à certaines compétences des médecins, telles que l'interprétation des radiographies et l'établissement de diagnostics basés sur des indices visuels, comme le cancer de la peau. L'intelligence artificielle peut fournir une assistance cognitive, mais les urgentistes doivent interpréter les résultats de l'intelligence artificielle dans le contexte clinique de chaque patient. Ils doivent également défendre la confidentialité des patients, la couverture de la responsabilité professionnelle et le rôle essentiel d'urgentistes spécialisés.

Comparison of Commercial Versus Homemade Models for Teaching Ultrasound-Guided Peripheral I.V. Placement.
Sajadi K, Crosby L, Yu M, Longenbach J, Welch KC, Cooper M. | J Emerg Med.  2022 Apr;62(4):500-507
DOI: https://doi.org/10.1016/j.jemermed.2022.01.003  | Télécharger l'article au format  
Keywords: graduate medical education; medical education; procedures; ultrasound; vascular access; venipuncture.

Education

Introduction : Various commercially available and do-it-yourself (DIY) models are used to teach emergency medicine (EM) residents and medical students ultrasound (US)-guided i.v. insertion. Expensive commercial models degrade over time, but DIY models are inexpensive, easily prepared, and readily discarded.
Objective: We tested the hypothesis that DIY models are equally effective as commercial models for teaching US-guided i.v. insertion, and using a controlled trial to subjectively evaluate how well DIY models and commercially manufactured models compare with human tissue both tactilely and sonographically.

Méthode : We tested three models for US-guided i.v. teaching-a commercially available model US training block model, a homemade tofu model, and a homemade gelatin model. All three models were compared with US-guided i.v. insertion involving human tissue. Study participants were EM residents and EM attendings experienced in US-guided i.v. placement in real patients. After practicing peripheral i.v. placement under US guidance using the three media, participants at various levels of training and experience with US-guided i.v. insertion subjectively described how each media compared tactilely and sonographically, which model was most similar to a live human overall, and which model was best for instructing learners.

Résultats : The overall score (sum of visual and sonographic scores) for the gelatin model was significantly higher than either of the other models, indicating that the gelatin model was evaluated as most approximate to the anatomy of a human compared with the other models.

Conclusion : Inexpensive homemade alternatives to commercial simulators can be realistic and effective surrogates for learning US-guided peripheral i.v.

Conclusion (proposition de traduction) : Des alternatives artisanales peu coûteuses aux simulateurs commerciaux peuvent être des substituts réalistes et efficaces pour l'apprentissage de l'intraveineuse périphérique guidée par ultrasons.

Pediatric Musculoskeletal Radiographs: Anatomy and Fractures Prone to Diagnostic Error Among Emergency Physicians.
Li W, Stimec J, Camp M, Pusic M, Herman J, Boutis K. | J Emerg Med.  2022 Apr;62(4):524-533
DOI: https://doi.org/10.1016/j.jemermed.2021.12.021  | Télécharger l'article au format  
Keywords: diagnosis; emergency; fracture; musculoskeletal; pediatric; radiographs.

Selected Topics: Emergency Radiology

Introduction :  Pediatric musculoskeletal (pMSK) radiograph interpretations are common, but the specific radiograph features at risk of incorrect diagnosis are relatively unknown. Objective: We determined the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians (EPs) reviewing pMSK radiographs.

Méthode : EPs interpreted 1850 pMSK radiographs via a web-based platform and we derived interpretation difficulty scores for each radiograph in 13 body regions using one-parameter item response theory. We compared the difficulty scores by presence or absence of a fracture and, where applicable, by fracture location and morphology; significance was adjusted for multiple comparisons. An expert panel reviewed the 65 most commonly misdiagnosed fracture-negative radiographs to identify imaging features mistaken for fractures.

Résultats : We included data from 244 EPs, which resulted in 185,653 unique interpretations. For elbow, forearm, wrist, femur, knee, and tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0.004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0.004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar fractures were more difficult to diagnose than other fracture patterns (p < 0.004 for all comparisons).

Conclusion : We identified actionable learning opportunities in pMSK radiograph interpretation for EPs.

Conclusion (proposition de traduction) : Nous avons identifié des opportunités d'apprentissage exploitables dans l'interprétation des radiographies musculo-squelettiques pédiatriques pour les urgentistes.

Balloon Tamponade for the Management of Gastrointestinal Bleeding.
Bridwell RE, Long B, Ramzy M, Gottlieb M. | J Emerg Med.  2022 Apr;62(4):545-558
DOI: https://doi.org/10.1016/j.jemermed.2021.11.004  | Télécharger l'article au format  
Keywords: Linton–Nachlas tube; Minnesota tube; Sengstaken–Blakemore tube; balloon tamponade; esophageal varices; gastrointestinal bleeding.

Techniques and Procedures

Introduction : Acute gastrointestinal bleeding is a potentially life-threatening condition that requires rapid intervention. In critically ill patients who are refractory to other therapies, balloon tamponade devices can be lifesaving. Objective: We provide a review of balloon tamponade devices for gastric and esophageal variceal bleeding for emergency clinicians.

Discussion : Balloon tamponade is intended for hemodynamically unstable patients with massive gastrointestinal bleeding and inability to perform endoscopy, failed endoscopy, delay in endoscopy, or the need to stabilize before transfer. There are 3 main tamponade devices: the Linton-Nachlas tube, the Sengstaken-Blakemore tube, and the Minnesota tube. Each tamponade device has some unique features including the number of balloons and ports. We describe the technique with pearls and pitfalls for placement.

Conclusion : It is essential for emergency physicians to be familiar with balloon tamponade for acute gastrointestinal bleeding. We review the common balloon tamponade devices, and this article is intended to serve as a resource for those interested in expanding their knowledge of balloon tamponade.

Conclusion (proposition de traduction) : Il est essentiel que les médecins urgentistes soient familiarisés avec la sonde de tamponnement œsophagien pour les saignements gastro-intestinaux aigus. Nous passons en revue les dispositifs de sonde de tamponnement courants, et cet article est destiné à servir de ressource pour ceux qui souhaitent approfondir leurs connaissances sur le tamponnement par sonde œsophagienne.

The Lancet

Safety of the oral factor XIa inhibitor asundexian compared with apixaban in patients with atrial fibrillation (PACIFIC-AF): a multicentre, randomised, double-blind, double-dummy, dose-finding phase 2 study.
Piccini JP, Caso V, Connolly SJ, Fox KAA, Oldgren J, Jones WS, Gorog DA, Durdil V, Viethen T, Neumann C, Mundl H, Patel MR; PACIFIC-AF Investigators. | Lancet.  2022 Apr 9;399(10333):1383-1390
DOI: https://doi.org/10.1016/s0140-6736(22)00456-1
Keywords: Aucun

ARTICLE

Introduction : Direct-acting oral anticoagulant use for stroke prevention in atrial fibrillation is limited by bleeding concerns. Asundexian, a novel, oral small molecule activated coagulation factor XIa (FXIa) inhibitor, might reduce thrombosis with minimal effect on haemostasis. We aimed to determine the optimal dose of asundexian and to compare the incidence of bleeding with that of apixaban in patients with atrial fibrillation.

Méthode : In this randomised, double-blind, phase 2 dose-finding study, we compared asundexian 20 mg or 50 mg once daily with apixaban 5 mg twice daily in patients aged 45 years or older with atrial fibrillation, a CHA2DS2-VASc score of at least 2 if male or at least 3 if female, and increased bleeding risk. The study was conducted at 93 sites in 14 countries, including 12 European countries, Canada, and Japan. Participants were randomly assigned (1:1:1) to a treatment group using an interactive web response system, with randomisation stratified by whether patients were receiving a direct-acting oral anticoagulant before the study start. Masking was achieved using a double-dummy design, with participants receiving both the assigned treatment and a placebo that resembled the non-assigned treatment. The primary endpoint was the composite of major or clinically relevant non-major bleeding according to International Society on Thrombosis and Haemostasis criteria, assessed in all patients who took at least one dose of study medication.

Résultats : Between Jan 30, 2020, and June 21, 2021, 862 patients were enrolled. 755 patients were randomly assigned to treatment. Two patients (assigned to asundexian 20 mg) never took any study medication, resulting in 753 patients being included in the analysis (249 received asundexian 20 mg, 254 received asundexian 50 g, and 250 received apixaban). The mean age of participants was 73·7 years (SD 8·3), 309 (41%) were women, 216 (29%) had chronic kidney disease, and mean CHA2DS2-VASc score was 3·9 (1·3). Asundexian 20 mg resulted in 81% inhibition of FXIa activity at trough concentrations and 90% inhibition at peak concentrations; asundexian 50 mg resulted in 92% inhibition at trough concentrations and 94% inhibition at peak concentrations. Ratios of incidence proportions for the primary endpoint were 0·50 (90% CI 0·14-1·68) for asundexian 20 mg (three events), 0·16 (0·01-0·99) for asundexian 50 mg (one event), and 0·33 (0·09-0·97) for pooled asundexian (four events) versus apixaban (six events). The rate of any adverse event occurring was similar in the three treatment groups: 118 (47%) with asundexian 20 mg, 120 (47%) with asundexian 50 mg, and 122 (49%) with apixaban.

Conclusion : The FXIa inhibitor asundexian at doses of 20 mg and 50 mg once daily resulted in lower rates of bleeding compared with standard dosing of apixaban, with near-complete in-vivo FXIa inhibition, in patients with atrial fibrillation.

Conclusion (proposition de traduction) : L'asundexian, inhibiteur du facteur XIa, à des doses de 20 mg et 50 mg une fois par jour, a entraîné une diminution des taux de saignement par rapport à la posologie standard d'apixaban, avec une inhibition quasi-complète du facteur XIa in vivo, chez les patients atteints de fibrillation auriculaire.

The New England Journal of Medicine

CT or Invasive Coronary Angiography in Stable Chest Pain.
DISCHARGE Trial Group, Maurovich-Horvat P, Bosserdt M and al.. | N Engl J Med.  2022 Apr 28;386(17):1591-1602
DOI: https://doi.org/10.1056/nejmoa2200963
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.

Méthode : We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.

Résultats : Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).

Conclusion : Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy.

Conclusion (proposition de traduction) : Parmi les patients référés pour une coronarographie invasive en raison de douleurs thoraciques stables et d'une probabilité pré-test intermédiaire de coronaropathie, le risque d'événements cardiovasculaires indésirables majeurs était similaire dans le groupe tomodensitométrie et dans le groupe coronarographie invasive. La fréquence des complications majeures liées à la procédure était plus faible avec une stratégie initiale de tomodensitométrie.

World Journal of Emergency Medicine

Treatment of hyperkalemic emergencies.
Wu Y, Fu YY, Zhu HD, Xu J, Walline JH. | World J Emerg Med.  2022;13(3):232-236
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2022.054  | Télécharger l'article au format  
Keywords: Aucun

Viewpoint

Editorial : Hyperkalemic emergency (HE) refers to life-threatening hyperkalemia consisting of a high serum potassium level with severe complications (e.g., dysrhythmias, cardiac arrest, or myopathy). Hyperkalemic emergencies (HEs) are commonly encountered (2%–3%) in the emergency department (ED). In-hospital mortality rate for hospitalized hyperkalemic patients is about 14.1% and 4.5 times higher than that of those with normal potassium. Quick recognition and treatment are critical for decreasing morbidity and mortality. Nevertheless, great variety and sparse evidence lie in current HE treatment. In this article, we will review the current medical literature on the treatment of HEs and propose a treatment flowchart for HEs.

Conclusion : Timely treatment can avoid life-threatening complications of hyperkalemia. However, treatment of hyperkalemia in the ED is highly variable, and no agreed flowchart exists because prospective, randomized controlled trials are minimal. Nevertheless, there is widespread agreement on three approaches to treatment: cardiac myocyte protection, shifting serum potassium intracellularly, and removing potassium from the body. Systematic treatment with frequent monitoring and evaluation according to the proposed flowchart might help ED clinicians make quick and reasonable decisions and improve outcomes.

Conclusion (proposition de traduction) : Un traitement rapide peut éviter les complications potentiellement mortelles de l'hyperkaliémie. Cependant, le traitement de l'hyperkaliémie aux urgences est très variable et il n'existe aucun organigramme convenu car les essais contrôlés randomisés prospectifs sont minimes. Néanmoins, il existe un large consensus sur trois approches de traitement : la protection des myocytes cardiaques, le transfert intracellulaire du potassium sérique et l'élimination du potassium de l'organisme. Un traitement systématique avec une surveillance et une évaluation fréquentes selon l'organigramme proposé pourrait aider les urgentistes à prendre des décisions rapides et raisonnables et à améliorer les résultats.

Commentaire :  Un organigramme pour le traitement des urgences hyperkaliémiques.
ECG : électrocardiogramme ; POC : point d'intervention ; K+ : potassium ; IV : intraveineux ; SZC : cyclosilicate de zirconium sodique (Lokelma®, on utilise plutôt le sulfonate de polystyrène sodique - Kayexalate® - en france).

Proposition de VIDAL Recos   (mise à jour : 11 mars 2022)


Mois d'avril 2022