Bibliographie de Médecine d'Urgence

Mois de mai 2022


Academic Emergency Medicine

Predictive accuracy of adding shock index to the American College of Surgeons' minimum criteria for full trauma team activation.
McCormick T, Haukoos J, Hopkins E, Trent S, Adelgais K, Platnick B, Cohen M. | Acad Emerg Med. 2022 May;29(5):561-571
DOI: https://doi.org/10.1111/acem.14459
Keywords: hospital triage; shock index; trauma team activation; trauma triage; triage criteria.

ORIGINAL CONTRIBUTION

Introduction : The American College of Surgeons requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS-6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity.

Méthode : We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h).

Résultats : A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS-6 alone for EOPI were 86% (95% confidence interval [CI] = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome.

Conclusion : The addition of SI to the ACS-6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under- and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need.

Conclusion (proposition de traduction) : L'ajout du "Shock Index" à l'ACS-6 pour l'activation de l'équipe de traumatologie a augmenté la sensibilité pour l'intervention procédurale opératoire d'urgence avec une plus grande diminution de la spécificité à tous les seuils. L'inclusion d'un seuil du "Shock Index" de ≥ 0,9 correspond étroitement aux repères de sous-triage et de sur-triage dans cette cohorte du registre des traumatismes en utilisant une définition stricte du besoin d'activation de l'équipe de traumatologie.

Commentaire : Le shock index (SI) est défini par le quotient (Fréquence Cardiaque)/(Pression Artérielle Systolique).
Un shock index ≥1 à une valeur pronostique chez le traumatisé sévère, facteur prédictif de transfusion en cas d'hémorragie...

Prehospital airway management for out-of-hospital cardiac arrest: A nationwide multicenter study from the KoCARC registry.
Chang H, Jeong D, Park JE, Kim T, Lee GT, Yoon H, Hwang SY, Cha WC, Shin TG, Sim MS, Jo IJ, Lee SH, Shin SD, Choi JH. | Acad Emerg Med. 2022 May;29(5):581-588
DOI: https://doi.org/10.1111/acem.14443
Keywords: advanced airway management; neurologically favorable survival; out-of-hospital cardiac arrest.

Original contribution

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

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

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

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

Conclusion (proposition de traduction) : Dans cette analyse des données du monde réel à l'échelle nationale sur l'arrêt cardiaque en dehors de l'hôpital, la survie neurologiquement favorable à 30 jours ne différait pas entre la gestion avancée des voies respiratoires supérieures en préhospitalier et la ventilation au BAVU après ajustement pour les caractéristiques cliniques.

Anesthesia & Analgesia

A Decision Tree Approach to Airway Management Pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists.
Rosenblatt WH, Yanez ND. | Anesth Analg. 2022 May 1;134(5):910-915
DOI: https://doi.org/10.1213/ane.0000000000005930  | Télécharger l'article au format  
Keywords: Aucun

Special Article

Editorial : The American Society of Anesthesiologists' (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist's choice of pathway in the ASA's Difficult Airway Algorithm. The tool prompts the anesthesiologist to consider the risk of difficulty with laryngoscopy (direct or indirect) and tracheal intubation, facemask or supraglottic ventilation, gastric contents aspiration, and rapid oxyhemoglobin desaturation. For every airway management event, the approach integrates the anesthesiologist's unique combination of experience, expertise, patient anatomy and disease, equipment availability, and other contextual conditions into the decision process. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation. The decision tree tool is anticipated to improve communication between anesthesiologists and others by clearly identifying those factors of concern and how decision-making is affected by those concerns.

Conclusion : The choice of awake intubation versus airway management after the induction of general anesthesia has been a fundamental element of the ASA Difficult Airway Algorithm since its inception, and deserves strategic guidance. The decision tree tool integrates the most basic elements of airway decision-making: clinical context, the patient’s history, physical examination, and assessment of ease of tracheal intubation, likely success of ventilation via facemask or supraglottic airway, aspiration risk, tolerance of prolonged apnea, and patient cooperation—all answered within the experience, capabilities, and resources of the singular anesthesiologist.
The call for a decision tree tool is twofold: to aid the anesthesiologist and other practitioners in understanding the process of airway management risk assessment and to assist them in plainly articulating their judgment process. This tool allows the anesthesiologist to use their subjective assessments of patient factors and contextual conditions to objectively guide decision-making in airway management.

Conclusion (proposition de traduction) : Le choix entre l'intubation à l’état éveillé et la prise en charge des voies aériennes après l'induction de l'anesthésie générale est un élément fondamental de l'algorithme des voies aériennes difficiles de l'ASA depuis sa création et mérite une orientation stratégique. L'outil de l'arbre de décision intègre les éléments les plus fondamentaux de la prise de décision en matière de voies aériennes : le contexte clinique, les antécédents du patient, l'examen clinique et l'évaluation de la facilité d'intubation trachéale, le succès probable de la ventilation par masque facial ou par voie supraglottique, le risque d'inhalation, la tolérance d'une apnée prolongée et la coopération du patient - tous ces éléments sont traités dans le cadre de l'expérience, des capacités et des ressources de l'anesthésiste.
La demande d'un outil d'arbre de décision est double : aider l'anesthésiste et les autres praticiens à comprendre le processus d'évaluation des risques liés à la gestion des voies aériennes et les aider à articuler clairement leur processus de jugement. Cet outil permet à l'anesthésiste d'utiliser ses évaluations subjectives des facteurs liés au patient et des conditions contextuelles pour guider objectivement la prise de décision dans la gestion des voies aériennes.

Commentaire :  Partie 1 des directives 2022 de pratique de l'American Society of Anesthesiologists pour la gestion des voies aériennes difficiles - Infographie pour adultes.

Anesthesiology

Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis.
Reale SC, Bauer ME, Klumpner TT, Aziz MF, Fields KG, Hurwitz R, Saad M, Kheterpal S, Bateman BT; Multicenter Perioperative Outcomes Group Collaborators. | Anesthesiology. 2022 May 1;136(5):697-708
DOI: https://doi.org/10.1097/aln.0000000000004173  | Télécharger l'article au format  
Keywords: Aucun

Perioperative Medicine: Clinical Science

Introduction : Estimates for the incidence of difficult intubation in the obstetric population vary widely, although previous studies reporting rates of difficult intubation in obstetrics are older and limited by smaller samples. The goals of this study were to provide a contemporary estimate of the frequency of difficult and failed intubation in women undergoing general anesthesia for cesarean delivery and to elucidate risk factors for difficult intubation in women undergoing general anesthesia for cesarean delivery.

Méthode : This is a multicenter, retrospective cohort study utilizing the Multicenter Perioperative Outcomes Group database. The study population included women aged 15 to 44 yr undergoing general anesthesia for cesarean delivery between 2004 and 2019 at 1 of 45 medical centers. Coprimary outcomes included the frequencies of difficult and failed intubation. Difficult intubation was defined as Cormack-Lehane view of 3 or greater, three or more intubation attempts, rescue fiberoptic intubation, rescue supraglottic airway, or surgical airway. Failed intubation was defined as any attempt at intubation without successful endotracheal tube placement. The rates of difficult and failed intubation were assessed. Several patient demographic, anatomical, and obstetric factors were evaluated for potential associations with difficult intubation.

Résultats : This study identified 14,748 cases of cesarean delivery performed under general anesthesia. There were 295 cases of difficult intubation, with a frequency of 1:49 (95% CI, 1:55 to 1:44; n = 14,531). There were 18 cases of failed intubation, with a frequency of 1:808 (95% CI, 1:1,276 to 1:511; n = 14,537). Factors with the highest point estimates for the odds of difficult intubation included increased body mass index, Mallampati score III or IV, small hyoid-to-mentum distance, limited jaw protrusion, limited mouth opening, and cervical spine limitations.

Conclusion : In this large, multicenter, contemporary study of more than 14,000 general anesthetics for cesarean delivery, an overall risk of difficult intubation of 1:49 and a risk of failed intubation of 1:808 were observed. Most risk factors for difficult intubation were nonobstetric in nature. These data demonstrate that difficult intubation in obstetrics remains an ongoing concern.

Conclusion (proposition de traduction) : Dans cette vaste étude contemporaine, multicentrique, portant sur plus de 14 000 anesthésies générales pour des accouchements par césarienne, on a observé un risque global d'intubation difficile de 1:49 et un risque d'intubation impossible de 1:808. La plupart des facteurs de risque d'intubation difficile étaient de nature non obstétricale. Ces données montrent que l'intubation difficile en obstétrique reste une préoccupation constante.

Ketamine Psychedelic and Antinociceptive Effects Are Connected.
Olofsen E, Kamp J, Henthorn TK, van Velzen M, Niesters M, Sarton E, Dahan A. | Anesthesiology. 2022 May 1;136(5):792-801
DOI: https://doi.org/10.1097/aln.0000000000004176  | Télécharger l'article au format  
Keywords: Aucun

Pain Medicine: Clinical Science

Introduction : Ketamine produces potent analgesia combined with psyche- delic effects. It has been suggested that these two effects are associated and possibly that analgesia is generated by ketamine-induced dissociation. The authors performed a post hoc analysis of previously published data to quantify the pharmacodynamic properties of ketamine-induced antinociception and psychedelic symptoms. The hypothesis was that ketamine pharmacodynamics (i.e., concentration–effect relationship as well as effect onset and offset times) are not different for these two endpoints.

Méthode : Seventeen healthy male volunteers received escalating doses of S- and racemic ketamine on separate occasions. Before, during, and after ketamine infusion, changes in external perception were measured together with pain pressure threshold. A population pharmacokinetic– pharmacodynamic analysis was performed that took S- and R-ketamine and S- and R-norketamine plasma concentrations into account.

Résultats : The pharmacodynamics of S-ketamine did not differ for antinoci- ception and external perception with potency parameter (median [95% CI]) C50, 0.51 (0.38 to 0.66) nmol/ml; blood-effect site equilibration half-life, 8.3 [5.1 to 13.0] min), irrespective of administration form (racemic ketamine or S-ketamine). R-ketamine did not contribute to either endpoint. For both end- points, S-norketamine had a small antagonistic effect.

Conclusion : The authors conclude that their data support an association or connectivity between ketamine analgesia and dissociation. Given the intri- cacies of the study related to the pain model, measurement of dissociation, and complex modeling of the combination of ketamine and norketamine, it is the opinion of the authors that further studies are needed to detect functional connectivity between brain areas that produce the different ketamine effects.

Conclusion (proposition de traduction) : Les auteurs concluent que leurs données soutiennent une association ou une connectivité entre l'analgésie de la kétamine et la dissociation. Étant donné les subtilités de l'étude liées au modèle de douleur, à la mesure de la dissociation et à la modélisation complexe de la combinaison de la kétamine et de la norkétamine, les auteurs estiment que d'autres études sont nécessaires pour détecter la connectivité fonctionnelle entre les zones du cerveau qui produisent les différents effets de la kétamine.

Annales Françaises de Médecine d'urgence

Trauma and Temperature.
Lapostolle F, Savary D. | Ann Fr Med Urgence . 2022 Mai:12(3):152-8
DOI: https://doi.org/10.3166/afmu-2022-0401
Keywords: Trauma; Temperature; Hypothermia; Perfusion; Warming; Hemostasis

Update

Editorial : Le patient traumatisé est exposé à l’hypothermie. La mortalité des traumatisés hypothermes est multipliée par quatre ou cinq. Les interactions de l’hypothermie avec l’hé- mostase et le système cardiovasculaire sont délétères. Les effets sur la coagulation sont multiples et concourent directement à la surmortalité faisant de l’hypothermie une composante majeure de la « triade létale ». Les causes d’hy- pothermie chez le patient traumatisé sont multiples : 1) envi- ronnementales, le risque augmente quand la température ambiante diminue ; 2) cliniques, le risque augmente avec la gravité ; et aussi 3) thérapeutiques, par exemple par la perfu- sion de solutés à température ambiante. Une prise en charge optimale repose sur une mesure précoce et un monitorage continu de la température corporelle. L’objectif thérapeu- tique est de maintenir une température corporelle au moins égale à 36 °C. Limiter le déshabillage du patient, le protéger du froid avec une couverture de survie, l’installer rapidement dans une ambulance chauffée, recourir à des dispositifs de réchauffement actifs, perfuser des solutés réchauffés sont les éléments fondamentaux de la prise en charge d’un patient traumatisé, potentiellement hypotherme.

Conclusion (proposition de traduction) : La façon dont une prise en charge invasive de la température peut, d’une part, limiter l’incidence de l’hypothermie et, d’autre part, améliorer le pronostic des patients demeure incertaine. Une étude préhospitalière française a comparé une prise en charge invasive (monitorage continu de la température, protection thermique par couverture, installation précoce du patient dans une UMH chauffée à 37 °C et réchauffement des solutés) à une prise en charge conventionnelle. Ses résultats seront prochainement publiés, permettant de proposer une stratégie de prévention et de prise en charge de l’hypothermie solidement validée. d’hypothermie chez le patient traumatisé sont multiples, environnementales, cliniques et aussi thérapeutiques. Une prise en charge optimale repose sur une mesure précoce et un monitorage de la température corporelle. L’objectif est de maintenir une température corporelle au moins égale à 36 °C.

Quality in Physician-Led Dispatch: Criteria and Evaluation.
Reuter PG, Marx T, Heidet M, Peschanski N, Penverne Y; Membres du groupe régulation de la SFMU. | Ann Fr Med Urgence . 2022 Mai;12(3):159-64
DOI: https://doi.org/10.3166/afmu-2022-0402
Keywords: Emergency medical communication centre; Quality; Evaluation; Access to health care service

Update

Editorial : Les Samu Centre 15 sont soumis à une politique de qualité qui répond à une approche transversale prenant en considération le patient, le professionnel et l’établissement de santé. La démarche qualité assure à chaque patient de pouvoir accéder à une plateforme de communication en tout point du territoire et d’obtenir pour toutes demandes de soins urgents ou non programmés une réponse juste et adaptée. Pour les professionnels des Samu Centres 15, la qualité en régulation appelle à améliorer puis sécuriser les pratiques dans un contexte de sollicitation constamment croissante depuis ces dernières années. Il s’agit également de garantir des conditions de travail optimales pour les intervenants et de contribuer ainsi à une réponse de qualité. Cette démarche s’intègre également dans la certification par la Haute Autorité de santé des établissements de santé et rentre dans le concept d’hôpitaux « magnétiques » pour allier résultats sanitaires performants et conditions de travail bienveillantes pour les soignants. La stratégie d’amélioration continue de la qualité doit s’appuyer sur des travaux de recherche appliquée à la régulation médicale qu’il convient de développer. S’inspirer des méthodes utilisées dans d’autres systèmes de traitement des appels d’urgence et intégrer de nouveaux outils au sein des Samu Centres 15 pourraient contribuer à atteindre cet objectif de qualité.

Conclusion (proposition de traduction) : L’amélioration de la qualité en régulation médicale est un objectif incontournable pour les Samu Centres 15. Il est capital de s’appuyer sur son évaluation via la recherche. Les travaux déjà menés doivent être considérés pour définir (et faire valoir) les orientations à prendre comme une plus grande souplesse dans la gestion managériale du plateau de régulation. Une adéquation optimale d’ARM en poste permettrait l’amélioration de l’accessibilité de la population en temps normal ou en cas d’afflux d’appels, la possibilité d’organiser de la formation continue et de mettre en place des procédures de qualité. L’amélioration de la performance des Samu Centres 15 doit conduire à une plus grande satisfaction des usagers, ainsi qu’à l’amélioration des conditions de travail des professionnels. Les futurs projets d’évaluation se doivent d’être réalisés à grande échelle et le groupe de régulation de la SFMU sera une aide à leur réalisation. La stratégie d’amélioration de la qualité en régulation en France pourrait s’appuyer sur les critères utilisés dans les systèmes étrangers. La revue de la littérature sur les critères utilisés outre nos frontières est, entre autres, une des missions du groupe.

Annals of Intensive Care

Timing of vasoactive agents and corticosteroid initiation in septic shock.
Ammar MA, Ammar AA, Wieruszewski PM, Bissell BD, T Long M, Albert L, Khanna AK, Sacha GL. | Ann Intensive Care. 2022 May 30;12(1):47
DOI: https://doi.org/10.1186/s13613-022-01021-9  | Télécharger l'article au format  
Keywords: Angiotensin II; Catecholamines; Corticosteroids; Resuscitation fluids; Sepsis; Septic shock; Vasoactive agents; Vasopressin.

Review

Editorial : Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommend early fluid resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive therapies and corticosteroids in patients who develop shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these therapies in relation to shock onset, sequence of treatments with regard to each other, and clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of shock onset is associated with lower mortality. Following norepinephrine initiation, the exact dose and timing of escalation to adjunctive vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive therapies, such as corticosteroids. Norepinephrine-equivalent dose and lactate concentration can aid in determining when to initiate vasopressin and angiotensin II in patients with septic shock. Future guidelines with clear recommendations on the time of initiation of septic shock therapies are warranted.

Conclusion : Clinicians should consider the addition of epinephrine in patients with a cardiogenic component to their shock state when doses of other vasopressors have been optimized and should not significantly delay initiation of epinephrine. Randomized controlled trials evaluating the use of corticosteroids included septic shock patients who received corticosteroids at a norepinephrine-equivalent dose of 0.5–1 mcg/ kg/min within at least 24 h from shock onset. Simplified guidelines with clear recommendations, reflecting realworld applicability, and based on well-designed studies are warranted.

Conclusion (proposition de traduction) : Les cliniciens doivent envisager l'ajout d'épinéphrine chez les patients dont l'état de choc présente une composante cardiogénique lorsque les doses des autres vasopresseurs ont été optimisées et ne doivent pas retarder de manière significative l'initiation de l'épinéphrine. Les essais contrôlés randomisés évaluant l'utilisation des corticostéroïdes ont inclus des patients en choc septique qui ont reçu des corticostéroïdes à une dose équivalente à la norépinéphrine de 0,5-1 mcg/ kg/min dans un délai d'au moins 24 heures après le début du choc. Des directives simplifiées avec des recommandations claires, reflétant l'applicabilité dans le monde réel et basées sur des études bien conçues sont justifiées.

Prediction of fluid responsiveness. What's new?.
Monnet X, Shi R, Teboul JL. | Ann Intensive Care. 2022 May 28;12(1):46
DOI: https://doi.org/10.1186/s13613-022-01022-8  | Télécharger l'article au format  
Keywords: Cardiac output; Fluid balance; Fluid challenge; Passive leg raising; Tidal volume; Volume expansion

Review

Editorial : Although the administration of fluid is the first treatment considered in almost all cases of circulatory failure, this therapeutic option poses two essential problems: the increase in cardiac output induced by a bolus of fluid is inconstant, and the deleterious effects of fluid overload are now clearly demonstrated. This is why many tests and indices have been developed to detect preload dependence and predict fluid responsiveness. In this review, we take stock of the data published in the field over the past three years. Regarding the passive leg raising test, we detail the different stroke volume surrogates that have recently been described to measure its effects using minimally invasive and easily accessible methods. We review the limits of the test, especially in patients with intra-abdominal hypertension. Regarding the end-expiratory occlusion test, we also present recent investigations that have sought to measure its effects without an invasive measurement of cardiac output. Although the limits of interpretation of the respiratory variation of pulse pressure and of the diameter of the vena cava during mechanical ventilation are now well known, several recent studies have shown how changes in pulse pressure variation itself during other tests reflect simultaneous changes in cardiac output, allowing these tests to be carried out without its direct measurement. This is particularly the case during the tidal volume challenge, a relatively recent test whose reliability is increasingly well established. The mini-fluid challenge has the advantage of being easy to perform, but it requires direct measurement of cardiac output, like the classic fluid challenge. Initially described with echocardiography, recent studies have investigated other means of judging its effects. We highlight the problem of their precision, which is necessary to evidence small changes in cardiac output. Finally, we point out other tests that have appeared more recently, such as the Trendelenburg manoeuvre, a potentially interesting alternative for patients in the prone position.

Conclusion : The most recent studies in the prediction of fluid responsiveness have primarily described means of measuring the effects of well-established preload responsiveness tests, such as the PLR test, the EEO test and the minifluid challenge. In particular, methods replacing invasive and costly measurements of cardiac output have been described. In addition, the limits of these tests have been better defined. Some recent studies have also developed and validated new tests, the best validated of which is the Vt challenge, which has the advantage of being assessed with no direct estimation of cardiac output. There is now some evidence that in the peri-operative period the use of a therapeutic strategy adapting fluid resuscitation to the detection of preload responsiveness reduces post-operative complications. In non-surgical critically ill patients, such as septic shock patients, few outcome studies have been performed, suggesting a reduction in the amount of administered fluid.

Conclusion (proposition de traduction) : Les études les plus récentes sur la prédiction de la réponse au remplissage ont principalement décrit des moyens de mesurer les effets de tests de réactivité à la précharge bien établis, tels que le test d'élévation passive des jambes, le test d'occlusion en fin d'expiration et le test de provocation à une remplissage minimal. En particulier, des méthodes remplaçant les mesures invasives et coûteuses du débit cardiaque ont été décrites. En outre, les limites de ces tests ont été mieux définies. Certaines études récentes ont également développé et validé de nouveaux tests, dont le mieux validé est le total volume challenge, qui a l'avantage d'être évalué sans estimation directe du débit cardiaque. Il existe maintenant des preuves que dans la période péri-opératoire, l'utilisation d'une stratégie thérapeutique adaptant la réanimation liquidienne à la détection de la réactivité de la précharge réduit les complications post-opératoires. Chez les patients non chirurgicaux gravement malades, comme les patients en choc septique, peu d'études de résultats ont été réalisées, suggérant une réduction de la quantité de liquide administrée.

Archives of Academic Emergency Medicine

Orthopedic Trauma During Pregnancy; a Narrative Review.
Jafari Kafiabadi M, Sabaghzadeh A, Khabiri SS, Sadighi M, Mehrvar A, Biglari F, Ebrahimpour A. | Arch Acad Emerg Med [Internet]. 2022 May 18;10(1):e39
DOI: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1573  | Télécharger l'article au format  
Keywords: Orthopedic Procedures; Wounds and Injuries; Pregnancy

REV I EWART I C L E

Introduction : Blunt traumas, like road accidents and falls, are common causes of injuries to pregnant women,and the major risk factors are young age and low socioeconomic level. Due to physiological and anatomicalchanges specific to pregnancy, such as changes in blood pressure and hemoglobin drop, trauma managementinvolves certain complexities. Physical trauma is estimated to cause at least 1 complication in every 12 pregnan-cies. This study aims to evaluate orthopedic trauma during pregnancy and appreciate the different approachesto circumvent the resultant challenges.

Méthode : We reviewed 55 articles, published on orthopedic traumaduring pregnancy between 2011 and 2021. The articles were identified by searching PubMed, google-scholar,Scopus, and Science-Direct. We utilized the search terms: fall in pregnancy, traumas in pregnancy, motor vehi-cle accident/crash in pregnancy, blunt trauma in pregnancy, pregnant trauma patient, penetrating injury dur-ing pregnancy, assault, interpersonal violence in pregnancy, and mortality and pregnancy.

Résultats : Accordingto available reports, after stabilizing the pregnant patient, diagnostic procedures, including radiography, andeven gadolinium-based techniques when needed, can be performed to examine extensive trauma. In contrastto elective orthopedic surgery, emergency orthopedic surgeries, including reduction of open fractures, shouldbe performed promptly.

Conclusion : Based on our investigation, pregnant women with orthopedic injuriesthat are severe, or even seemingly less severe, experience significantly increased adverse pregnancy outcomes,which include preterm birth, placental abruption, poor infant condition at birth, infant death, and even mater-nal death.

Conclusion (proposition de traduction) : D'après notre enquête, les femmes enceintes souffrant de lésions orthopédiques graves, ou même apparemment moins graves, connaissent une augmentation significative des issues de grossesse défavorables, notamment la naissance prématurée, le décollement placentaire, le mauvais état du nourrisson à la naissance, le décès du nourrisson et même le décès de la mère.

BMC Emergency Medicine

Association between prehospital shock index variation and 28-day mortality among patients with septic shock.
Jouffroy R, Gilbert B, Thomas L, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. | BMC Emerg Med. 2022 May 19;22(1):87
DOI: https://doi.org/10.1186/s12873-022-00645-1  | Télécharger l'article au format  
Keywords: Mortality; Prehospital setting; Septic shock; Shock index; Variation.

RESEARCH

Introduction : Septic shock (SS) hyperdynamic phase is characterized by tachycardia and low-blood pressure reflecting the relative hypovolemia. Shock index (SI), the ratio between heart rate and systolic blood pressure, is a simple objective tool, usable for SS prognosis assessment. This study aims to evaluate the relationship between prehospital SI variation and 28-day mortality of SS patients initially cared for in prehospital setting by a mobile intensive care unit (mICU).

Méthode : From April 6th, 2016 to December 31st, 2020, 406 patients with SS requiring prehospital mICU were retrospectively analyzed. Initial SI, i.e. first measurement after mICU arrival to the scene, and final SI, i.e. last measurement of the prehospital stage, were used to calculate delta SI (initial SI-final SI) and to define positive and negative delta SI. A survival analysis after propensity score matching compared the 28-day mortality of SS patients with positive/negative delta SI.

Résultats : The main suspected origins of infection were pulmonary (42%), digestive (25%) and urinary (17%). The 28-day overall mortality reached 29%. Cox regression analysis revealed a significant association between 28-day mortality and delta SI. A negative delta SI was associated with an increase in mortality (adjusted hazard ratio (HRa) of 1.88 [1.07-3.31] (p = 0.03)), whereas a positive delta SI was associated with a mortality decrease (HRa = 0.53 [0.30-0.94] (p < 10-3)).

Conclusion : Prehospital hemodynamic delta SI among SS patients cared for by a mICU is associated with 28-day mortality. A negative prehospital delta SI could help physicians to identify SS with higher risk of 28-day mortality.

Conclusion (proposition de traduction) : Le delta hémodynamique du "Shock Index" préhospitalier chez les patients en choc septique pris en charge par une unité mobile de soins intensifs (SMUR) est associé à la mortalité à 28 jours. Le delta négatif du "Shock Index" préhospitalier pourrait aider les médecins à identifier le choc septique avec un risque plus élevé de mortalité à 28 jours.

How effective are chest compressions when wearing mask? A randomised simulation study among first-year health care students during the COVID-19 pandemic.
Bánfai B, Musch J, Betlehem J, Sánta E, Horváth B, Németh D, Bánfai-Csonka H. | BMC Emerg Med. 2022 May 8;22(1):82
DOI: https://doi.org/10.1186/s12873-022-00636-2  | Télécharger l'article au format  
Keywords: COVID-19; Chest compressions; Fatigue; Health care students; Simulation; Wearing mask.

RESEARCH ARTICLE

Introduction : The resuscitation guidelines provided for the COVID-19 pandemic strongly recommended wearing personal protective equipment. The current study aimed to evaluate and compare the effectiveness of chest compressions and the level of fatigue while wearing two different types of mask (surgical vs. cloth).

Méthode : A randomized, non-inferiority, simulation study was conducted. Participants were randomised into two groups: surgical mask group (n = 108) and cloth mask group (n = 108). The effectiveness (depth and rate) of chest compressions was measured within a 2-min continuous chest-compression-only CPR session. Data were collected through an AMBU CPR Software, a questionnaire, recording vital parameters, and using Borg-scale related to fatigue (before and after the simulation). For further analysis the 2-min session was segmented into 30-s intervals.

Résultats : Two hundred sixteen first-year health care students participated in our study. No significant difference was measured between the surgical mask and cloth mask groups in chest compression depth (44.49 ± 10.03 mm vs. 45.77 ± 10.77 mm), rate (113.34 ± 17.76/min vs. 111.23 ± 17.51/min), and the level of fatigue (5.72 ± 1.69 vs. 5.56 ± 1.67) (p > 0.05 in every cases). Significant decrease was found in chest compression depth between the first 30-s interval and the second, third, and fourth intervals (p < 0.01).

Conclusion : The effectiveness of chest compressions (depth and rate) was non-inferior when wearing cloth mask compared to wearing surgical mask. However, the effectiveness of chest compressions decreased significantly in both groups during the 2-min chest-compression-only CPR session and did not reach the appropriate chest compression depth range recommended by the ERC.

Conclusion (proposition de traduction) : L'efficacité des compressions thoraciques (profondeur et fréquence) était non inférieure lors du port d'un masque en tissu par rapport au port d'un masque chirurgical. Cependant, l'efficacité des compressions thoraciques a diminué de manière significative dans les deux groupes au cours de la séance de RCP de 2 minutes avec compression thoracique uniquement et n'a pas atteint la plage de profondeur de compression thoracique appropriée recommandée par l'ERC.

Adequacy of compression positioning using the feedback device during chest compressions by medical staff in a simulation study.
Koyama Y, Matsuyama T, Kaino T, Hoshino T, Nakao J, Shimojo N, Inoue Y. | BMC Emerg Med. 2022 May 6;22(1):76
DOI: https://doi.org/10.1186/s12873-022-00640-6  | Télécharger l'article au format  
Keywords: Adequate position for chest compressions; Chest compressions; Feedback device; Flexible pressure sensor; Hypothenar side.

RESEARCH

Introduction : The 2020 American Heart Association guidelines recommend the use of a feedback device during chest compressions (CCs). However, these devices are only placed visually by medical personnel on the lower half of the sternum and do not provide feedback on the adequacy of the pressure-delivery position. In this study, we investigated whether medical staff could deliver CCs at the adequate compression position using a feedback device and identified where the inadequate position was compressed.

Méthode : This simulation-based, prospective single-centre study enrolled 44 medical personnel who were assigned to four different groups based on the standing position and the hand in contact with the feedback device as follows: right-left (R-l), right-right (R-r), left-right (L-r), and left-left (L-l), respectively. The sensor position where the maximal average pressure was applied during CCs using the feedback device were ascertained with a flexible capacitive pressure sensor. We determined if this position is the adequate compression position or not. The intergroup differences in the frequency of the adequate compression position, the maximal average pressure, compression rate, depth and recoil were determined.

Résultats : The frequencies of adequate compression positioning were 55, 50, 58, and 60% in the R-l, R-r, L-r, and L-l groups, respectively, with no significant intergroup difference (p = 0.917). Inadequate position occurred in the front, back, hypothenar and thenar sides. The maximal average pressure did not significantly differ among the groups (p = 0.0781). The average compression rate was 100-110 compressions/min in each group, the average depth was 5-6 cm, and the average recoil was 0.1 cm, with no significant intergroup differences (p = 0.0882, 0.9653, and 0.2757, respectively).

Conclusion : We found that only approximately half of the medical staff could deliver CCs using the feedback device at an adequate compression position and the inadequate position occurred in all sides. Resuscitation courses should be designed to educate trainees about the proper placement during CCs using a feedback device while also evaluating the correct compression position.

Conclusion (proposition de traduction) : Nous avons constaté qu'environ la moitié seulement du personnel médical pouvait effectuer des compressions thoraciques à l'aide du dispositif de rétroaction dans une position de compression adéquate et que la position inadéquate se produisait de tous les côtés. Les cours de réanimation doivent être conçus pour éduquer les stagiaires sur le placement approprié pendant les compressions thoraciques à l'aide d'un dispositif de rétroaction tout en évaluant la position de compression correcte.

Burns

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial.
Tapking C, Hundeshagen G, Kirchner M, Fischer S, Kneser U, Bliesener B. | Burns. 2022 May;48(3):522-528
DOI: https://doi.org/10.1016/j.burns.2022.03.002  | Télécharger l'article au format  
Keywords: Blood loss; Blood transfusion; Burns; Tranexamic acid.

Research article

Introduction : Early excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.

Méthode : Patients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.

Résultats : Twenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).

Conclusion : This study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.

Conclusion (proposition de traduction) : Cette étude montre que la nécessité de transfusions sanguines dans la chirurgie des grands brûlés peut être réduite de manière significative par l'administration d'acide tranexamique en périopératoire. Des essais contrôlés randomisés sont nécessaires pour prouver ces résultats.

Differences by age in the obesity paradox in severe burns.
Lin JC, Zheng JJ, Wu GH, Chen ZH, Chen XD, Jiang Q. | Burns. 2022 May;48(3):547-554
DOI: https://doi.org/10.1016/j.burns.2022.02.004  | Télécharger l'article au format  
Keywords: BMI; Burn; Obesity paradox; The elderly.

Research article

Introduction : Many studies show a "obesity paradox", which seems to protect against death. Whether an obesity paradox space is present in severe burn patients remains a matter of great debate. Most research on the obesity paradox of burn injuries is classified by body mass index (BMI) rather than by age.
Objective: To investigate whether the obesity paradox exists in severe burn patients stratified by age.

Méthode : Retrospective analysis was performed on 490 patients with severe burns who were ≥ 18 years of age and were admitted to Fujian Medical University Union Hospital from January 2005 to December 2020. Demographic and clinical characteristics were collected, including age, BMI, total body surface area (TBSA), presence of inhalation injury, abbreviated burn severity index (ABSI) score, diabetes comorbidities, hypertension comorbidities, and in-hospital mortality. The patients were divided into the younger group (18 ≤ age<65 years) and the older group (age ≥ 65 years). The important variables of the two groups were compared. The predictive value of BMI stratified by age on in-hospital mortality was evaluated by binary logistic regression analysis and the Cochran's and Mantel-Haenszel statistics.

Résultats : A total of 490 patients were selected for this study, and were divided into the younger group (413) and the elderly group (77) according to their ages. In the younger group, logistic regression analyses indicated that high BMI remained significantly and independently associated with decreased in-hospital mortality (P = 0.021). That is, in-hospital mortality decreased by 17.8% when BMI increased by 1 kg/m2. In the older group, BMI was not associated with in-hospital mortality (P = 0.808). In the younger group, the results of Pearson's chi-square test was less than 0.05, indicating a correlation between BMI and prognosis. In the older group, the conclusion was contrary with, no correlation between BMI and prognosis. If the confounding factors of age were not considered, this results in no correlation between BMI and prognosis. In the younger group, the survival/death ratio of patients with overweight and obesity was 2.078 times that of patients with normal weight.

Conclusion : In this study of patients with severe burns, overweight and obesity had protective effect on burn injury in the younger group (18 ≤ age<65 years), but not in the older group (age ≥ 65 years). Investigating the obesity paradox in burn patients needs to consider age differences. However, multicentre clinical trials are needed to verify the results.

Conclusion (proposition de traduction) : Dans cette étude portant sur des patients gravement brûlés, le surpoids et l'obésité ont eu un effet protecteur sur les brûlures dans le groupe plus jeune (18 ans ≤ âge < 65 ans), mais pas dans le groupe plus âgé (âge ≥ 65 ans). L'étude du paradoxe de l'obésité chez les patients brûlés doit tenir compte des différences d'âge. Cependant, des essais cliniques multicentriques sont nécessaires pour vérifier les résultats.

Chest

Off-Label Use and Inappropriate Dosing of Direct Oral Anticoagulants in Cardiopulmonary Disease.
Hussein AA, Alvarez P, Reed G, Heresi GA. | Chest. 2022 May;161(5):1360-1369
DOI: https://doi.org/10.1016/j.chest.2022.01.033
Keywords: direct oral anticoagulant; off-label use; thromboembolism.

CHEST Reviews

Editorial : Direct oral anticoagulants (DOACs) are increasingly used in clinical practice and have become essential in the management of atrial fibrillation and VTE. The enthusiasm for DOACs has fueled the off-label application of these agents in cardiopulmonary disease, and their use has often outpaced the evidence supporting their application. This article reviews the evidence and current off-label use of DOACs in various cardiopulmonary disease states.

Conclusion : DOACs have become a cornerstone in the management of atrial fibrillation and VTE. Justified enthusiasm for DOACs, based on data from large clinical trials, has fueled the off-label application of these agents in cardiopulmonary disease. Even though the use of DOACs in clinical practice has often outpaced the evidence supporting their application, further investigations may support a stronger role for DOACs in various cardiopulmonary disease states.

Conclusion (proposition de traduction) : Les AOD sont devenus une pierre angulaire de la prise en charge de la fibrillation atriale et de la thrombophlébite veineuse. L'enthousiasme justifié pour les AOD, basé sur les données de grands essais cliniques, a alimenté l'utilisation hors AMM de ces médicaments dans les maladies cardio-pulmonaires. Même si l'utilisation des AOD dans la pratique clinique a souvent dépassé les preuves à l'appui de leur application, d'autres recherches pourraient soutenir un rôle plus important des AOD dans divers états de maladies cardiopulmonaires.

The Frequency, Risk Factors, and Management of Complications From Pleural Procedures.
Sundaralingam A, Bedawi EO, Harriss EK, Munavvar M, Rahman NM. | Chest. 2022 May;161(5):1407-1425
DOI: https://doi.org/10.1016/j.chest.2021.11.031
Keywords: complications; indwelling pleural catheter; intercostal drain; local anesthetic thoracoscopy; pleural procedures; safety; thoracocentesis.

Review article

Editorial : Pleural disease is a common presentation and spans a heterogeneous population across broad disease entities; a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. This narrative review was based on a structured search of the literature. Searches were limited to 2010 onward, in recognition of the transformation in procedural complications following the mainstream use of thoracic ultrasound. Procedures of interest were limited to thoracocentesis, intercostal drains, indwelling pleural catheters (IPCs), and local anesthetic thoracoscopy. A total of 4,308 studies were screened, and 48 studies were identified for inclusion. Iatrogenic pneumothorax remains the most common complication following thoracocentesis (3.3%; 95% CI, 3.2-3.4), although pneumothorax requiring intervention was rare (0.3%; 95% CI, 0.2-0.4) when the procedure was ultrasound guided. Drain blockage and displacement were the most common complications following intercostal drain insertion (6.3% and 6.8%, respectively). IPC-related infections can be a significant problem (5.8%; 95% CI, 5.1-6.7). However, most cases can be managed without removal of the IPC. Local anesthetic thoracoscopy has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodologic problems, and novel methods to study this topic should be considered. Although complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events to ensure high quality and, above all, safe care.

Conclusion : Through a combination of retrospective and prospective, observational, and interventional studies, we have attempted to provide an answer to some of the most common questions surrounding the risks associated with pleural interventions, steps to mitigate these risks, and managing subsequent complications. Although complications are rare, once encountered, they have the potential to rapidly escalate and lead to lifethreatening situations, if not recognized early or acted upon swiftly. Therefore, it is of paramount importance for operators to prepare and have in place plans for such events to ensure high quality and, above all, safe care.

Conclusion (proposition de traduction) : Grâce à une combinaison d'études rétrospectives et prospectives, observationnelles et interventionnelles, nous avons tenté de fournir une réponse à certaines des questions les plus courantes concernant les risques associés aux interventions pleurales, les étapes pour atténuer ces risques et la gestion des complications ultérieures. Bien que les complications soient rares, une fois rencontrées, elles ont le potentiel de s'aggraver rapidement et de conduire à des situations potentiellement mortelles, si elles ne sont pas détectées tôt ou si elles ne sont pas traitées rapidement. Par conséquent, il est d'une importance primordiale pour les opérateurs de préparer et de mettre en place des plans pour de tels événements afin d'assurer des soins de haute qualité et, surtout, sûrs.

Critical Care

Termination-of-resuscitation rule in the emergency department for patients with refractory out-of-hospital cardiac arrest: a nationwide, population-based observational study.
Goto Y, Funada A, Maeda T, Goto Y. | Crit Care. 2022 May 16;26(1):137
DOI: https://doi.org/10.1186/s13054-022-03999-x  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Emergency department; Epidemiology; Out-of-hospital cardiac arrest; Outcome; Termination-of-resuscitation rule.

Research

Introduction : In Japan, emergency medical service (EMS) providers are prohibited from field termination-of-resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA) patients. In 2013, we developed a TOR rule for emergency department physicians (Goto's TOR rule) immediately after hospital arrival. However, this rule is subject to flaws, and there is a need for revision owing to its relatively low specificity for predicting mortality compared with other TOR rules in the emergency department. Therefore, this study aimed to develop and validate a modified Goto's TOR rule by considering prehospital EMS cardiopulmonary resuscitation (CPR) duration.

Méthode : We analysed the records of 465,657 adult patients with OHCA from the All-Japan Utstein registry from 2016 to 2019 and divided them into two groups: development (n = 231,363) and validation (n = 234,294). The primary outcome measures were specificity, false-positive rate (FPR), and positive predictive value (PPV) of the revised TOR rule in the emergency department for predicting 1-month mortality.

Résultats : Recursive partitioning analysis for the development group in predicting 1-month mortality revealed that a modified Goto's TOR rule could be defined if patients with OHCA met the following four criteria: (1) initial asystole, (2) unwitnessed arrest by any laypersons, (3) EMS-CPR duration > 20 min, and (4) no prehospital return of spontaneous circulation (ROSC). The specificity, FPR, and PPV of the rule for predicting 1-month mortality were 99.2% (95% confidence interval [CI], 99.0-99.4%), 0.8% (0.6-1.0%), and 99.8% (99.8-99.9%), respectively. The proportion of patients who fulfilled the rule and the area under the receiver operating curve (AUC) was 27.5% (95% CI 27.3-27.7%) and 0.904 (0.902-0.905), respectively. In the validation group, the specificity, FPR, PPV, proportion of patients who met the rule, and AUC were 99.1% (95% CI 98.9-99.2%), 0.9% (0.8-1.1%), 99.8% (99.8-99.8%), 27.8% (27.6-28.0%), and 0.889 (0.887-0.891), respectively.

Conclusion : The modified Goto's TOR rule (which includes the following four criteria: initial asystole, unwitnessed arrest, EMS-CPR duration > 20 min, and no prehospital ROSC) with a > 99% predictor of 1-month mortality is a reliable tool for physicians treating refractory OHCAs immediately after hospital arrival.

Conclusion (proposition de traduction) : La règle modifiée d'arrêt de la réanimation pour les médecins des services d'urgence (qui comprend les quatre critères suivants : asystolie initiale, arrêt sans témoin, durée de la RCP par le service médical d'urgence > 20 minutes, et pas de retour de la circulation spontanée avant l'hospitalisation) avec un facteur prédictif de mortalité à un mois > 99 % est un outil fiable pour les médecins qui traitent les arrêts cardiaques réfractaires en dehors de l'hôpital immédiatement après l'arrivée à l'hôpital.

Critical Care Medicine

Coronavirus Disease 2019 and Out-of-Hospital Cardiac Arrest: No Survivors.
Baert V, Beuscart JB, Recher M, Javaudin F, Hugenschmitt D, Bony T, Revaux F, Mansouri N, Larcher F, Chazard E, Hubert H; French National OHCA Registry (RéAC) Study Group. | Crit Care Med. 2022 May 1;50(5):791-798
DOI: https://doi.org/10.1097/ccm.0000000000005374  | Télécharger l'article au format  
Keywords: Aucun

Clinical Investigation

Introduction : To describe and compare survival among patients with out-of-hospital cardiac arrest as a function of their status for coronavirus disease 2019.
Design: We performed an observational study of out-of-hospital cardiac arrest patients between March 2020 and December 2020. Coronavirus disease 2019 status (confirmed, suspected, or negative) was defined according to the World Health Organization's criteria.

Méthode : Information on the patients and their care was extracted from the French national out-of-hospital cardiac arrest registry. The French prehospital emergency medical system has two tiers: the fire department intervenes rapidly to provide basic life support, and mobile ICUs provide advanced life support. The study data (including each patient's coronavirus disease 2019 status) were collected by 95 mobile ICUs throughout France.
Patients: We included 6,624 out-of-hospital cardiac arrest patients: 127 cases with confirmed coronavirus disease 2019, 473 with suspected coronavirus disease 2019, and 6,024 negative for coronavirus disease 2019.
Interventions: None.

Résultats : The "confirmed" and "suspected" groups of coronavirus disease 2019 patients had similar characteristics and were more likely to have suffered an out-of-hospital cardiac arrest with a respiratory cause (confirmed: 53.7%, suspected coronavirus disease 2019: 56.5%; p = 0.472) than noncoronavirus disease 2019 patients (14.0%; p < 0.001 vs confirmed coronavirus disease 2019 patients). Advanced life support was initiated for 57.5% of the confirmed coronavirus disease 2019 patients, compared with 64.5% of the suspected coronavirus disease 2019 patients (p = 0.149) and 70.6% of the noncoronavirus disease 2019 ones (p = 0.002). The survival rate at 30-day postout-of-hospital cardiac arrest was 0% in the confirmed coronavirus disease 2019 group, 0.9% in the suspected coronavirus disease 2019 group (p = 0.583 vs confirmed), and 3.5% (p = 0.023) in the noncoronavirus disease 2019 group.

Conclusion : Our results highlighted a zero survival rate in out-of-hospital cardiac arrest patients with confirmed coronavirus disease 2019. This finding raises important questions with regard to the futility of resuscitation for coronavirus disease 2019 patients and the management of the associated risks.

Conclusion (proposition de traduction) : Nos résultats ont mis en évidence un taux de survie nul chez les patients victimes d'un arrêt cardiaque extrahospitalier avec une maladie à Covid-19 confirmée. Ce résultat soulève des questions importantes quant à l'inutilité de la réanimation des patients atteints de la maladie à Covid-19 et à la gestion des risques associés.

Emergency Medicine Australasia

Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation in the emergency department: A systematic review..
Tessarolo E, Alkhouri H, Lelos N, Sarrami P, McCarthy S. | Emerg Med Australas. 2022 May 16
DOI: https://doi.org/10.1111/1742-6723.13993  | Télécharger l'article au format  
Keywords: airway management; airway maneuvers; cricoid pressure; emergency department; sellick manoeuvre.

Review article

Introduction : The use of cricoid pressure (CP) to prevent aspiration during rapid sequence induction (RSI) has become controversial, although CP is considered central to the practice of RSI. There is insufficient research to support its efficacy in reducing aspiration, and emerging concerns it reduces the first-pass success (FPS) of intubation.

Méthode : his systematic review aims to assess the safety and efficacy of CP during RSI in EDs by investigating its effect on FPS and the incidence of complications, including gastric regurgitation and aspiration. A systematic review of four databases was performed for all primary research investigating CP during RSI in EDs. The primary outcome was FPS; secondary outcomes included complications such as gastric regurgitation, aspiration, hypoxia, hypotension and oesophageal intubation.

Résultats : After screening 4208 citations, three studies were included: one randomised controlled trial (n = 54) investigating the incidence of aspiration during the application of CP and two registry studies (n = 3710) comparing the rate of FPS of RSI with and without CP.

Conclusion : The results of these individual studies are not sufficient to draw concrete conclusions but do suggest that aspiration occurs regardless of the application of CP, and that FPS is not reduced by the application of CP. There is insufficient evidence to conclude whether applying CP during RSI in EDs affects the rate of FPS or the incidence of complications such as aspiration. Further research in the ED, including introducing CP usage into other existing airway registries, is needed.

Conclusion (proposition de traduction) : Les résultats de ces études individuelles ne sont pas suffisants pour tirer des conclusions concrètes, mais suggèrent que l'inhalation se produit indépendamment de l'application de la pression cricoïde, et que le succès du premier essai n'est pas réduit par l'application de la pression cricoïde. Il n'y a pas suffisamment de preuves pour conclure si l'application d'une pression cricoïdienne pendant l'induction à séquence rapide dans les services d'urgence affecte le taux de réussite du premier essai ou l'incidence de complications telles que l'inhalation. Des recherches plus approfondies au service des urgences, y compris l'introduction de l'utilisation de la pression cricoïde dans d'autres registres des voies respiratoires existants, sont nécessaires.

Emergency Medicine Clinics of North America

Metabolic Acidosis: Differentiating the Causes in the Poisoned Patient.
Judge BS | Emerg Med Clin N Am. 2022 May;40:251–264
DOI: https://doi.org/10.1016/j.emc.2022.01.002
Keywords: Metabolic acidosis; Poisoned patients; Toxins; Drugs; Overdose

Metabolic Acidosis

Editorial : Metabolic acidosis can be an important consequence of several toxins. Deter- mining which drugs or toxins might be responsible for metabolic acidosis in a pa- tient with an accidental exposure, unknown ingestion, or from therapeutic drug use can present daunting diagnostic and therapeutic challenges. More importantly, vital cellular functions and metabolic processes become impaired with increasing acidosis.1 Therefore, it is paramount that a clinician recognize those substances that can result in metabolic acidosis so that timely and appropriate therapy can be instituted.

Conclusion : Metabolic acidosis can arise from several drugs and toxins through a variety of mechanisms. Differentiating the causes of metabolic acidosis in the poisoned patient is an indispensable skill in clinical practice. Comprehension of toxin-induced metabolic acidosis, combined with a thorough history, physical examination, appropriate use of laboratory tests, and a stepwise approach should aid the clinician in determining the cause of metabolic acidosis in the poisoned patient. It is imperative when confronted with such a patient that appropriate antidotal therapy is administered when necessary and the patient receives exceptional supportive care.

Conclusion (proposition de traduction) : L'acidose métabolique peut être provoquée par plusieurs médicaments et toxiques par le biais d'une variété de mécanismes. La différenciation des causes de l'acidose métabolique chez le patient intoxiqué est une compétence indispensable dans la pratique clinique. La compréhension de l'acidose métabolique induite par les toxiques, associée à une anamnèse approfondie, un examen physique, une utilisation appropriée des tests de laboratoire et une approche progressive, devrait aider le clinicien à déterminer la cause de l'acidose métabolique chez le patient intoxiqué. Il est impératif, lorsque l'on est confronté à un tel patient, d'administrer un traitement antidote approprié si nécessaire et de fournir au patient des soins de soutien exceptionnels.

Carbon Monoxide Toxicity.
Nañagas KA, Penfound SJ, Kao LW. | Emerg Med Clin North Am. 2022 May;40(2):283-312
DOI: https://doi.org/10.1016/j.emc.2022.01.005
Keywords: Carbon monoxide; Carboxyhemoglobin; Delayed neurologic sequelae; Hyperbaric oxygen; Neuropsychometric testing; Normobaric oxygen; Poisoning; Toxicity.

Review article

Editorial : Carbon monoxide accounts for thousands of deaths worldwide each year. Clinical effects can be diverse and include headache, dizziness, nausea, vomiting, syncope, seizures, coma, dysrhythmias, and cardiac ischemia, and severe toxicity generally affects the nervous and cardiovascular systems. Because of its complex pathophysiology, effects of toxicity can be acute or delayed. The diagnosis can be elusive, as carboxyhemoglobin levels do not always correlate with the degree of poisoning. Even when the diagnosis is certain, appropriate therapy is widely debated. Normobaric oxygen is the standard therapy, and the efficacy of hyperbaric oxygen is unclear.

Conclusion : CO is a ubiquitous poison with many sources of exposure. CO poisoning produces diverse signs and symptoms, which are often subtle and can be easily misdiagnosed. Failure to diagnose CO poisoning may result in significant morbidity and mortality and allows for continued exposure to a dangerous environment.
Treatment of CO poisoning begins with inhalation of supplemental oxygen and aggressive supportive care. Securing the scene of exposure is critical, as this can prevent additional exposures. Hyperbaric oxygen therapy accelerates dissociation of CO from hemoglobin, but its ability to prevent delayed neurologic sequelae remains uncertain, given the weaknesses and limitations of existing randomized trials. Hyperbaric chambers are not ubiquitously available and may require long transport times or may not be able to provide for all the specialized needs of the patient. The ideal regimen of oxygen therapy has yet to be determined, and significant controversy exists regarding hyperbaric oxygen therapy treatment protocols. Often the local medical toxicologist, poison control center, or hyperbaric unit can assist the treating physician with decisions regarding therapy

Conclusion (proposition de traduction) : Le CO est un poison omniprésent dont les sources d'exposition sont nombreuses. L'intoxication au CO produit divers signes et symptômes, qui sont souvent discrets et peuvent facilement être mal diagnostiqués. Le fait de ne pas diagnostiquer une intoxication au CO peut entraîner une morbidité et une mortalité importantes et favorise une exposition continue à un environnement dangereux.
Le traitement de l'intoxication au CO commence par l'inhalation d'oxygène additionnelle et des soins de soutien intensifs. La sécurisation de la scène d'exposition est essentielle, car cela peut empêcher des expositions à venir. L'oxygénothérapie hyperbare accélère la dissociation du CO de l'hémoglobine, mais sa capacité à prévenir les séquelles neurologiques ultérieures reste incertaine, compte tenu des faiblesses et des limites des essais randomisés existants. Les caissons hyperbares ne sont pas disponibles partout et peuvent nécessiter de longs temps de transport ou ne pas être en mesure de répondre à tous les besoins spécialisés du patient. Le protocole idéal d'oxygénothérapie n'a pas encore été déterminé et il existe une importante controverse concernant les protocoles de traitement par oxygénothérapie hyperbare. Souvent, le toxicologue médical local, le centre antipoison ou l'unité hyperbare peuvent aider le médecin traitant à prendre des décisions concernant le traitement.

Toxic Alcohol Poisoning.
Ross JA, Borek HA, Holstege CP, King JD. | Emerg Med Clin North Am. 2022 May;40(2):327-341
DOI: https://doi.org/10.1016/j.emc.2022.01.012
Keywords: Acetone; Diethylene glycol; Ethylene glycol; Isopropyl alcohol; Methanol; Osmol gap; Propylene glycol; Toxic alcohol.

Review article

Editorial : This article reviews the background, metabolism, clinical effects, and treatment of toxic alcohols, specifically ethylene glycol, methanol, diethylene glycol, propylene glycol, and isopropyl alcohol. This article also reviews the importance of an anion gap metabolic acidosis in relation to toxic alcohols and explores both the utility and the limitations of the osmol gap in patient management.

Conclusion : Toxic alcohol exposures can cause patients to become critically ill, and many products containing toxic alcohols are readily accessible. Ethylene glycol and methanol are found in numerous household products. Diethylene glycol, propylene glycol, and isopropyl alcohol, although less commonly ingested, can lead to unique clinical toxidromes that must be recognized and appropriately treated. It is important for critical care clinicians to know how to calculate, interpret, and identify the differential diagnosis for an anion gap metabolic acidosis. An osmol gap can be useful in identifying toxic alcohol ingestions; however, it has many limitations that must be recognized. It is important for critical care specialists to be familiar with these formulas as well as each toxic alcohol, so that an exposure can be identified promptly and treated appropriately.

Conclusion (proposition de traduction) : L'exposition aux alcools toxiques peut entraîner une pathologie grave chez les patients, et de nombreux produits contenant des alcools toxiques sont facilement accessibles. L'éthylène glycol et le méthanol sont présents dans de nombreux produits ménagers. Le diéthylène glycol, le propylène glycol et l'alcool isopropylique, bien que moins souvent ingérés, peuvent entraîner des toxidromes cliniques uniques qui doivent être reconnus et traités de manière adaptée. Il est important que les spécialistes en soins intensifs sachent comment analyser, interpréter et identifier le diagnostic différentiel d'une acidose métabolique à trou anionique. Le trou anionique peut être utile pour identifier les ingestions toxiques d'alcool, mais il présente de nombreuses limites qui doivent être reconnues. Il est important que les spécialistes en soins intensifs connaissent ces formules ainsi que chaque alcool toxique, afin qu'une exposition puisse être identifiée rapidement et traitée de manière appropriée.

The Roles of Antidotes in Emergency Situations.
Kaiser SK, Dart RC. | Emerg Med Clin North Am. 2022 May;40(2):381-394
DOI: https://doi.org/10.1016/j.emc.2022.01.008
Keywords: Acetylcysteine; Antidote; Fomepizole; Hydroxocobalamin; Intralipid; Levocarnitine; Lipid emulsion; Methylene blue.

Review article

Editorial : Management of the acutely poisoned patient requires supportive care and timely administration of antidotes to minimize ongoing toxicity and mortality. New applications for old antidotes include utilization of methylene blue and hydroxocobalamin in vasoplegia. Fomepizole is also being evaluated as a potential adjunct in acetaminophen toxicity. Other advancements include individualized acetylcysteine dosing regimens for acetaminophen toxicity and carnitine supplementation in valproic acid toxicity. Additional antidote considerations include administration of lipid emulsion in lipophilic xenobiotic exposure not responsive to standard resuscitative modalities. These expert recommendations provide guidance for providers caring for the acutely poisoned patient.

Conclusion : Antidotes are commonly used to reduce or eliminate the toxic effects of a poison. Often, there is no acceptable substitute. Although recognized over 25 years ago, numerous publications documenting insufficient stocking of antidotes by hospitals in the United States and many other countries continue to be published. The medical and financial implications can be enormous. Failing to use the antidote for acetaminophen, for example, can lead to acute liver failure, which may result in liver transplant or death.

Conclusion (proposition de traduction) : Les antidotes sont couramment utilisés pour réduire ou éliminer les effets toxiques d'un poison. Souvent, il n'existe aucun substitut acceptable. Bien qu'elles aient été reconnues il y a plus de 25 ans, de nombreuses publications documentant le stockage insuffisant d'antidotes par les hôpitaux aux États-Unis et dans de nombreux autres pays continuent d'être publiées. Les implications médicales et financières peuvent être énormes. Le fait de ne pas utiliser l'antidote pour l'acétaminophène, par exemple, peut conduire à une insuffisance hépatique aiguë, qui peut entraîner une transplantation du foie ou la mort.

Commentaire : • L'administration de bleu de méthylène et d'hydroxocobalamine peut être envisagée chez les patients intoxiqués présentant un choc vasoplégique réfractaire.
• L'administration de bleu de méthylène peut entraîner une lecture faussement basse de l'oxymétrie de pouls immédiatement après l'administration.
• Envisager d'augmenter la dose d'acétylcystéine si le patient présente une concentration d'acétaminophène supérieure à la ligne de 300 mg/mL.
• Le fomépizole a été étudié dans des études de cas et des modèles animaux comme traitement d'appoint potentiel de la toxicité de l'acétaminophène, en plus de l'acétylcystéine.
• Envisager l'administration intraveineuse de lévocarnitine chez les patients présentant une hépatotoxicité ou une neurotoxicité induite par l'acide valproïque.
• Administrer une émulsion lipidique intraveineuse en plus des soins de réanimation standard aux patients présentant une toxicité systémique des anesthésiques locaux.
• Si elle est envisagée, l'émulsion lipidique intraveineuse est plus susceptible d'être efficace en cas de surdosage de médicaments lipophiles (log P>2).

Cardiotoxic Medication Poisoning.
Cole JB, Arens AM. | Emerg Med Clin North Am. 2022 May;40(2):395-416
DOI: https://doi.org/10.1016/j.emc.2022.01.014
Keywords: Beta-blocker; Calcium channel blocker; Digoxin; ECMO; Flecainide; High-dose insulin; Poisoning.

Review article

Editorial : Beta-blockers and calcium channel blockers result in a disproportionate number of fatalities from cardiac medication overdoses, and share similar characteristics. High-dose insulin is a superior therapy for both overdoses, but is likely synergistic with vasopressors; therefore we recommend starting vasopressors and high-dose insulin simultaneously. Digoxin remains an important cardiac poison and can likely be safely treated with smaller doses of fab fragments than in the past, except for patients in extremis. Extracorporeal membrane oxygenation is an invasive but promising nonspecific therapy for refractory shock from cardiotoxic overdose and should be considered primarily in cases of refractory cardiogenic shock.

Conclusion : Beta-blockers and calcium channel blockers result in a disproportionate number of fatalities from cardiac medication overdoses, and share similar characteristics. HDI is a superior therapy for both overdoses, but is likely synergistic with vasopressors; therefore we recommend starting vasopressors and HDI simultaneously. Digoxin remains an important cardiac poison and can likely be safely treated with smaller doses of fab fragments than in the past, except for patients in extremis. In patients with features of cardioactive steroid poisoning after ingestion of weight loss products, occult yellow oleander poisoning should be suspected. Flecainide is also a major cause of drug-induced cardiogenic shock and should be treated with hypertonic sodium bicarbonate in addition to usual therapies for cardiotoxic overdoses. ECMO is an invasive but promising nonspecific therapy for refractory shock from cardiotoxic overdose and should be considered primarily in cases of refractory cardiogenic shock

Conclusion (proposition de traduction) : Les bêta-bloquants et les inhibiteurs calciques sont à l'origine d'un nombre excessif de décès dus à des surdosages de médicaments cardiaques et partagent des caractéristiques similaires. L'insuline à forte dose est un traitement supérieur pour les deux intoxications, mais elle est probablement synergique avec les vasopresseurs ; nous recommandons donc de commencer simultanément les vasopresseurs et l'insuline à forte dose. La digoxine reste un poison cardiaque important et peut probablement être traitée en toute sécurité avec des doses de fragments de fab plus faibles que par le passé, sauf pour les patients in extremis. Chez les patients présentant des caractéristiques d'intoxication aux stéroïdes cardioactifs après l'ingestion de produits amaigrissants, une intoxication occulte au laurier-rose doit être suspectée. La flécaïnide est également une cause majeure de choc cardiogénique d'origine médicamenteuse et doit être traitée avec du bicarbonate de sodium hypertonique en plus des traitements habituels des surdoses cardiotoxiques. L'ECMO est une technique invasive mais prometteuse et non spécifique pour le choc réfractaire dû à un surdosage cardiotoxique et doit être envisagée principalement dans les cas de choc cardiogénique réfractaire.

Emergency Medicine International

Prognostic Accuracy of qSOFA and SIRS for Mortality in the Emergency Department: A Meta-Analysis and Systematic Review of Prospective Studies.
Ruan H, Ke D, Liao D. | Emerg Med Int. 2022 May 5;2022:1802707
DOI: https://doi.org/10.1155/2022/1802707  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Introduction : This meta-analysis aimed to determine the prognostic performance of quick sequential organ failure assessment (qSOFA) score in comparison to systemic inflammatory response syndrome (SIRS) in predicting in-hospital mortality in the emergency department (ED) patients.

Méthode : Eligible studies comparing the performance of qSOFA and SIRS in predicting in-hospital death of ED patients were identified from searching PubMed, Embase, and Cochrane. Raw data were collected, and the pooled sensitivity and specificity were calculated for qSOFA and SIRS. The summary receiver operating curve was also plotted to calculate the area under the curve.

Résultats : A total of 16 prospective studies with 35,756 patients and 2,285 deaths were included. The pooled sensitivity was 0.43 (95% CI: 0.32-0.54) and 0.8 (95% CI: 0.73-0.86) for qSOFA and SIRS, respectively. The pooled specificity was 0.89 (95% CI: 0.84-0.93) and 0.39 (95% CI: 0.3-0.5) for qSOFA and SIRS, respectively. The area under the summary receiver operating curve was 0.76 (95% CI: 0.72-0.8) and 0.67 (95% CI: 0.62-0.72) for qSOFA and SIRS, respectively. A significant heterogeneity was observed for both qSOFA and SIRS studies.

Conclusion : The present meta-analysis suggested that qSOFA had a higher specificity but a lower sensitivity as compared with SIRS in predicting in-hospital mortality in the ED patients. qSOFA appeared to be a more concise and simple way to recognize patients at high risk for death. However, the use of SIRS in the ED cannot be completely replaced since the sensitivity of qSOFA was relatively lower.

Conclusion (proposition de traduction) : La présente méta-analyse suggère que le qSOFA a une spécificité plus élevée mais une sensibilité plus faible que le SIRS pour prédire la mortalité hospitalière chez les patients des urgences. Le qSOFA semble être un moyen plus simple et plus rapide pour reconnaître les patients à haut risque de décès. Cependant, l'utilisation du SIRS aux urgences ne peut pas être complètement remplacée puisque la sensibilité du qSOFA était relativement plus faible.

Emergency Medicine Journal

Assessment of emergency physicians' performance in identifying shockable rhythm in out-of-hospital cardiac arrest: an observational simulation study.
Derkenne C, Jost D, Roquet F, Corpet P, Frattini B, Kedzierewicz R, Bellec G, Rajon B, Fernandez M, Loeb T, Pierantoni E, Lamblin A, Prunet B; Paris Fire Brigade Cardiac Arrest Task Force. | Emerg Med J. 2022 May;39(5):347-352
DOI: https://doi.org/10.1136/emermed-2021-211417  | Télécharger l'article au format  
Keywords: arrhythmias; theraputics.

Original research

Introduction : Emergency physicians can use a manual or an automated defibrillator to provide defibrillation of patients who had out-of-hospital cardiac arrest (OHCA). Performance of emergency physicians in identifying shockable rhythm with a manual defibrillator has been poorly explored whereas that of automated defibrillators is well known (sensitivity 0.91-1.00, specificity 0.96-0.99). We conducted this study to estimate the sensitivity/specificity and speed of shock/no-shock decision-making by prehospital emergency physicians for shockable or non-shockable rhythm, and their preference for manual versus automated defibrillation.

Méthode : We developed a web application that simulates a manual defibrillator (https://simul-shock.firebaseapp.com/). In 2019, all (262) emergency physicians of six French emergency medical services were invited to participate in a study in which 60 ECG rhythms from real OHCA recordings were successively presented to the physicians for determination of whether they would or would not administer a shock. Time to decision was recorded. Answers were compared with a gold standard (concordant answers of three experts). We report sensitivity for shockable rhythms (decision to shock) and specificity for non-shockable rhythms (decision not to shock). Physicians were also asked whether they preferred manual or automated defibrillation.

Résultats : Among 215 respondents, we were able to analyse results for 190 physicians. 57% of emergency physicians preferred manual defibrillation. Median (IQR) sensitivity for a shock delivery for shockable rhythm was 0.91 (0.81-1.00); median specificity for no-shock delivery for non-shockable rhythms was 0.91 (0.80-0.96). More precisely, sensitivities for shock delivery for ventricular tachycardia (VT) and coarse ventricular fibrillation (VF) were both 1.0 (1.0-1.0); sensitivity for fine VF was 0.6 (0.2-1). Specificity for not shocking a pulseless electrical activity (PEA) was 0.83 (0.72-0.86), and for asystole, specificity was 0.93 (0.86-1). Median speed of decision-making (in seconds) were: VT 2.0 (1.6-2.7), coarse VF 2.1 (1.7-2.9), asystole 2.4 (1.8-3.5), PEA 2.8 (2.0-4.2) and fine VF 2.8 (2.1-4.3).

Conclusion : Global sensitivity and specificity were comparable with published automated external defibrillator studies. Shockable rhythms with the best clinical prognoses (VT and coarse VF) were very rapidly recognised with very good sensitivity. The decision-making for fine VF or asystole and PEA was less accurate.

Conclusion (proposition de traduction) : La sensibilité et la spécificité globales étaient comparables aux études publiées sur les défibrillateurs externes automatisés. Les rythmes choquables avec les meilleurs pronostics cliniques (tachycardie ventriculaire et fibrillation ventriculaire grossière) ont été reconnus très rapidement avec une très bonne sensibilité. La prise de décision concernant la fibrillation ventriculaire fine ou l'asystolie et l'activité électrique sans pouls était moins précise.

European Respiratory Journal

Extended D-dimer cut-offs and machine learning for ruling out pulmonary embolism in individuals undergoing computed tomography pulmonary angiography.
Franciosi AN, McCarthy N, Gaffney B, Duignan J, Sweeney E, O'Connell N, Murphy K, Ní Áinle F, Butler MW, Dodd JD, Keane MP, Murphy DJ, Curran KM, McCarthy C. | Eur Respir J. 2022 May 26;59(5):2200075
DOI: https://doi.org/10.1183/13993003.00075-2022
Keywords: Aucun

Research letter

Editorial : Pulmonary embolism (PE) is a major cause of morbidity and mortality. Computed tomography pulmonary angiography (CTPA) is the gold standard for diagnosing PE and a common investigation which contributes to potentially avoidable radiation exposure. CTPA use has quadrupled in the past two decades, and this has been associated with lower rates of PE detection [4] and possible overdiagnosis.

Conclusion : Extending D-dimer cut-offs beyond the upper limit of normal may be applicable even in populations with moderate-to-high pre-test probability of PE, potentially extending the insights from YEARS and PeGed and improving pre-test-prediction and resource utilisation. These results provide insights into possible future of PE risk stratification strategies.

Conclusion (proposition de traduction) : L'élargissement des seuils de D-dimères au-delà de la limite supérieure de la normale peut être applicable même dans les populations ayant une probabilité pré-test modérée à élevée d'embolie pulmonaire, ce qui pourrait élargir les connaissances acquises par YEARS et PeGed et améliorer la prédiction pré-test et l'utilisation des ressources. Ces résultats donnent un aperçu de l'avenir possible des stratégies de stratification du risque d'embolie pulmonaire.

Commentaire : Pulmonary Embolism Graduated d-Dimer study - PEGeD (Kearon C, de Wit K, Parpia S, et al. Diagnosis of pulmonary embolism with D-dimer adjusted to clinical probability. N Engl J Med 2019; 381: 2125–2134  ).

Intensive Care Medicine

Drugs for advanced life support.
Andersen LW, Nolan JP, Sandroni C. | Intensive Care Med. 2022 May;48(5):606-608
DOI: https://doi.org/10.1007/s00134-022-06678-1
Keywords: Aucun

What's New in Intensive Care

Editorial : Treatment of patients with cardiac arrest includes basic and advanced life support (ALS) as outlined by the Euro- pean Resuscitation Council. An integral part of ALS is the establishment of vascular access and administration of drugs including vasopressors and antiarrhythmics. Until recently, there has been limited evidence to show that administration of these drugs improved patient out- comes. However, several randomized clinical trials test- ing various drugs during cardiac arrest have been pub- lished within the last years and we review these in this article. Drugs that are given in special circum- stances without new trial evidence are not covered.

Conclusion : Despite an increase in clinical trials, there has been lit- tle change to the ALS algorithm over the last decades. The PARAMEDIC2 trial reinforced that adrenaline con- tinues to have a role in the treatment of patients with cardiac arrest although the absolute effect on long-term outcomes is small. There is a continuing need for high-quality clinical trials to test new drugs to improve outcomes for patients with cardiac arrest.

Conclusion (proposition de traduction) : Malgré une augmentation des essais cliniques, l'algorithme de réanimation cardiopulmonaire spécialisé a peu changé au cours des dernières décennies. L'essai PARAMEDIC2 a confirmé que l'adrénaline continue de jouer un rôle dans le traitement des patients en arrêt cardiaque, bien que l'effet absolu sur les résultats à long terme soit faible. Il existe un besoin continu d'essais cliniques de haute qualité pour tester de nouveaux médicaments afin d'améliorer les résultats pour les patients en arrêt cardiaque.

Commentaire : 

International Journal of Emergency Medicine

Comparison of emergency airway management techniques in the performance of emergent Cricothyrotomy.
George N, Consunji G, Storkersen J, Dong F, Archambeau B, Vara R, Serrano J, Hajjafar R, Tran L, Neeki MM. | Int J Emerg Med. 2022 May 30;15(1):24
DOI: https://doi.org/10.1186/s12245-022-00427-3  | Télécharger l'article au format  
Keywords: Cricothyrotomy; Cricothyrotomy techniques; Emergency airway; Emergent cricothyrotomy.

Educational Advances in Emergency Medicine

Introduction : Emergent cricothyrotomy (EC) is a rare and lifesaving procedure to secure a difficult airway when other methods have failed. Many techniques have been discussed in the literature. This study aimed to identify major techniques used to perform EC in a regional trauma center and evaluate outcomes associated with the techniques.

Méthode : Patients who underwent EC at Arrowhead Regional Medical Center between 1-1-2009 and 1-1-2019 were reviewed for eligibility for this study. Patients' data were extracted from the trauma database. Chi-square tests were conducted to assess the difference on variables between the techniques.

Résultats : A total of 51 (0.17%) of these patients required EC and were included in the database. The two most prevalent techniques were the scalpel-bougie-tube (SBT) and the surgical cricothyrotomy technique (SCT). More than half (n = 27, 52.9%) of the cohort received the SBT. There was no statistically significant difference between the two techniques with regards to demographic variables, including age (p = 0.7528), injury severity score (ISS, p = 0.896), gender (p = 0.3709), and race (p = 0.8935). However, the SCT group had a statistically higher Glasgow Coma Scale (GCS) than the SBT group (p = 0.0036). There was no statistically significant difference in mortality or complications between these two groups (p = 0.2172 for mortality).

Conclusion : Two techniques of EC were identified as preferred techniques. Both procedures were successful in securing an emergency airway, noting a difference in the time to completion of the two techniques. Given the rarity of the procedure, practitioners may choose the method based on their training and the availability of appropriate instruments.

Conclusion (proposition de traduction) : Deux techniques de cricothyrotomie marquantes ont été identifiées comme techniques préférées. Les deux procédures ont réussi à sécuriser les voies aériennes en urgence, notant une différence dans le temps nécessaire à la réalisation des deux techniques. Compte tenu de la rareté de la procédure, les praticiens peuvent choisir la méthode en fonction de leur formation et de la disponibilité des instruments appropriés.

Clinical and electrocardiogram presentations of patients with high serum potassium concentrations within emergency settings: a prospective study.
Raffee LA, Alawneh KZ, Ababneh MJ, Hijazi HH, Al Abdi RM, Aboozour MM, Alghzawi FA, Al-Mistarehi AH. | Int J Emerg Med. 2022 May 26;15(1):23
DOI: https://doi.org/10.1186/s12245-022-00422-8  | Télécharger l'article au format  
Keywords: ECG; Electrocardiogram; Hyperkalemia; Sensitivity; Serum potassium.

ORIGINAL RESEARCH

Introduction : Elevated potassium level is a common and reversible peri-arrest condition. Diagnosis and management of hyperkalemia in a short time is critical, where electrocardiogram (ECG) alterations might be helpful. We aimed to investigate the role of clinical features and ECGs in early diagnosing and treating hyperkalemia.

Méthode : Prospectively, adult patients who presented to the emergency department (ED) from July 2019 to March 2020 with hyperkalemia (serum potassium ≥5.5mmol/L) were included. History was obtained, and laboratory investigations and ECGs were performed at the presentation and before initiating hyperkalemia therapy. Hyperkalemia severity was divided into mild (5.5-5.9mmol/L), moderate (6.0-6.4mmol/L), and severe (≥6.5mmol/L). A cardiologist and emergency physician blinded to laboratory values, study design, and patients' diagnoses interpreted ECGs and presenting symptoms independently to predict hyperkalemia.

Résultats : Sixty-seven hyperkalemic patients with a mean (±SD) serum potassium level of 6.5±0.7mmol/L were included in this study. The mean age was 63.9±15.1, and 58.2% were females. Hyperkalemia was mild in 10.4%, moderate in 40.3%, and severe in 49.3%. Almost two thirds of patients (71.6%) had hypertension, 67.2% diabetes, and 64.2% chronic kidney disease. About one-quarter of patients (22.4%) were asymptomatic, while fatigue (46.3%), dyspnea (28.4%), and nausea/vomiting (20.9%) were the most common presenting symptoms. Normal ECGs were observed in 25.4% of patients, while alterations in 74.6%. Atrial fibrillation (13.4%), peaked T wave (11.9%), widened QRS (11.9%), prolonged PR interval (10.5%), and flattening P wave (10.5%) were the most common. Peaked T wave was significantly more common in severe hyperkalemia (87.5%) than in mild and moderate hyperkalemia (12.5%, 0.0%, respectively) (p=0.041). The physicians' sensitivities for predicting hyperkalemia were 35.8% and 28.4%, improved to 51.5% and 42.4%, respectively, when limiting the analyses to severe hyperkalemia. The mean (±SD) time to initial hyperkalemia treatment was 63.8±31.5 min. Potassium levels were positively correlated with PR interval (r=0.283, p=0.038), QRS duration (r=0.361, p=0.003), peaked T wave (r=0.242, p=0.041), and serum levels of creatinine (r=0.347, p=0.004), BUN (r=0.312, p=0.008), and CK (r=0.373, p=0.039).

Conclusion : The physicians' abilities to predict hyperkalemia based on ECG and symptoms were poor. ECG could not be solely relied on, and serum potassium tests should be conducted for accurate diagnosis.

Conclusion (proposition de traduction) : Les capacités des médecins à prédire l'hyperkaliémie sur la base de l'ECG et des symptômes étaient médiocres. L'ECG ne peut pas être utilisé uniquement et des tests de potassium sérique doivent être effectués pour un diagnostic précis.

JAMA Internal Medicine

Diagnostic Dilemma of Pericarditis Concurrent With ST Elevation Myocardial Infarction.
Alsagaff MY, Oktaviono YH, Lusida TTE. | JAMA Intern Med. 2022 May 1;182(5):551-552
DOI: https://doi.org/10.1001/jamainternmed.2022.0318
Keywords: Aucun

Challenges in Clinical Electrocardiography (case report)

Editorial : The ST-segment changes observed in patients with STEMI and pericarditis may present a diagnostic dilemma for emergency physicians. Furthermore, pericarditismay complicate the course ofmyocardial infarction (MI), and, in this case, pericarditis might mask the STEMI-derived need for reperfusion. Theworking diagnosis of pericarditis in this casewas made based on diffuse STE, pericardial friction rub, and PE.

Conclusion : Take-home Points
• ST elevation myocardial infarction and pericarditis may occur together.
• In most cases, ECG, TTE, and cardiac markers may help in differentiating acute pericarditis from STEMI. • In cases of pericarditis with suspected myocardial involvement, invasive coronary angiography is recommended to exclude STEMI diagnosis.

Conclusion (proposition de traduction) : Take-home Points
• L'infarctus du myocarde avec sus-décalage du segment ST et la péricardite peuvent survenir ensemble.
• Dans la plupart des cas, l'ECG, l'ETT et les marqueurs cardiaques peuvent aider à différencier la péricardite aiguë du STEMI.
• En cas de péricardite avec suspicion d'atteinte myocardique, une coronarographie invasive est recommandée pour exclure le diagnostic de STEMI.

Journal of Emergency Medicine

Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study.
Baid H, Vempalli N, Kumar S, Arora P, Walia R, Chauhan U, Shukla K, Verma A, Chawang H, Agarwal D. | Int J Emerg Med. 2022 Jun 13;15(1):27.
DOI: https://doi.org/10.1186/s12245-022-00430-8  | Télécharger l'article au format  
Keywords: Bedside ultrasound; Diagnostic accuracy; Dyspnea; Emergency department; PoCUS; Point of care ultrasound.

Research

Introduction : Dyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, causing unnecessary delay. Point of care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus, becoming a popular tool in ED while saving time and maintaining safety standards. Our study aimed to determine the utilization of point of care ultrasound in patients with acute dyspnea as an initial diagnostic tool in our settings.

Méthode : The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Adult patients presenting with acute dyspnea were prospectively enrolled. They were clinically evaluated and necessarily investigated, and a provisional diagnosis was made. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations (not the clinical parameters), and made a PoCUS diagnosis. Our gold standard was the final composite diagnosis made by two Emergency Medicine consultants (who had access to all investigations). Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was compared.

Résultats : Two hundred thirty-seven patients were enrolled. The PoCUS and final composite diagnosis showed good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). High overall specificity was seen. A high positive predictive value for all except left ventricular dysfunction, pericardial effusion, non-cardiopulmonary causes of dyspnea, and a low negative predictive value was seen for pneumonia. The median time to make a PoCUS diagnosis was 16 (5-264) min compared to the 170 (8-1346) min taken for the final composite diagnosis. Thus, time was significantly lower for PoCUS diagnosis (p value <0.001).

Conclusion : By combining the overall accuracy of PoCUS, the concordance with the final composite diagnosis, and the statistically significant reduction in time taken to formulate the diagnosis, PoCUS shows immense promise as an initial diagnostic tool that may expedite the decision-making in ED for patients' prompt management and disposition with reliable accuracy.

Conclusion (proposition de traduction) : En combinant la précision générale de l’échographie au point d'intervention, la concordance avec le diagnostic composite final et la réduction statistiquement significative du temps nécessaire à la formulation du diagnostic, l’échographie au point d'intervention s’avère extrêmement prometteuse comme outil de diagnostic initial qui peut accélérer la prise de décision aux urgences pour une prise en charge rapide et un traitement précis des patients.

Journal of the American College of Cardiology

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. | J Am Coll Cardiol. 2022 May 3;79(17):1757-1780
DOI: https://doi.org/10.1016/j.jacc.2021.12.011  | Télécharger l'article au format  
Keywords: ACC/AHA Clinical Practice Guidelines; ACE inhibitors; SGLT2 inhibitors; acute decompensated heart failure; angiotensin and neprilysin receptor antagonist; angiotensin receptor antagonist; atrial fibrillation; beta blockers; cardiac amyloidosis; cardiac failure; cardio-oncology; cardiogenic shock; cardiomyopathy; cardiomyopathy in pregnancy; chronic heart failure; congestive heart failure; diabetes; guideline-directed medical therapy; heart failure; heart failure rehabilitation; heart failure with mildly reduced ejection fraction; heart failure with preserved ejection fraction; heart failure with reduced ejection fraction; mineralocorticoid receptor antagonists; mitral regurgitation; palliati

Clinical Practice Guideline: Executive Summary

Introduction : The “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure” replaces the “2013 ACCF/AHA Guideline for the Management of Heart Failure” and the “2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.” The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

Méthode : A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

Conclusion : Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Conclusion (proposition de traduction) : L'insuffisance cardiaque reste l'une des principales causes de morbidité et de mortalité dans le monde. La ligne directrice sur l'insuffisance cardiaque de 2022 fournit des recommandations fondées sur des preuves contemporaines pour le traitement de ces patients. Les recommandations présentent une approche fondée sur des données probantes pour la prise en charge des patients atteints d'insuffisance cardiaque, dans le but d'améliorer la qualité des soins et de s'aligner sur les intérêts des patients. De nombreuses recommandations des lignes directrices antérieures sur l'insuffisance cardiaque ont été mises à jour avec de nouvelles preuves, et de nouvelles recommandations ont été créées lorsqu'elles sont étayées par des données publiées. Des déclarations de valeur sont fournies pour certains traitements avec des analyses économiques publiées de haute qualité.

Commentaire : « Patients hospitalisés pour une insuffisance cardiaque aiguë décompensée », page e341 et suivantes

Pediatric Emergency Care

Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success.
Pacheco GS, Patanwala AE, Leetch AN, Mendelson JS, Hurst NB, Sakles JC. | Pediatr Emerg Care. 2022 May 1;38(5):e1271-e1276
DOI: https://doi.org/10.1097/pec.0000000000002592
Keywords: Aucun

Original Article

Introduction : Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED.

Méthode : This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients.

Résultats : Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77).

Conclusion : In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.

Conclusion (proposition de traduction) : Dans cette étude, nous avons constaté que l'arrêt cardiaque pédiatrique en dehors de l'hôpital était associé à une réduction du succès du premier essai en urgence. Bien que des études supplémentaires soient nécessaires, les secouristes doivent donner la priorité au rétablissement d'une oxygénation et d'une ventilation efficaces et à l'optimisation des conditions d'intubation avant une tentative avancée d'intubation.

Prehospital Emergency Care

The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study.
Whitfield D, Bosson N, Kaji AH, Gausche-Hill M. | Prehosp Emerg Care. 2022 May-Jun;26(3):339-347
DOI: https://doi.org/10.1080/10903127.2021.1897197
Keywords: EMS; intranasal; midazolam; pediatric seizure.

Article

Introduction : Intranasal (IN) midazolam allows for rapid, painless treatment of pediatric seizures in the prehospital setting and may be a preferred administration route if determined to be non-inferior to intravenous (IV) or intramuscular (IM) routes. We sought to evaluate the effectiveness of IN midazolam for terminating prehospital pediatric seizures compared to midazolam administered by alternate routes.

Méthode : We performed a retrospective, non-inferiority analysis using data from a regional Emergency Medical Services (EMS) database. We included pediatric patients ≤ 14 years treated with midazolam (0.1 mg/kg) by EMS for non-traumatic seizures. The primary outcome was the proportion of patients requiring redosing of midazolam after initial treatment with IN midazolam compared to those that received IV or IM midazolam. We established a priori a risk difference of 6.5% as the non-inferiority margin.

Résultats : We evaluated outcomes from 2,034 patients (median age 6 years [interquartile range 3 - 10 years], 55% male). Initial administration routes were 461 (23%) IN, 547 (27%) IM, 1024 (50%) IV, and 2 (0.1%) intraosseous (IO). Midazolam redosing occurred in 116 patients (25%) who received IN midazolam versus 222 patients (14%) treated initially with midazolam via alternate routes (risk difference 11% [95%CI 7 - 15%]). The age-adjusted odds ratio for redosing midazolam after intranasal administration compared to alternate route administration was 2.0 (95% CI 1.6 - 2.6).

Conclusion : Prehospital treatment of pediatric seizure with intranasal midazolam was associated with increased frequency of redosing compared to midazolam administered by other routes, suggesting that 0.1 mg/kg is a subtherapeutic dose for intranasal midazolam administration.

Conclusion (proposition de traduction) : Le traitement préhospitalier des convulsions pédiatriques avec du midazolam intranasal a été associé à une fréquence accrue d'administrations répétées par rapport au midazolam administré par d'autres voies, ce qui suggère que 0,1 mg/kg est une dose sous-thérapeutique pour l'administration intranasale de midazolam.

Resuscitation

Efficacy of defibrillator pads placement during ventricular arrhythmias, a before and after analysis.
Steinberg MF, Olsen JA, Persse D, Souders CM, Wik L. | Resuscitation. 2022 May;174:16-19
DOI: https://doi.org/10.1016/j.resuscitation.2022.03.004
Keywords: CPR; Cardiac arrest; Defibrillation; Emergency medical services; Ventricular arrhythmias.

Clinical Paper

Introduction : European resuscitation guidelines describe several acceptable placements of defibrillator pads during resuscitation of cardiac arrest. However, no clinical trial has compared defibrillation efficacy between any of the different pad placements. Houston Fire Department emergency medical system (EMS) used anterior-posterior (AP) defibrillator pad placement before becoming a study site in the circulation improving resuscitation care trial (CIRC). During CIRC, Houston Fire EMS used sternal-apical (SA) pad placement.

Méthode : Data from electronic defibrillator records was compared between a pre-CIRC dataset and patients in the CIRC trial receiving manual cardiopulmonary resuscitation (CPR). Only shocks from patients with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) were included. Measured outcome was defibrillation efficacy, defined as termination of VF/VT. The general estimatingequations model was used to study the association between defibrillation efficacy rates in the AP vs SA group.

Résultats : In the pre-CIRC dataset, 207 included patients received 1023 shocks with AP pad placement, compared with 277 patients from the CIRC trial who received 1020 shocks with SA pad placement. There was no significant difference in defibrillation efficacy between AP and SA pads placement (82.1 % vs 82.2 %, p = 0.98).

Conclusion : No difference was observed in defibrillation efficacy between AP and SA pad placement in this study. A randomized clinical trial may be indicated.

Conclusion (proposition de traduction) : Aucune différence n'a été observée dans l'efficacité de la défibrillation entre le placement du coussinet antéro-postérieur et sterno-apical dans cette étude. Un essai clinique randomisé peut être indiqué.

Commentaire :  Trouvé sur 123rf  

Near-infrared spectroscopy during cardiopulmonary resuscitation for pediatric cardiac arrest: A prospective, observational study. .
Francoeur C, Landis WP, Winters M, Naim MY, Donoghue A, Dominick CL, Huh JW, MacDonald JM, Lang SS, Yuan I, Berg RA, Nadkarni VM, Kilbaugh TJ, Sutton RM, Kirschen MP, Morgan RW, Topjian AAv. | Resuscitation. 2022 May;174:35-41
DOI: https://doi.org/10.1016/j.resuscitation.2022.03.014
Keywords: Cerebral oximetry; Near-infrared spectroscopy; Pediatric cardiac arrest; Pediatric cardiopulmonary resuscitation.

Clinical Paper

Introduction : Cerebral oxygenation (rSO2) is not routinely measured during pediatric cardiopulmonary resuscitation (CPR). We aimed to determine whether higher intra-arrest rSO2 was associated with return of spontaneous circulation (ROSC) and survival to hospital discharge.

Méthode : Prospective, single-center observational study of cerebral oximetry using near-infrared spectroscopy (NIRS) during pediatric cardiac arrest from 2016 to 2020. Eligible patients had ≥30 s of rSO2 data recorded during CPR. We compared median rSO2 and percentage of rSO2 measurements above a priori thresholds for the entire event and the final five minutes of the CPR event between patients with and without ROSC and survival to discharge.

Résultats : Twenty-one patients with 23 CPR events were analyzed. ROSC was achieved in 17/23 (73.9%) events and five/21 (23.8%) patients survived to discharge. The median rSO2 was higher for events with ROSC vs. no ROSC for the overall event (62% [56%, 70%] vs. 45% [35%, 51%], p = 0.025) and for the final 5 minutes of the event (66% [55%, 72%] vs. 43% [35%, 44%], p = 0.01). Patients with ROSC had a higher percentage of measurements above 50% during the final five minutes of CPR (100% [100%, 100%] vs. 0% [0%, 29%], p = 0.01). There was no association between rSO2 and survival to discharge.

Conclusion : Higher cerebral rSO2 during CPR for pediatric cardiac arrest was associated with higher rates of ROSC but not with survival to discharge.

Conclusion (proposition de traduction) : Une rSO2 cérébrale plus élevée pendant la RCR pour un arrêt cardiaque pédiatrique était associée à des taux plus élevés de ROSC, mais pas à la survie jusqu'à la sortie.

Metformin protects against cardiac and renal damage in diabetic cardiac arrest patients.
Rutledge CA, Kaufman BA, Dezfulian C, Elmer J. | Resuscitation. 2022 May;174:42-46
DOI: https://doi.org/10.1016/j.resuscitation.2022.03.017
Keywords:

Short Paper

Introduction : Metformin is a first-line diabetic therapy that improves survival in a wide number of ischemic pathologies. We tested the association of metformin with markers of cardiac and renal injury in diabetic post-arrest patients.

Méthode : We performed a retrospective analysis of clinical outcomes in diabetic cardiac arrest patients with and without metformin therapy at a single academic medical center. We used generalized linear models to test the independent association of metformin, insulin, and other hypoglycemic agents with peak 24-hour serum creatinine and peak 24-hour serum troponin.

Résultats : Metformin prescription at the time of SCA was independently associated with lower 24-hour peak serum troponin and lower 24-hour peak serum creatinine when compared to non-metformin patients.

Conclusion : Metformin pretreatment may offer cardiac and renal protection for diabetic patients during sudden cardiac arrest.

Conclusion (proposition de traduction) : Le prétraitement par la metformine peut offrir une protection cardiaque et rénale aux patients diabétiques en cas de mort subite.

Pilot study on VF-waveform based algorithms for early detection of acute myocardial infarction during out-of-hospital cardiac arrest.
Thannhauser J, Nas J, van der Sluijs K, Zwart H, de Boer MJ, van Royen N, Bonnes J, Brouwer M. | Resuscitation. 2022 May;174:62-67
DOI: https://doi.org/10.1016/j.resuscitation.2022.03.025
Keywords: Acute coronary syndrome; Acute myocardial infarction; Cardiac arrest; Machine learning; Ventricular fibrillation; Waveform analysis.

Short paper

Introduction : On-scene detection of acute coronary occlusion (ACO) during ongoing ventricular fibrillation (VF) may facilitate patient-tailored triage and treatment during cardiac arrest. Experimental studies have demonstrated the diagnostic potential of the amplitude spectrum area (AMSA) of the VF-waveform to detect myocardial infarction (MI). In follow-up, we performed this clinical pilot study on VF-waveform based discriminative models to diagnose acute MI due to ACO in real-world VF-patients.

Méthode : In our registry of VF-patients transported to a tertiary hospital (Nijmegen, The Netherlands), we studied patients with high-quality VF-registrations. We calculated VF-characteristics prior to the first shock, and first-to-second shock changes (Δ-characteristics). Primary aim was to assess the discriminative ability of the AMSA to detect patients with ACO. Secondarily, we investigated the discriminative value of adding ΔAMSA-measures using machine learning algorithms. Model performances were assessed using C-statistics.

Résultats : In total, there were 67 VF-patients with and 34 without an ACO, and baseline characteristics did not differ significantly. Based on the AMSA prior to the first defibrillation attempt, discrimination between ACO and non-ACO was possible, with a C-statistic of 0.66 (0.56-0.75). The discriminative model using AMSA + ΔAMSA yielded a C-statistic of 0.80 (0.69-0.88).

Conclusion : These clinical pilot data confirm previous experimental findings that early detection of MI using VF-waveform analysis seems feasible, and add insights on the diagnostic impact of accounting for first-to-second shock changes in VF-characteristics. Confirmative studies in larger cohorts and with a variety of VF-algorithms are warranted to further investigate the potential of this innovative approach.

Conclusion (proposition de traduction) : Ces données pilotes cliniques confirment les résultats expérimentaux antérieurs selon lesquels la détection précoce de l'infarctus du myocarde à l'aide de l'analyse de la forme d'onde de la fibrillation ventriculaire semble faisable, et donnent un aperçu de l'impact diagnostique de la prise en compte des changements du premier au deuxième choc électrique dans les caractéristiques de la fibrillation ventriculaire. Des études de confirmation dans des cohortes plus importantes et avec une variété d'algorithmes de fibrillation ventriculaire sont justifiées pour étudier plus avant le potentiel de cette approche innovante.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Prehospital fluid therapy in patients with suspected infection: a survey of ambulance personnel's practice.
Jensen ME, Jensen AS, Meilandt C, Jørgensen KW, Væggemose U, Bach A, Kirkegaard H, Jessen MK. | Scand J Trauma Resusc Emerg Med. 2022 May 31;30(1):38
DOI: https://doi.org/10.1186/s13049-022-01025-1  | Télécharger l'article au format  
Keywords: Aucun

Original research

Introduction : Fluid therapy in patients with suspected infection is controversial, and it is not known whether fluid treatment administered in the prehospital setting is beneficial. In the absence of evidence-based guidelines for prehospital fluid therapy for patients with suspected infection, Emergency Medical Services (EMS) personnel are challenged on when and how to initiate such therapy. This study aimed to assess EMS personnel's decision-making in prehospital fluid therapy, including triggers for initiating fluid and fluid volumes, as well as the need for education and evidence-based guidelines on prehospital fluid therapy in patients with suspected infection.

Méthode : An online survey concerning fluid administration in prehospital patients with suspected infection was distributed to all EMS personnel in the Central Denmark Region, including ambulance clinicians and prehospital critical care anaesthesiologists (PCCA). The survey consisted of sections concerning academic knowledge, statements about fluid administration, triggers to evaluate patient needs for intravenous fluid, and clinical scenarios.

Résultats : In total, 468/807 (58%) ambulance clinicians and 106/151 (70%) PCCA responded to the survey. Of the respondents, 73% (n = 341) of the ambulance clinicians and 100% (n = 106) of the PCCA felt confident about administering fluids to prehospital patients with infections. However, both groups primarily based their fluid-related decisions on "clinical intuition". Ambulance clinicians named the most frequently faced challenges in fluid therapy as "Unsure whether the patient needs fluid" and "Unsure about the volume of fluid the patient needs". The five most frequently used triggers for evaluating fluid needs were blood pressure, history taking, skin turgor, capillary refill time, and shock index, the last of which only applied to ambulance clinicians. In the scenarios, the majority administered 500 ml to a normotensive woman with suspected sepsis and 1000 ml to a woman with suspected sepsis-related hypotension. Moreover, 97% (n = 250) of the ambulance clinicians strongly agreed or agreed that they were interested in more education about fluid therapy in patients with suspected infection.

Conclusion : The majority of ambulance clinicians and PCCA based their fluid administration on "clinical intuition". They faced challenges deciding on fluid volumes and individual fluid needs. Thus, they were eager to learn more and requested research and evidence-based guidelines.

Conclusion (proposition de traduction) : La majorité des ambulanciers et des anesthésistes spécialisés en soins intensifs préhospitaliers fondent leur administration de liquides sur une « intuition clinique ». Ils ont eu du mal à décider des volumes de liquide et des besoins individuels en remplissage. Ils étaient donc désireux d'en savoir plus et demandaient des recherches et des recommandations fondées sur des preuves.

Shock

Association between Vitamin D deficiency and Neurologic Outcomes in Patients after Cardiopulmonary Resuscitation.
Chae B, Shin YS, Kim SM, Hong SI, Kim YJ, Ryoo SM, Kim WY. | Shock. 2022 May 1;57(5):639-644
DOI: https://doi.org/10.1097/shk.0000000000001909
Keywords: Aucun

Clinical Aspect

Introduction : We investigated the association between vitamin D deficiency and neurologic outcomes after cardiopulmonary resuscitation.

Méthode : Data from the prospective cardiac arrest registry in the emergency department between October 2019 and April 2021 were retrospectively analyzed. Blood samples were obtained during cardiopulmonary resuscitation wherein 25-hydroxyvitamin D serum levels were analyzed; deficiency was defined as levels < 10 ng/mL. The primary outcome was neurologic outcomes at 3 months assessed using the modified Rankin Scale.

Résultats : A total of 195 patients (mean age, 64.5 ± 16.1 years; 135 [69.2%] men) were included. A significantly greater proportion of patients with poor outcomes had vitamin D deficiency compared with those with good outcomes (49.4% vs. 18.2%, P = 0.001). The area under the curve for a sustained return of spontaneous circulation and 3-month poor neurologic outcomes was 0.595 (P = 0.031) and 0.704 (P < 0.001), respectively. In a multivariate analysis, vitamin D deficiency (odds ratio [OR]: 10.22; 95% confidence interval [CI]: 1.47-70.82, P = 0.019), initial shockable rhythm (OR: 0.03; 95% CI: 0.00-0.84, P = 0.040), low flow time (OR: 1.10; 95% CI: 1.03-1.16, P = 0.003), and thrombocytopenia (OR: 10.66; 95% CI: 1.13-100.41, P = 0.039) were significantly associated with 3-month poor neurologic outcomes.

Conclusion : The prevalence of vitamin D deficiency in patients with cardiac arrest was 44% and was associated with poor neurological outcomes at 3 months.

Conclusion (proposition de traduction) : La prévalence de la carence en vitamine D chez les patients ayant subi un arrêt cardiaque était de 44 % et était associée à de mauvais résultats neurologiques à 3 mois.

Extracorporeal Life-support for Out-of-hospital Cardiac Arrest: A Nationwide Multicenter Study.
Jeong D, Lee GT, Park JE, Chang H, Kim T, Cha WC, Yoon H, Hwang SY, Shin TG, Sim MS, Jo I, Lee SH, Shin SD, Choi JH. | Shock. 2022 May 1;57(5):680-686
DOI: https://doi.org/10.1097/shk.0000000000001924
Keywords: Aucun

Clinical Aspect

Introduction : Despite potential clinical roles of extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) compared to that of conventional cardiopulmonary resuscitation (CCPR), use of ECLS for OHCA is not strongly endorsed by current clinical guidelines.
Objective: The purpose of this study is to investigate the clinical roles of extracorporeal life support (ECLS) compared with that of conventional cardiopulmonary resuscitation (CCPR) for out-of-hospital cardiac arrest (OHCA) patients.

Méthode : The outcomes of OHCA between 2015 and 2020, enrolled in the Korean Cardiac Arrest Research Consortium (KoCARC), a multicenter OHCA patient registry including 65 participating hospitals throughout the Republic of Korea (ClinicalTrials.gov, number NCT03222999). Differences in clinical features were adjusted by matching the propensity for ECLS. The primary outcome was 30-day neurologically favorable survival with cerebral performance category of 1 or 2. Restricted mean survival time (RMST) was used to compare outcomes between groups.

Résultats : Of 12,006 patients included, ECLS was applied to 272 patients (2.2%). The frequency of neurologically favorable survival was higher in the ECLS group than the CCPR group (RMST difference, 5.5 days [95% CI, 4.1-7.0 days], P < 0.001). In propensity score-matched 271 pairs, the clinical outcome of ECLS and CCPR did not differ to a statistically significant extent (RMST difference, 0.4 days [95% CI -1.6 to 2.5 days], P = 0.67). Subgroup analyses revealed that the clinical roles of ECLS was evident in patients with nonshockable rhythm or CPR time ≥20 min (RMST difference, 2.7 days [95% CI 0.5-4.8 days], P = 0.015), but not in patients without these features (RMST difference, -3.7 days [95% CI -7.6 to 0.2 days], P = 0.07).

Conclusion : In this real-world data analysis, ECLS compared to CCPR did not result in better overall clinical outcomes of OHCA. The clinical efficacy of ECLS may be limited to a subgroup of high-risk patients.

Conclusion (proposition de traduction) : Dans cette analyse de données réelles, l'assistance cardio-respiratoire extracorporel comparée à la réanimation cardio-pulmonaire conventionnelle n'a pas permis d'obtenir de meilleurs résultats cliniques globaux en cas d'arrêt cardiaque extrahospitalier. L'efficacité clinique de la réanimation extracorporelle pourrait être limitée à un sous-groupe de patients à haut risque.

Stroke

Intensive Versus Standard Treatment of Hyperglycemia in Acute Ischemic Stroke Patient: A Randomized Clinical Trial Subgroups Analysis.
Torbey MT, Pauls Q, Gentile N, Falciglia M, Meurer W, Pettigrew CL, Durkalski VL, Bleck T, Bruno A; Neurological Emergencies Treatment Trials Network and SHINE Trial Investigators. | Stroke. 2022 May;53(5):1510-1515
DOI: https://doi.org/10.1161/strokeaha.120.033048  | Télécharger l'article au format  
Keywords: diabetes; glucose; hemoglobin; insulin; ischemic stroke.

Clinical Trial

Introduction : Benefit from blood glucose (BG) control during acute ischemic stroke may depend on glycemic parameters. We evaluated for associations between the SHINE (Stroke Hyperglycemia Insulin Network Effort) randomized treatment group and the SHINE predefined 90-day functional outcome, within-patient subgroups defined by various glycemic parameters.

Méthode : The SHINE Trial randomized 1151 patients within 12 hours with acute ischemic stroke and hyperglycemia to standard (target BG 80-179 mg/dL) or intensive (target BG 80-130 mg/dL) BG control for 72 hours. We predefined 6 glycemic parameters: acute BG level, absence versus presence of diagnosed and undiagnosed diabetes, hemoglobin A1c, glycemic gap (acute BG-average daily hemoglobin A1c based BG), stress hyperglycemia ratio (acute BG/average daily hemoglobin A1c based BG), and BG variability (SD). Favorable functional outcome was defined by the SHINE Trial and based on the modified Rankin Scale score at 90 days, adjusted for stroke severity. We computed relative risks adjusted for baseline stroke severity and thrombolysis use.

Résultats : Likelihood for favorable outcome was lowest among patients with undiagnosed diabetes compared to patients with true nondiabetes (adjusted relative risk, 0.42 [99% CI, 0.19-0.94]). We did not find any relationship between the favorable outcome rate and baseline BG or any of the glycemic parameters. No differences between SHINE treatment groups were identified among any of these patient subgroups.

Conclusion : In this exploratory subgroup analysis, intensive versus standard insulin treatment of hyperglycemia in acute ischemic stroke patient subgroups, did not influence the 90-day functional outcomes, nor did we identify associations between these glycemic parameters and 90-day functional outcomes.

Conclusion (proposition de traduction) : Dans cette analyse exploratoire de sous-groupes, le traitement intensif versus standard de l'hyperglycémie par l'insuline chez les patients victimes d'un AVC ischémique aigu n'a pas influencé les résultats fonctionnels à 90 jours, et nous n'avons pas non plus identifié d'associations entre ces paramètres glycémiques et les résultats fonctionnels à 90 jours.

Magnesium Sulfate and Hematoma Expansion: An Ancillary Analysis of the FAST-MAG Randomized Trial.
Naidech AM, Naidech AM, Shkirkova K, Villablanca JP, Sanossian N, Liebeskind DS, Sharma L, Eckstein M, Stratton S, Conwit R, Hamilton S, Saver JL; FAST-MAG Investigators and Coordinators. | Stroke. 2022 May;53(5):1516-1519
DOI: https://doi.org/10.1161/strokeaha.121.037999
Keywords: hematoma; hemorrhage; hypertension; magnesium; serum.

Clinical Trial

Introduction : Intracerebral hemorrhage (ICH) is the deadliest form of stroke. In observational studies, lower serum magnesium has been linked to more hematoma expansion (HE) and intracranial hemorrhage, implying that supplemental magnesium sulfate is a potential acute treatment for patients with ICH and could reduce HE. FAST-MAG (Field Administration of Stroke Therapy - Magnesium) was a clinical trial of magnesium sulfate started prehospital in patients with acute stroke within 2 hours of last known well enrolled. CT was not required prior to enrollment, and several hundred patients with acute ICH were enrolled. In this ancillary analysis, we assessed the effect of magnesium sulfate treatment upon HE in patients with acute ICH.

Méthode : We retrospectively analyzed data that were prospectively collected in the FAST-MAG study. Patients received intravenous magnesium sulfate or matched placebo within 2 hours of onset. We compared HE among patients allocated to intravenous magnesium sulfate or placebo with a Mann-Whitney U. We used the same method to compare neurological deficit severity (National Institutes of Health Stroke Scale) and global disability (modified Rankin Scale) at 3 months.

Résultats : Among 268 patients with ICH meeting study entry criteria, mean 65.4±13/4 years, 33% were female, and 211 (79%) had a history of hypertension. Initial deficit severities were median (interquartile range) of 4 (3-5) on the Los Angeles Motor Scale in the field and National Institutes of Health Stroke Scale score of 16 (9.5-25.5) early after hospital arrival. Follow-up brain imaging was performed a median of 17.1 (11.3-22.7) hours after first scan. The magnesium and placebo groups did not statistically differ in hematoma volume on arrival, 10.1 (5.6-28.7) versus 12.4 (5.6-28.7) mL (P=0.6), or HE, 2.0 (0.1-7.4) versus 1.5 (-0.2 to 8) mL (P=0.5). There was no difference in functional outcomes (modified Rankin Scale score of 3-6), 59% versus 50% (P=0.5).

Conclusion : Magnesium sulfate did not reduce HE or improve functional outcomes at 90 days. A benefit for patients with initial hypomagnesemia was not addressed.

Conclusion (proposition de traduction) : Le sulfate de magnésium n'a pas réduit l'expansion de l'hématome et n'a pas amélioré le fonctionnement de l'hôpital.

The American Journal of Emergency Medicine

Gender differences and survival after out of hospital cardiac arrest.
Rob D, Kavalkova P, Smalcova J, Franek O, Smid O, Komarek A, Pisinger M, Belohlavek J. | Am J Emerg Med. 2022 May;55:27-31
DOI: https://doi.org/10.1016/j.ajem.2022.02.032
Keywords: Cardiac arrest; Gender; Outcome; Resuscitation; Sex; Women.

Original Contribution

Introduction : Published evidence regarding the effect of gender on outcome after out of hospital cardiac arrest (OHCA) is inconsistent. We aimed to investigate the association of gender to outcome and resuscitation characteristics in OHCA patients admitted to the cardiac arrest center.

Méthode : In this retrospective analysis of prospective registry data, all patients admitted for OHCA were included. The influence of gender on 30-day survival and good neurological outcome (cerebral performance category of 1 or 2) were examined using Kaplan-Meier estimates and multivariable logistic regression.

Résultats : In total, 932 patients were analysed (239 women, 26%). Women were older (64 vs 60 years, p < 0.001) and less commonly had a shockable rhythm (47% vs 65%, P < 0.001) compared to men. Women were less likely to have a cardiac cause of arrest (54% vs. 75%, p < 0.001), received less therapeutic hypothermia (74% vs 86%, p < 0.001) and coronary angiography (63% vs. 79%, p < 0.001). The overall 30-day survival was lower for women (45% vs. 53%, log-rank p = 0.005) as well as good neurological outcome (37% vs. 46%, p = 0.008). However, according to the multivariate logistic regression, gender was not associated with survival (OR 0.98, 95% CI 0.65-1.50, p = 0.94) nor with good neurological outcome (OR 0.91, 95% CI 0.59-1.40, p = 0.67).

Conclusion : Women admitted for OHCA to a cardiac center had a different cause of arrest that had a different treatment and outcome compared to men. Survival and good neurological outcome were lower in women, however, after adjusting for baseline characteristics, gender was not associated with survival nor neurological outcome.

Conclusion (proposition de traduction) : Les femmes admises pour un arrêt cardiaque en dehors de l'hôpital dans un service de cardiologie avaient des causes d'arrêt cardiaque différentes dont le traitement et les résultats étaient différents par rapport aux hommes. La survie et les bons résultats neurologiques étaient plus faibles chez les femmes, cependant, après ajustement pour les caractéristiques de base, le sexe n'était pas associé à la survie ni aux résultats neurologiques.

Andexanet alfa versus four-factor prothrombin complex concentrate for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhages.
Pham H, Medford WG, Horst S, Levesque M, Ragoonanan D, Price C, Colbassani H, Piper K, Chastain K. | Am J Emerg Med. 2022 May;55:38-44
DOI: https://doi.org/10.1016/j.ajem.2022.02.029
Keywords: Antidotes; Apixaban; Cerebral hemorrhage; Direct factor Xa inhibitor; Direct-acting oral anticoagulant; Factor Xa inhibitor; Hemostasis; Intracranial hemorrhages; Prothrombin complex concentrate; Rivaroxaban.

Original contribution

Introduction : Existing research recommends either andexanet alfa (AA) or four-factor prothrombin complex concentrate (4F-PCC) as an antidote for major bleeding events due to apixaban or rivaroxaban. Currently, there is limited published research that directly compares the risks and benefits of the two agents in patients with oral factor Xa inhibitor related traumatic and spontaneous intracerebral hemorrhages. Additional head-to-head data is needed to support favoring either AA or 4F-PCC when it comes to efficacy, safety, and cost.

Méthode : A retrospective chart review was conducted to assess patients admitted to a multi-center healthcare system and a stand-alone teaching hospital in central Florida from June 2016 to December 2020. Patients included in the study were at least 18 years of age, taking apixaban or rivaroxaban prior to admission, had radiographical evidence of an intracranial hemorrhage, and received either AA or 4F-PCC as a reversal agent. The primary outcome analyzed was the level of excellent hemostasis achieved, based on a standardized rating system for effective hemostasis defined by the International Society of Thrombosis and Hemostasis (ISTH), after administration of AA or 4F-PCC. Secondary outcomes analyzed included changes in the initial hemorrhage volume as reported on computed tomography (CT) scan and at 12 to 24 h post treatment, rate of thromboembolic events, rate of inpatient mortality, and total cost of treatment after AA or 4F-PCC administration.

Résultats : A total of 109 patients were included in the study with 47 in the AA group (43.1%) and 62 in the 4F-PCC group (56.9%). There were no statistically significant differences between AA and 4F-PCC in terms of the primary and secondary outcomes with the exception of total cost of treatment. The level of excellent hemostasis achieved after reversal administration of AA was seen in 27 patients (71.1%) and 41 patients (70.7%) after 4F-PCC administration (p = 1, p adjusted = 0.654 after controlling for age, ICH score, regional mass effect, and midline shift). There was no statistically significant difference in the median percentage change in hemorrhagic volume from baseline to 12-24 h after reversal treatment (0 [-0.17--0.24] vs. 0 [-0.021-0.29], p = 0.439, adjusted p = 0.601) in the AA and 4F-PCC groups, respectively. The total incidence of thromboembolic events (4 [8.5%] vs. 6 [9.7%], p = 1, adjusted p = 0.973) and rate of inpatient mortality was similar between the two groups (16 [34.0%] vs. 13 [21.0%], p = 0.134, adjusted p = 0.283). A statistically significant difference was observed with the total cost of reversal treatment: $23,602 for treatment with AA and $6692 for treatment with 4F-PCC.

Conclusion : No statistically significant differences were identified in primary or secondary outcomes between the two agents with the exception of total treatment cost. There is insufficient evidence based on this study to recommend AA over 4F-PCC for patients with intracranial hemorrhages associated with the use of apixaban or rivaroxaban.

Conclusion (proposition de traduction) : Aucune différence statistiquement significative n'a été identifiée dans les résultats primaires ou secondaires entre les deux agents, à l'exception du coût total du traitement. Il n'y a pas suffisamment de preuves basées sur cette étude pour recommander l'andexanet alfa (Ondexxya®) plutôt que le concentré de complexe prothrombique à quatre facteurs chez les patients présentant des hémorragies intracrâniennes associées à l'utilisation d'apixaban (Eliquis®) ou de rivaroxaban (Xarelto®).

Commentaire : Une autorisation de mise sur le marché (AMM) européenne conditionnelle a été accordée en avril 2019 pour l'andexanet alfa (Ondexxya®), premier antidote aux anticoagulants oraux directs (AOD) anti-facteur Xa apixaban (Eliquis®, Bristol-Myers Squibb/Pfizer) et rivaroxaban (Xarelto®, Bayer/Johnson & Johnson).
Les complexes prothrombiques à quatre facteurs (PPSB) : Kanokad®, Confidex®, Octaplex® sont facile d’accès et peu coûteux.
L’idarucizumab (Plaxbind®), agent de neutralisation spécifique visant le dabigatran (Pradaxa®), est actuellement le seul antidote spécifique disponible.

Implementation of a geriatric emergency medicine assessment team decreases hospital length of stay.
Keene SE, Cameron-Comasco L. | Am J Emerg Med. 2022 May;55:45-50
DOI: https://doi.org/10.1016/j.ajem.2022.02.027
Keywords: Cost Savings; Geriatric Assessment; Geriatrics; Quality Improvement.

Original contribution

Introduction : Patients over the age of 65 who present to the Emergency Department (ED) are more likely to be admitted to the hospital and, if admitted, often have a longer length of stay (LOS) in the hospital than younger patients.
To determine if assessment and intervention by a Geriatric Emergency Medicine Assessment (GEMA) team would decrease the admission rate and reduce the hospital LOS for admitted geriatric patients.

Méthode : We conducted a case-control study of the impact of a GEMA team in a large ED. The team screened patients ≥65 years of age for functional decline to determine the need for targeted interventions. Potential interventions included: occupational therapy consultation in the ED, rehabilitation placement, geriatric clinic referral, and delirium management. Our control population was unassessed geriatric ED patients seen in the six months before and after GEMA team implementation.

Résultats : A total of 815 patients were assessed between June and November 2019. Assessed patients were more likely to be discharged from the ED (54% vs 29%, OR 2.06). Mean ED LOS was nineteen minutes longer in assessed patients (4.94 vs 4.62 h, p < 0.01). The mean hospital LOS was 25 h less in assessed patients (4.50 vs 5.54 days, p < 0.01). Assessed and unassessed patients who were admitted to the hospital had the same baseline health status as measured by the Charlson Comorbidity Index (median score 2, p = 0.087). The reduction in hospital LOS resulted in an estimated savings of $1.7 million per year using the national average cost for 24 h of inpatient care.

Conclusion : Patients who were assessed by the GEMA team were more likely to be discharged directly from the ED, and if admitted, hospital LOS was reduced by over 24 h. This indicates that a targeted intervention in the ED can help reduce hospital LOS in geriatric patients and therefore provide cost savings.

Conclusion (proposition de traduction) : Les patients qui ont été évalués par l'équipe d'évaluation de médecine d'urgence gériatrique étaient plus susceptibles d'être renvoyés directement du service des urgences et, s'ils étaient admis, la durée de séjour à l'hôpital était réduite de plus de 24 h. Cela indique qu'une intervention ciblée au service des urgences peut aider à réduire la durée d'hospitalisation des patients gériatriques et donc à réduire les coûts.

Effectiveness and safety of tranexamic acid in pediatric trauma: A systematic review and meta-analysis.
Kornelsen E, Kuppermann N, Nishijima DK, Ren LY, Rumantir M, Gill PJ, Finkelstein Y. | Am J Emerg Med. 2022 May;55:103-110
DOI: https://doi.org/10.1016/j.ajem.2022.01.069
Keywords: Children; Injury; Tranexamic acid; Trauma.

Original contribution

Introduction : Trauma is the leading cause of childhood death in the United States. Our goal was to determine the effectiveness of tranexamic acid (TXA) in improving survival in pediatric trauma.

Méthode : MEDLINE (OVID), Embase (OVID), Cochrane Central Register databases, CINAHL (EBSCO), Web of Science (Clarivate Analytics), and grey literature sources were searched for publications reporting survival and safety outcomes in children receiving TXA in acute trauma, with no language restrictions, published until February 11, 2021. Two independent researchers assessed studies for eligibility, bias, and quality. Data on the study setting, injury type, participants, design, interventions, TXA dosing and outcomes were extracted. The primary outcome was survival in children who received TXA following trauma. Forest plots of effect estimates were constructed for each study. Heterogeneity was assessed and data were pooled by meta-analysis using a random-effects model.

Résultats : Fourteen articles met inclusion criteria - six single-institution and eight multicentre retrospective cohort studies. Overall, TXA use was not associated with increased survival in pediatric trauma (adjusted odds ratio [aOR]: 0.61, 95% CI: 0.30-1.22) after adjustment for patient-level variables, such as injury severity. Increased survival was documented in the subset of children experiencing trauma in combat settings (aOR for mortality: 0.31, 95% CI: 0.14-0.68). There were no differences in the odds of thromboembolic events (OR 1.15, 95% CI: 0.46-2.87) in children who received TXA versus not.

Conclusion : The utility of TXA in children with trauma is unclear. Guidelines supporting TXA use in pediatric trauma may not be based on the available evidence of its use in this context. Rigorous trials measuring survival and other meaningful outcomes and exploring optimal TXA dosing are urgently needed

Conclusion (proposition de traduction) : L'utilité de l'acide tranexamique chez les enfants traumatisés n'est pas claire. Les lignes directrices à l'appui de l'utilisation de l'acide tranexamique dans les traumatismes en pédiatrie peuvent ne pas être fondées sur les données probantes disponibles concernant son utilisation dans ce contexte. Des essais rigoureux mesurant la survie et d'autres résultats significatifs et explorant le dosage optimal de l'acide tranexamique sont nécessaires d’urgence.

Procainamide for shockable rhythm cardiac arrest in the Resuscitation Outcome Consortium.
Huebinger R, Harvin JA, Chan HK, Idris A, Cooper B, Giordano J, Wang HE. | Am J Emerg Med. 2022 May;55:143-146
DOI: https://doi.org/10.1016/j.ajem.2022.02.031
Keywords: Cardiac arrest; Out-of-hospital cardiac arrest; Procainamide.

Original contribution

Introduction : With recent negative studies of amiodarone and lidocaine for cardiac arrest, research into other antiarrhythmics is warranted. Literature on procainamide in cardiac arrest is limited. We evaluated procainamide for out-of-hospital cardiac arrests (OHCA) from the Resuscitation Outcomes Consortium (ROC).

Méthode : We included all ROC Epistry 3 OHCAs with an initial shockable rhythm that received an antiarrhythmic. We stratified cases by antiarrhythmic: procainamide, amiodarone, or lidocaine. The outcomes were prehospital return of spontaneous circulation (ROSC), ROSC in the ED, and survival to hospital discharge. We defined propensity scores based on possible confounders utilizing 1:1 propensity score matching to compare procainamide to amiodarone and lidocaine. We analyzed the matched data using logistic regression. We also used multivariable logistic regression to evaluate the association between antiarrhythmic and outcomes.

Résultats : 3087 subjects met inclusion criteria; 51 patients received only procainamide, 1776 received amiodarone, and 1418 received lidocaine. On propensity score analysis and compared to procainamide, amiodarone had similar prehospital ROSC (OR 0.7, 95% CI 0.3-1.8), ED ROSC (OR 0.6, 95% CI 0.3-1.3), and survival (OR 1.0, 95% CI 0.3-3.1). Lidocaine also had a similar prehospital ROSC (OR 0.9, 95% CI 0.4-2.2), ED ROSC (OR 1.2, 95% CI 0.5-2.7), and survival (OR 1.4, 95% CI 0.5-4.0). However, using multivariable regression, amiodarone had lower prehospital ROSC than procainamide (aOR 0.3, 95% CI 0.1-0.6).

Conclusion : While associated with increased prehospital ROSC when compared with amiodarone using multivariable regression, procainamide otherwise had similar prehospital ROSC, ED ROSC, and survival. The role of procainamide in OHCA remains unclear.

Conclusion (proposition de traduction) : Bien qu’il ait été associé à une augmentation du retour à une activité circulatoire spontanée (RACS) en préhospitalier par rapport à l’amiodarone en utilisant une régression multivariable, le procaïnamide a par ailleurs présenté des taux similaires de RACS en préhospitalière, de RACS aux urgences et de survie. Le rôle du procaïnamide dans les arrêts cardiaques extra-hospitaliers demeure incertain.

Commentaire : Le procaïnamide (non commercialisé en France) est un calcium bloqueur, antiarythmique de classe « Ia » dans la classification de Vaughan Williams, utilisé pour le traitement médical des arythmies cardiaques, il ralentit la conduction cardiaque et donc le rythme cardiaque. Il peut être utilisé pour effectuer une « cardioversion chimique », particulièrement dans les cas de fibrillation auriculaire et tachycardies causées par un phénomène de réentrée.

The impact of prehospital endotracheal intubation on mortality in traumatic brain injury.
Jung E, Cho YS, Ryu SJ, Kim DK, Lee JH, Han JH. | Am J Emerg Med. 2022 May;55:152-156
DOI: https://doi.org/10.1016/j.ajem.2022.02.001
Keywords: Endotracheal intubation; Hypercarbia; Hypocarbia; Traumatic brain injury.

Original contribution

Introduction : Our study aimed to evaluate whether prehospital endotracheal intubation (ETI) affects the mortality of individuals who sustain traumatic brain injury (TBI) compared with bag-valve mask (BVM) ventilation, as well as to test the interaction effect of ETI on study outcome according to carbon dioxide level.

Méthode : Our retrospective study involving patients who experienced TBI between January 2019 and December 2020. The main exposure variable was the prehospital airway management technique (ETI vs. BVM) performed by emergency medical service technicians and the primary outcome was survival at hospital discharge and the secondary outcome was good functional recovery at hospital discharge and six-month survival. We performed multivariable logistic regression analysis and interaction analysis between the prehospital airway management and blood level of carbon dioxide for adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

Résultats : Of 562 eligible patients, 79 (14.1%) underwent ETI and 483 (85.9%) underwent BVM ventilation. After adjusting for possible confounders, TBI patients in the ETI group has a significantly lower likehood of survival to discharge than those in the BVM group (aOR 0.57 (0.41-0.73). In interaction analysis, the rates of survival to discharge and 6-month survival with ETI were significantly lower only in groups with hypocarbia (AOR 0.61 [95% CI 0.49-0.72] and AOR 0.82 [95% CI 0.65-0.99], respectively).

Conclusion : Among individuals who experienced severe TBI, prehospital intubation did not have a significant effect on survival outcomes and good functional recovery. Patients exhibiting hypocarbia measured on hospital arrival demonstrated lower survival outcomes in the interaction analysis.

Conclusion (proposition de traduction) : Parmi les patient ayant subi un traumatisme crânien grave, l'intubation en préhospitalier n'a pas eu d'effet significatif sur les résultats de survie et une bonne récupération fonctionnelle. Les patients présentant une hypocapnie mesurée à l'arrivée à l'hôpital ont présenté des résultats de survie inférieurs dans l'analyse des interactions.

The impact of prehospital endotracheal intubation on mortality in traumatic brain injury.
Jung E, Cho YS, Ryu SJ, Kim DK, Lee JH, Han JH. | Am J Emerg Med. 2022 May;55:152-156
DOI: https://doi.org/10.1016/j.ajem.2022.02.001
Keywords: Endotracheal intubation; Hypercarbia; Hypocarbia; Traumatic brain injury.

Original contribution

Introduction : Our study aimed to evaluate whether prehospital endotracheal intubation (ETI) affects the mortality of individuals who sustain traumatic brain injury (TBI) compared with bag-valve mask (BVM) ventilation, as well as to test the interaction effect of ETI on study outcome according to carbon dioxide level.

Méthode : Our retrospective study involving patients who experienced TBI between January 2019 and December 2020. The main exposure variable was the prehospital airway management technique (ETI vs. BVM) performed by emergency medical service technicians and the primary outcome was survival at hospital discharge and the secondary outcome was good functional recovery at hospital discharge and six-month survival. We performed multivariable logistic regression analysis and interaction analysis between the prehospital airway management and blood level of carbon dioxide for adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

Résultats : Of 562 eligible patients, 79 (14.1%) underwent ETI and 483 (85.9%) underwent BVM ventilation. After adjusting for possible confounders, TBI patients in the ETI group has a significantly lower likehood of survival to discharge than those in the BVM group (aOR 0.57 (0.41-0.73). In interaction analysis, the rates of survival to discharge and 6-month survival with ETI were significantly lower only in groups with hypocarbia (AOR 0.61 [95% CI 0.49-0.72] and AOR 0.82 [95% CI 0.65-0.99], respectively).

Conclusion : Among individuals who experienced severe TBI, prehospital intubation did not have a significant effect on survival outcomes and good functional recovery. Patients exhibiting hypocarbia measured on hospital arrival demonstrated lower survival outcomes in the interaction analysis.

Conclusion (proposition de traduction) : Parmi les patient ayant subi un traumatisme crânien sévère (ndlr : nom classiquement donné au traumatisme crânien grave), l'intubation en préhospitalier n'a pas eu d'effet significatif sur les résultats de survie et la bonne récupération fonctionnelle. Les patients présentant une hypocapnie mesurée à l'arrivée à l'hôpital ont présenté des résultats de survie inférieurs dans l'analyse des interactions.

Commentaire : L'hypocapnie (conséquence d'une hyperventilation) induit une hypoxie cérébrale associée à un moins bon pronostic neurologique chez les traumatisés crâniens sévères.
L'hyperventilation est définie par la présence au cours d’une analyse des gaz du sang d’une PaCO2 < 35 mmHg et d’un pH > 7,45 et l’hyperventilation sévère par des taux de PaCO2 < 30 mmHg et d’un pH > 7,50.

Les principales ACSOS (Agressions cérébrales Secondaires d'Origine systémique) sont :
• l’hypotension artérielle ;
• l’hypo- ou l’hypercapnie ;
• un apport en O2 insuffisant par rapport aux besoins du patient : hypoxémie, anémie, débit cardiaque insuffisant ;
• une augmentation de la consommation cérébrale en O2 (CMRO2) : sédation insuffisante, hyperthermie, crise d’épilepsie ;
• l’hyponatrémie ;
• l’hypo- ou l’hyperglycémie.

Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis.
Pence M, Tran QK, Shesser R, Payette C, Pourmand A. | Am J Emerg Med. 2022 May;55:157-166
DOI: https://doi.org/10.1016/j.ajem.2022.03.004
Keywords: Congestive heart failure; End stage renal disease; Sepsis; Septic shock; Volume overload.

Original contribution

Introduction : The outcomes of large-volume IVF administration to septic shock patients with comorbid congestive heart failure (CHF) and/or end-stage renal disease (ESRD) are uncertain and widely debated in the existing literature. Despite this uncertainty, CMS continues to recommend that 30 ml/kg of an intravenous crystalloid solution be administered to patients in septic shock starting within 3 h of presentation. We performed a systematic review and meta-analysis to assess the relationship between adherence to this guideline and outcomes among patients whose underlying comorbidities present a risk of fluid overload.

Méthode : Our search was conducted on PubMed and Scopus through November 5, 2021 to identify studies that evaluated clinical outcomes among septic patients with CHF/ESRD based on volume of fluid administered. The primary outcome measured was mortality at 30 days post-hospital discharge. Other outcomes included the rates of vasopressor requirements, invasive mechanical ventilation during hospitalization, as well as length of stay in the intensive care unit and/or hospital. We used random effects meta-analysis when two or more studies reported the same outcome.

Résultats : We included five studies in the final meta-analysis, which comprised 5804 patients, 5260 (91%) of whom received non-aggressive fluid resuscitation, as defined by the studies' authors. Random-effects meta-analysis for all-cause mortality showed that aggressive fluid resuscitation was associated with statistically non-significant increased odds of mortality (OR 1.42, 95% CI 0.88-2.3, P = 0.15, I2 = 35%). There was no statistical association between volume of IVF administration and other outcomes evaluated.

Conclusion : Among septic shock patients with CHF and/or ESRD, administration of greater than or equal to 30 ml/kg IVF was associated with a non-significant increase in odds of mortality. All other outcomes measured were found to be non-significant, although there was a trend toward better outcomes among patients in the restricted-volume compared to the standard-volume IVF groups. Since this meta-analysis only included five observational studies, more studies are needed to guide an optimal volume and rate of fluid administration in this patient population.

Conclusion (proposition de traduction) : Chez les patients en choc septique avec insuffisance cardiaque congestive et/ou insuffisance rénale terminale, l'administration de liquides intraveineux supérieurs ou égaux à 30 ml/kg a été associée à une augmentation non significative du risque de mortalité. Tous les autres résultats mesurés se sont avérés non significatifs, bien qu'il y ait eu une tendance vers de meilleurs résultats chez les patients du groupe à volume restreint par rapport aux groupes de fluides intraveineux à volume standard. Étant donné que cette méta-analyse ne comprenait que cinq études observationnelles, d'autres études sont nécessaires pour guider un volume et un débit optimaux d'administration de liquide dans cette population de patients.

Commentaire : Les CMS (Centers from Medicare & Medicaid Services) sont les agences fédérales du département américain de la Santé et des Services sociaux (HHS) qui administrent le programme Medicare et travaillent en partenariat avec les gouvernements des États pour administrer Medicaid, le programme d'assurance maladie pour enfants (Children's Health Insurance Program, CHIP) et les normes de portabilité de l'assurance maladie (normes de qualité dans les établissements de soins de longue durée [plus communément appelés Nursing homes] grâce à son processus d'enquête et de certification, aux normes de qualité des laboratoires cliniques en vertu des amendements pour l'amélioration des laboratoires cliniques [Clinical Laboratory Improvement Amendments] et à la supervision de HealthCare.gov).

An assessment on the use of infra-scanner for the diagnosis of the brain hematoma in head trauma.
Esmaeili S, Mojtahed M, Mirzaasgari Z, Masoumi G, Alavi SNR, Abolmaali M, Chaibakhsh S, Naderkhani M, Famouri A, Allahdadian S, Gharab SG, Joghataei MT, Motamed MR, Zabeti A, Shirani P. | Am J Emerg Med. 2022 May;55:174-179
DOI: https://doi.org/10.1016/j.ajem.2021.09.074
Keywords: Brain injury; CT scan; Head injury; Hematoma; Infra-scanner; NIR sensors.

Original contribution

Introduction : Timely identification and treatment of intracranial hematomas in patients with brain injury is essential for successful treatment. This study evaluates Infra-scanner as a handy medical screening tool for diagnosing, on-site, cerebral hematomas in patients with head injury.

Méthode : Patients referred to the emergency department of university hospitals with mild to moderate brain trauma, up to 12 h from injury were included. NIR sensors of infra-scan device were placed on the right and left frontal, temporal, peritoneal and occipital parts of the head and light absorption was recorded. Positive or negative cerebral hemorrhage cases were compared with contrast-enhanced CT scan results as the gold standard. Diagnostic parameters of the device and cases related to bleeding were analyzed and reported.

Résultats : A total of 300 patients were studied. Sensitivity of the infrasound scanner in the Iranian study population was 94.8 (95% CI: 88% -100) and its specificity was 86.9 (95% CI: 79% -99% 99). Negative predictive value (NPV) was 90.3% and positive predictive value (PPV) was 92.9%. Sensitivity in men (95.7%) (95%CI, 90% -1) was more than women (95% CI, 81% -99%)90%. At the ages of less than 36 years, sensitivity (95.3%) and specificity (87.1%) were more than sensitivity (94.4%) and specificity (86.5%) over 36 years old. If the test had been performed in less than / equal to two hours from trauma, the sensitivity (94.9%) and the specificity (92%) were greater than the sensitivity (94.6%) and the specificity (75%) during when the scan had been performed in more than two hours from trauma. In general, in extra-axial bleeding including EDH, SAH, SDH, the sensitivity was 95.1% and the specificity was 84.5%, while in intra-axial bleeding, including ICH and IVH, the sensitivity was lower (93.9%) and the specificity was 91.7. The sensitivity of the device in detecting bleeding in the occipital lobe (95.8%) was higher than other brain lobes.

Conclusion : This study shows that Infra-scanner is useful in initial examination and screening of patients with head injury and can be used as an adjunct to a CT scan or when not available and may allow earlier treatment which reduce the secondary damage to the hematoma.

Conclusion (proposition de traduction) : Cette étude montre que l'infra-scanner est utile dans l'examen initial et le dépistage des patients présentant un traumatisme crânien et peut être utilisé en complément d'un scanner ou lorsqu'il n'est pas disponible et peut permettre un traitement plus précoce qui réduit les dommages secondaires à l'hématome.

Commentaire : L'infrascanner (ou Handheld Brain Scanner)
C'est un outil de diagnostique simple à utiliser qui fourni un réponse positive ou négative grâce à un code couleur sur plusieurs surfaces du crane.
Il détecte les hémorragies cérébrales supérieures à 3,5 cc de volume, et jusqu’à 2,5 cm de profondeur.
La mesure est prise en seulement 2 à 3 minutes.
C'est une analyse non invasive en 8 points symétriques : comparaison des 2 hémisphères du cerveau grâce à la technologie des rayons infrarouges.
Il permet de localiser la zone et la taille de l’hémorragie, et de monitorer l’évolution de l’état de la victime (prises de mesures régulières).

IFS Brochure 1 9 15  
Poids : 400 grammes. Produit : Infrascanner® 2000

The Journal of Emergency Medicine

Modified Shock Index as a Predictor for Mortality and Hospitalization Among Patients With Dementia.
Sadeh R, Shashar S, Shaer E, Slutsky T, Sagy I, Novack V, Zeldetz V. | J Emerg Med. 2022 May;62(5):590-599
DOI: https://doi.org/10.1016/j.jemermed.2021.12.023
Keywords: Modified shock index; dementia; emergency department.

Original Contribution

Introduction : One in four older adults in the Emergency Department (ED) suffers from severe cognitive impairment, creating great difficulty for the emergency physicians who determine the urgency of their patients' condition, which informs decisions regarding discharge or hospitalization.
Objective: Our objective was to determine whether modified shock index (MSI) can be a clinical mortality and hospitalization predictor when applied to older patients with dementia in the ED.

Méthode : Included in the research were all patients with dementia, > 65 years old, who arrived at the Soroka University Medical Center ED during 2014-2017. The population was divided into three groups according to their MSI score, calculated as heart rate/mean arterial pressure: MSI < 0.7; 0.7 > MSI < 1.3; and MSI > 1.3. We performed multivariable logistic regression as a predictor of death within 30 days, Cox analysis for number of days to death, and a negative binominal regression for predicting the number of admission days.

Résultats : Included were 1437 patients diagnosed with dementia. Patients with an MSI > 1.3 vs. those with MSI < 0.7 had an odds ratio of 8.23 (95% confidence interval [CI] 4.64-4.54) for mortality within 30 days, increased mortality risk within 180 days (hazard ratio 4.42; 95% CI 2.64-7.41), and longer hospitalization duration (incidence rate ratio 1.8; 95% CI 1.32-2.45).

Conclusion : High MSI scores were associated with high mortality rates and longer hospitalization duration for patients diagnosed with dementia who were > 65 years old. We suggest performing prospective studies utilizing the MSI score as an indicator in ED triage settings to classify patients with dementia by their severity of risk, to determine if this benefits health, minimizes expenses, and prevents unnecessary hospitalizations.

Conclusion (proposition de traduction) : Des scores élevés de Shock Index modifié étaient associés à des taux de mortalité élevés et à une durée d'hospitalisation plus longue pour les patients diagnostiqués avec une démence âgés de plus de 65 ans. Nous suggérons de réaliser des études prospectives utilisant le Shock Index modifié comme indicateur dans les contextes de triage à l'urgence pour classer les patients atteints de démence en fonction de la gravité de leur risque, afin de déterminer si cela est bénéfique pour la santé, minimise les dépenses et évite les hospitalisations inutiles.

A Multicenter, Prospective Study Comparing Subxiphoid and Parasternal Views During Brief Echocardiography: Effect on Image Quality, Acquisition Time, and Visualized Anatomy.
Gaspari RJ, Gleeson T, Alerhand S, Caputo W, Damewood S, Dicroce C, Dwyer K, Gibbons R, Greenstein J, Harvey J, Hill M, Hoffmann B, Jordan MK, Karfunkle B, Kropf C, Lindsay R, Luo S, Lusiak M, Nalbandian A, Naraghi L, Nelson B, Nickels LC, Nolting L, Nordberg A, Panicker A, Pare J, Peach M, Pinto D, Graham P, Rose G, Russell F, Schafer J, Scheatzle M, Schnittke N, Shpilko M, Soucy Z, Stowell JR, Vryhof D, Gottlieb M. | J Emerg Med. 2022 May;62(5):648-656
DOI: https://doi.org/10.1016/j.jemermed.2021.10.032
Keywords: cardiac arrest; echocardiography; parasternal long; resuscitation; subxyphoid; ultrasound.

Original contribution

Introduction : Recent literature has suggested echocardiography (echo) may prolong pauses in chest compressions during cardiac arrest.
Objectives: We sought to determine the impact of the sonographic approach (subxiphoid [SX] vs. parasternal long [PSL]) on time to image completion, image quality, and visualization of cardiac anatomy during echo, as performed during Advanced Cardiac Life Support.

Méthode : This was a multicenter, randomized controlled trial conducted at 29 emergency departments (EDs) assessing the time to image acquisition and image quality between SX and PSL views for echo. Patients were enrolled in the ED and imaged in a simulated cardiac arrest scenario. Clinicians experienced in echo performed both SX and PSL views, first view in random order. Image quality and time to image acquisition were recorded. Echos were evaluated for identification of cardiac landmarks. Data are presented as percentages or medians with interquartile ranges (IQRs).

Résultats : We obtained 6247 echo images, comprising 3124 SX views and 3123 PSL. Overall time to image acquisition was 9.0 s (IQR 6.7-14.1 s). Image acquisition was shorter using PSL (8.8 s, IQR 6.5-13.5 s) compared with SX (9.3 s, IQR 6.7-15.0 s). The image quality was better with the PSL view (3.86 vs. 3.54; p < 0.0001), twice as many SX images scoring in the worst quality category compared with PSL (8.6% vs. 3.7%). Imaging of the pericardium, cardiac chambers, and other anatomic landmarks was superior with PSL imaging.

Conclusion : Echo was performed in < 10 s in > 50% of patients using either imaging technique. Imaging using PSL demonstrated improved image quality and improved identification of cardiac landmarks.

Conclusion (proposition de traduction) : L'écho a été réalisée en < 10 s chez > 50 % des patients utilisant l'une ou l'autre des techniques d'imagerie. L'incidence parasternale grand axe a longtemps été considérée comme ayant une meilleure qualité d'image et une meilleure identification des repères cardiaques.

Commentaire :  Éléments anatomiques visibles par l'imagerie cardiaque en incidence parasternale grand axe et sous-costale 4 cavités.
Les données sont présentées en pourcentage de toutes les images où les zones anatomiques cardiaques ont été visualisées. Les zones pour la coupe sous-costale 4 cavités comprennent les cavités (ventricule gauche et droit, oreillette gauche et droite), les valves (mitrale et tricuspide), le myomètre (parois latérales, septum, apex et base) et le péricarde (indiqué sur la figure au niveau de l'apex mais toute visualisation du péricarde était acceptée). Les zones pour la coupe parasternale grand axe comprennent les cavités (ventricule gauche et droit, oreillette gauche), les valves (mitrale et aortique), le myomètre (parois antérieures et postérieures, septum et apex), la chambre aortique et le péricarde (indiqué sur la figure à côté du canal de sortie aortique, mais toute visualisation du péricarde était acceptée).

Coupes échographie cardiaque, tiré de www.lexipatho.fr  

The Journal of Trauma and Acute Care Surgery

Beta blockade in TBI: Dose-dependent reductions in BBB leukocyte mobilization and permeability in vivo.
Lopez AJ, ElSaadani M, Jacovides CL, Georges A, Culkin MC, Ahmed S, Kumar MA, Kaplan LJ, Smith DH, Pascual JL. | J Trauma Acute Care Surg. 2022 May 1;92(5):781-791
DOI: https://doi.org/10.1097/ta.0000000000003537  | Télécharger l'article au format  
Keywords: Aucun

2021 AAST PODIUM PAPERS

Introduction : Traumatic brain injury (TBI) is accompanied by a hyperadrenergic catecholamine state that can cause penumbral neuroinflammation. Prospective human studies demonstrate improved TBI survival with beta blockade (bb), although mechanisms remain unclear. We hypothesized that deranged post-TBI penumbral blood brain barrier (BBB) leukocyte mobilization and permeability are improved by beta-blockade.

Méthode : CD1 male mice (n=64) were randomly assigned to severe TBI – controlled cortical impact: 6m/sec velocity, 1mm depth, 3mm diameter – or sham craniotomy, and IP injection of either saline or propranolol (1, 2 or 4mg/kg) every 12 hours for 2 days. At 48hrs, in vivo pial intravital microscopy visualized live endothelial-leukocyte (LEU) interactions and BBB microvascular leakage. Twice daily clinical recovery was assessed by regaining of lost body weight and the Garcia Neurological Test (GNT: motor, sensory, reflex, balance assessments). Brain edema was determined by hemispheric wet-to-dry ratios.

Résultats : Propranolol after TBI reduced both in vivo LEU rolling and BBB permeability in a dose-dependent fashion compared to no treatment (p<0.001). Propranolol reduced cerebral edema (p<0.001) and hastened recovery of lost body weight at 48 hours (p<0.01). Compared to no treatment (14.9 ± 0.2), 24-hour GNT scores were improved with 2 (15.8 ± 0.2, p=0.02) and 4 (16.1 ± 0.1, p=0.001) but not with 1mg/kg propranolol.

Conclusion : Propranolol reduces post-TBI LEU mobilization and microvascular permeability in the murine penumbral neurovasculature and leads to reduced cerebral edema. This is associated with hastened recovery of post-TBI weight loss and neurologic function with bb treatment. Dose-dependent effects frame a mechanistic relationship between beta blockade and improved human outcomes after TBI.

Conclusion (proposition de traduction) : Le propranolol réduit la mobilisation des leucocytes endothéliaux vivants et la perméabilité microvasculaire dans la pénombrale neurovasculaire murine après une lésion cérébrale traumatique et entraîne une réduction de l'œdème cérébral. Ceci est associé à une récupération accélérée de la perte de poids et de la fonction neurologique après une lésion cérébrale post-traumatique avec un traitement par bêta-bloquant. Les effets dépendants de la dose encadrent une relation mécaniste entre le bêta-bloquant et l'amélioration des résultats humains après une lésion cérébrale traumatique.

The effect of tranexamic acid dosing regimen on trauma/hemorrhagic shock-related glycocalyx degradation and endothelial barrier permeability: An in vitro model.
Carge M, Diebel LN, Liberati DM. | J Trauma Acute Care Surg. 2022 May 1;92(5):812-820
DOI: https://doi.org/10.1097/ta.0000000000003548
Keywords: Aucun

2021 AAST PODIUM PAPERS

Introduction : Improved outcomes with early tranexamic acid (TXA) following trauma hemorrhagic shock (T/HS) may be related to its antifibrinolytic, as well as anti-inflammatory properties. Previous in vitro studies have shown that early TXA administration protects against T/HS endothelial barrier dysfunction and associated glycocalyx degradation. An intact endothelial glycocalyx may protect against subsequent neutrophil mediated tissue injury. We postulated that early TXA administration would mitigate against glycocalyx damage and resultant neutrophil adherence and transmigration through the endothelial barrier. This was studied in vitro using a microfluidic flow platform.

Méthode : Human umbilical vein endothelial cell monolayers were subjected to control or shock conditions (hypoxia + epinephrine) followed by administration of TXA 90 minutes or 180 minutes later.

Résultats : "Early" TXA administration protected against glycocalyx degradation, biomarkers of increased permeability and the development of a fibrinolytic phenotype. This was associated with decreased neutrophil endothelial adherence and transmigration. There were no differences in low versus high TXA concentrations. The protective effects were only significant with "early" TXA administration.

Conclusion : There was a concentration and temporal effect of TXA administration on endothelial glycocalyx degradation. This was associated with "vascular leakiness" as indexed by the relative ratio of Ang-2/1 and polymorphonuclear neutrophil transmigration. Tranexamic acid if administered in patients with T/HS should be administered "early"; this includes in the prehospital setting.

Conclusion (proposition de traduction) : L'administration d'acide tranexamique a eu un effet de concentration et un effet dans le temps sur la dégradation du glycocalyx endothélial. Cet effet était associé à une "fuite vasculaire", indexée par le rapport relatif de l'angiopoïétine 2/1 et la transmigration des neutrophiles polymorphonucléaires. L'acide tranexamique, s'il est administré à des patients souffrant d'un choc hémorragique dû à un traumatisme, doit l'être "tôt", y compris dans le contexte préhospitalier.

The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation.
Tatebe LC, Schlanser V, Hampton D, Chang G, Hanson I, Doherty J, Issa N, Ghandour H, Kingsley S, Stewart A, Anstadt M, Dennis A. | J Trauma Acute Care Surg. 2022 May 1;92(5):890-896
DOI: https://doi.org/10.1097/ta.0000000000003491
Keywords: Aucun

INDEPENDENT SUBMISSION

Introduction : As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation.

Méthode : Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05.

Résultats : A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission.

Conclusion : Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control.

Conclusion (proposition de traduction) : Il est toujours difficile de déterminer quelles lésions nécessitent des garrots plutôt que des pansements compressifs. Les sauveteurs formés présentaient des taux élevés de poses superflues et inadéquates. Alors que la généralisation des garrots se poursuit, l'accent doit être mis sur l'amélioration de la formation, le développement des dispositifs et le contrôle de la qualité.

The New England Journal of Medicine

Preeclampsia.
Magee LA, Nicolaides KH, von Dadelszen P. | N Engl J Med. 2022 May 12;386(19):1817-1832
DOI: https://doi.org/10.1056/nejmra2109523
Keywords: Aucun

REVIEW ARTICLE

Editorial : Preeclampsia, which complicates 2 to 4% of pregnancies globally, is progressive, unpredictable, and serious. It is associated with approximately 46,000 maternal deaths and approximately 500,000 fetal and newborn deaths annually. The disease burden is borne disproportionately by women in low- and middle-income countries or who are otherwise disadvantaged. Much of the literature focuses on preterm preeclampsia, which accounts for up to one third of cases and is associated with a much higher risk of maternal and fetal or newborn complications than preeclampsia at term. However, a much larger number of women have term disease, which makes a substantial contribution to preeclampsia-related morbidity and mortality.

Conclusion : The American Heart Association lists hypertension during pregnancy (including preeclampsia) as a major cardiovascular risk factor and recommends that affected women undergo cardiovascular risk screening within 3 months after giving birth. However, no cardiovascular prediction model adequately captures the 10-year risks among young women, and the development of a bespoke model in a large, population-based cohort was not successful. To further complicate matters, postpartum cardiovascular risk reduction has been challenged by suboptimal patient engagement, high attrition, and a lack of proven effectiveness in reducing the long-term risk of cardiovascular events. Nevertheless, many cardiovascular risk factors are modifiable and related to lifestyle, so at minimum, all women with prior preeclampsia should be offered lifestyle advice in accordance with national or international guidelines.

Conclusion (proposition de traduction) : L'American Heart Association classe l'hypertension pendant la grossesse (y compris la prééclampsie) parmi les principaux facteurs de risque cardiovasculaire et recommande aux femmes concernées de se soumettre à un dépistage du risque cardiovasculaire dans les trois mois suivant l'accouchement. Cependant, aucun modèle de prédiction cardiovasculaire ne rend compte de manière adéquate des risques à 10 ans chez les jeunes femmes et le développement d'un modèle sur mesure dans une grande cohorte basée sur la population n'a pas abouti. Pour compliquer encore les choses, la réduction du risque cardiovasculaire post-partum a été mise à mal par un engagement sous-optimal des patientes, une attrition élevée et un manque d'efficacité prouvée dans la réduction du risque à long terme d'événements cardiovasculaires. Néanmoins, de nombreux facteurs de risque cardiovasculaire sont modifiables et liés au mode de vie, de sorte qu'au minimum, toutes les femmes présentant des antécédents de prééclampsie devraient se voir proposer des conseils sur le mode de vie, conformément aux directives nationales ou internationales.

Commentaire :  Pathogénie de la prééclampsie. La réduction de l'apport sanguin utéroplacentaire, l'augmentation de la demande fœtoplacentaire ou les deux entraînent une inadéquation utéroplacentaire. Cela conduit à la libération de facteurs dérivés du stress du syncytiotrophoblaste placentaire (par exemple, des cytokines pro-inflammatoires ou des pro-inflammatoires ou débris placentaires) et un déséquilibre des taux circulants de facteur de croissance placentaire proangiogène et de de la tyrosine kinase 1 soluble de type fms (sFlt-1). Des perturbations moins graves de ces facteurs entraîneront une maladie clinique chez les femmes ayant une prédisposition maternelle. femmes ayant une prédisposition maternelle, comme indiqué. Il en résulte une dérégulation endothéliale systémique, une inflammation systémique excessive et, en fin de compte, des problèmes de santé maternelle et infantile. et finalement, des manifestations maternelles et fœtales de prééclampsie. Les flèches en pointillés indiquent que ces processus peuvent également entraîner d'autres syndromes placentaires, même en l'absence de manifestations cliniques de la prééclampsie. prééclampsie. Les manifestations de la prééclampsie sont particulièrement susceptibles de se produire chez les femmes présentant une prédisposition qui est liée à des conditions préexistantes (par exemple, obésité, diabète et hypertension chronique). L'annotation "Mixte" indique que les types de pathogénie ne sont pas distincts ou mutuellement exclusifs. ALT alanine aminotransférase, AST aspartate aminotransférase, BP pression sanguine, DIC coagulation intravasculaire disséminée.

Prévention de la prééclampsie. Les femmes enceintes doivent être encouragées à faire de l'exercice pour réduire le risque de prééclampsie et pour leur santé générale. Avant 16 semaines de gestation, les femmes présentant un risque élevé de prééclampsie doivent être identifiées et se voir proposer de l'aspirine (≥100 mg par jour). Les femmes appartenant à des populations à faible consommation de calcium doivent se voir proposer un supplément de calcium, à une dose d'au moins 500 mg par jour, au cours de la seconde moitié de la grossesse. Les femmes nullipares à faible risque bénéficient d'un déclenchement du travail au cours de la 39e semaine de gestation, entre 39 semaines 0 jour et 39 semaines 4 jours de gestation.

The Ultrasound Journal

International consensus conference recommendations on ultrasound education for undergraduate medical students.
Hoppmann RA, and al.. | Ultrasound J. 2022 Jul 27;14(1):31
DOI: https://doi.org/10.1186/s13089-022-00279-1  | Télécharger l'article au format  
Keywords: Curriculum recommendations; Education; International consensus conference; Medical student; Ultrasound; Undergraduate.

Original article

Introduction : The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students.

Méthode : 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting.

Résultats : A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care.

Conclusion : The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Conclusion (proposition de traduction) : La conférence internationale de consensus a fourni le premier document complet de recommandations pour un programme d'études de base en échographie. Ce document reflète l'opinion d'un groupe diversifié et représentatif d'experts internationaux en échographie, de praticiens, d'enseignants et d'étudiants. Ces recommandations peuvent normaliser l'enseignement de l'échographie pour les étudiants en médecine de premier cycle tout en servant de base à des recherches supplémentaires sur l'enseignement de la médecine et l'application de l'échographie dans la pratique clinique.

World Journal of Emergency Medicine

Comparing the precision of the pSOFA and SIRS scores in predicting sepsis-related deaths among hospitalized -children: a multi-center retrospective cohort study.
Zhao C, Xin MY, Li J, Zhao JF, Wang YJ, Wang W, Gao Q, Chen J, Wang QW, Jin YP. | World J Emerg Med. 2022;13(4):259-265
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2022.060  | Télécharger l'article au format  
Keywords: Children; Infection; Mortality; SIRS; Simple-pSOFA; pSOFA.

Original Article

Introduction : The latest sepsis definition includes both infection and organ failure, as evidenced by the sequential organ failure assessment (SOFA) score. However, the applicability of the pediatric SOFA score (pSOFA) is not yet determined. This study evaluated the effectiveness of both pSOFA and system inflammatory reaction syndrome (SIRS) scores in predicting sepsis-related pediatric deaths.

Méthode : This is a retrospective multi-center cohort study including hospitalized patients <18 years old with diagnosed or not-yet-diagnosed infections. Multivariate analyses were carried out to evaluate risk factors for in-hospital mortality. According to Youden index (YI), three sub-categories of pSOFA were screened out and a new simplified pSOFA score (spSOFA) was formed. The effectiveness and accuracy of prediction of pSOFA, SIRS and spSOFA was retrieved from the area under the receiver operating characteristic curve (AUROC) and Delong's test.

Résultats : A total of 1,092 participants were eligible for this study, and carried a 23.4% in-hospital mortality rate. The 24-h elevated pSOFA score (24 h-pSOFA), bloodstream infection, and mechanical ventilation (MV) requirement were major risk factors associated with sepsis-related deaths. The AUROC analysis confirmed that the spSOFA provided good predictive capability in sepsis-related pediatric deaths, relative to the 24 h-pSOFA and SIRS.

Conclusion : The pSOFA score performed better than SIRS in diagnosing infected children with high mortality risk. However, it is both costly and cumbersome. We, therefore, proposed spSOFA to accurately predict patient outcome, without the disadvantages. Nevertheless, additional investigations, involving a large sample population, are warranted to confirm the conclusion of this study.

Conclusion (proposition de traduction) : Le score SOFA pédiatrique a obtenu de meilleurs résultats que le SIRS dans le diagnostic des enfants infectés à haut risque de mortalité. Cependant, il est à la fois coûteux et encombrant. Nous avons donc proposé un score SOFA pédiatrique simplifié pour prédire avec précision les résultats des patients, sans les inconvénients. Néanmoins, des investigations supplémentaires, impliquant un large échantillon de population, sont justifiées pour confirmer la conclusion de cette étude.

Comparing the precision of the pSOFA and SIRS scores in predicting sepsis-related deaths among hospitalized -children: a multi-center retrospective cohort study.
Zhao C, Xin MY, Li J, Zhao JF, Wang YJ, Wang W, Gao Q, Chen J, Wang QW, Jin YP. | World J Emerg Med. 2022;13(4):259-265
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2022.060  | Télécharger l'article au format  
Keywords: Children; Infection; Mortality; SIRS; Simple-pSOFA; pSOFA.

Original Article

Introduction : The latest sepsis definition includes both infection and organ failure, as evidenced by the sequential organ failure assessment (SOFA) score. However, the applicability of the pediatric SOFA score (pSOFA) is not yet determined. This study evaluated the effectiveness of both pSOFA and system inflammatory reaction syndrome (SIRS) scores in predicting sepsis-related pediatric deaths.

Méthode : This is a retrospective multi-center cohort study including hospitalized patients <18 years old with diagnosed or not-yet-diagnosed infections. Multivariate analyses were carried out to evaluate risk factors for in-hospital mortality. According to Youden index (YI), three sub-categories of pSOFA were screened out and a new simplified pSOFA score (spSOFA) was formed. The effectiveness and accuracy of prediction of pSOFA, SIRS and spSOFA was retrieved from the area under the receiver operating characteristic curve (AUROC) and Delong's test.

Résultats : A total of 1,092 participants were eligible for this study, and carried a 23.4% in-hospital mortality rate. The 24-h elevated pSOFA score (24 h-pSOFA), bloodstream infection, and mechanical ventilation (MV) requirement were major risk factors associated with sepsis-related deaths. The AUROC analysis confirmed that the spSOFA provided good predictive capability in sepsis-related pediatric deaths, relative to the 24 h-pSOFA and SIRS.

Conclusion : The pSOFA score performed better than SIRS in diagnosing infected children with high mortality risk. However, it is both costly and cumbersome. We, therefore, proposed spSOFA to accurately predict patient outcome, without the disadvantages. Nevertheless, additional investigations, involving a large sample population, are warranted to confirm the conclusion of this study.

Conclusion (proposition de traduction) : Le score SOFA pédiatrique a obtenu de meilleurs résultats que le SIRS dans le diagnostic des enfants infectés à haut risque de mortalité. Cependant, il est à la fois coûteux et encombrant. Nous avons donc proposé un score SOFA pédiatrique simplifié pour prédire avec précision les résultats des patients, sans les inconvénients. Néanmoins, des investigations supplémentaires, impliquant un large échantillon de population, sont justifiées pour confirmer la conclusion de cette étude.


Mois de mai 2022