Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial.
Ferguson I, Buttfield A, Burns B, Reid C, Shepherd S, Milligan J, Harris IA, Aneman A; Australasian College for Emergency Medicine Clinical Trials Network. | Acad Emerg Med. 2022 Jun;29(6):719-728
DOI: https://doi.org/10.1111/acem.14446 | Télécharger l'article au format
Méthode : The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre-specified target range of 100-150 mm Hg following the induction of anesthesia. Methods This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight-based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100-150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first-pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator-free days 30 days following enrollment.
Résultats : A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = -10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First-pass success rate, 30 day mortality, and ventilator-free days were similar.
Conclusion : There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine.
Conclusion (proposition de traduction) : Il n'y a pas eu de différence entre les groupes en ce qui concerne le résultat principal, bien que les pressions sanguines plus basses aient été plus fréquentes avec le fentanyl. Les cliniciens doivent tenir compte de l'hémodynamique de base et des objectifs post-induction lorsqu'ils décident d'utiliser le fentanyl comme agent de coinduction avec la kétamine.
Prehospital airway management in the pediatric patient: A systematic review.
Weihing VK, Crowe EH, Wang HE, Ugalde IT. | Acad Emerg Med. 2022 Jun;29(6):765-771
SYSTEMATIC REVIEWS (WITH OR WITHOUT META-ANALYSES)
Introduction : Critically ill children may require airway management to optimize delivery of oxygen and ventilation during resuscitation. We performed a systematic review of studies comparing the use of bag-valve-mask ventilation (BVM), supraglottic airway devices (SGA), and endotracheal intubation (ETI) in pediatric patients requiring prehospital airway management.
Méthode : We searched Ovid MEDLINE, EMBASE, and Cochrane databases for papers that compared SGA or ETI to BVM use in children, including studies that reported survival outcomes. We followed the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed study quality using the Newcastle-Ottawa Scale. We compared key characteristics of the candidate papers, including inclusion criteria, definitions of airway interventions, and association with outcomes.
Résultats : Of 773 studies, eight met criteria for inclusion. Only one study was a randomized controlled trial; the other seven studies were observational. Four studies compared ETI to BVM, two studies compared SGA to BVM, one study compared ETI to SGA, and two studies compared advanced airway management (AAM) to BVM. Primary outcomes varied, ranging from overall mortality and 24-h mortality to 1-month survival, hospital survival, and neurologically favorable survival. Four of the studies found no difference in survival with the use of ETI, and four found increased mortality with the use of ETI. Associations with outcomes could not be assessed by meta-analysis due to limited number of studies and the wide variation in the design, population, interventions, and outcome measures of the included studies.
Conclusion : In this systematic review, studies of prehospital pediatric airway management varied in scope, design, and conclusions. There was insufficient evidence to evaluate efficacy of pediatric prehospital airway management; however, the current research suggests that there are equal or worse outcomes with the use of ETI compared to other airway techniques. Additional clinical trials are needed to assess the merits of this practice.
Conclusion (proposition de traduction) : Dans cette revue systématique, les études sur la gestion préhospitalière des voies respiratoires en pédiatrie varient en termes de portée, de conception et de conclusions. Les données probantes étaient insuffisantes pour évaluer l'efficacité de la prise en charge préhospitalière des voies respiratoires chez l'enfant ; cependant, les recherches actuelles suggèrent que les résultats sont égaux ou pires avec l'utilisation de l'intubation endotrachéale par rapport aux autres techniques de prise en charge des voies respiratoires. Des essais cliniques supplémentaires sont nécessaires pour évaluer le bien-fondé de cette pratique.
PaO2 / FiO2 ratio responsiveness to prone positioning in intubated patients with severe COVID-19: a retrospective observational study.
Kawakami A, Yamakawa K, Nishioka D, Ota K, Kusaka Y, Umegaki O, Ito Y, Takasu A. | Acute Med Surg. 2022 Jun 4;9(1):e765
DOI: https://doi.org/10.1002/ams2.765 | Télécharger l'article au format
Keywords: Acute respiratory distress syndrome; COVID‐19; ECMO; PaO2/FiO2 ratio; prone positioning.
Introduction : Prone positioning of coronavirus disease 2019 (COVID-19) patients could improve oxygenation. However, clinical data on prone positioning of intubated COVID-19 patients are limited. We investigated trends of PaO2/FiO2 ratio values in patients during prone positioning to identify a predictive factor for early detection of patients requiring advanced therapeutic intervention such as extracorporeal membrane oxygenation (ECMO).
Méthode : This retrospective, observational cohort study was undertaken between April 2020 and May 2021 in a tertiary referral hospital for COVID-19 in Osaka, Japan. We included intubated adult COVID-19 patients treated with prone positioning within the first 72 h of admission to the intensive care unit and followed them until hospital discharge or death. Primary outcomes were in-hospital mortality and escalation of care to ECMO. We used unsupervised k-means clustering modeling to categorize COVID-19 patients by PaO2/FiO2 ratio responsiveness to prone positioning.
Résultats : The final study cohort comprised 54 of 155 consecutive severe COVID-19 patients. Three clusters were generated according to trends in PaO2/FiO2 ratios during prone positioning (cluster A, n = 16; cluster B, n = 24; cluster C, n = 14). Baseline characteristics of all clusters were almost similar. Cluster A (no increase in PaO2/FiO2 ratio during prone positioning) had a significantly higher proportion of patients placed on ECMO or who died (6/16, 37.5%). Numbers of patients with ECMO and with in-hospital death were significantly different between the three groups (p = 0.017).
Conclusion : In Japanese patients intubated due to COVID-19, clinicians should consider earlier escalation of treatment, such as facility transfer or ECMO, if the PaO2/FiO2 ratio does not increase during initial prone positioning.
Conclusion (proposition de traduction) : Chez les patients japonais intubés en raison d'une COVID-19, les cliniciens doivent envisager une escalade plus précoce du traitement, comme le transfert d'établissement ou l'ECMO, si le rapport PaO2/FiO2 n'augmente pas lors du positionnement initial en décubitus ventral.
Association of Positive End-Expiratory Pressure and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis.
Dianti J, Tisminetzky M, Ferreyro BL, Englesakis M, Del Sorbo L, Sud S, Talmor D, Ball L, Meade M, Hodgson C, Beitler JR, Sahetya S, Nichol A, Fan E, Rochwerg B, Brochard L, Slutsky AS, Ferguson ND, Serpa Neto A, Adhikari NKJ, Angriman F, Goligher EC. | Am J Respir Crit Care Med. 2022 Jun 1;205(11):1300-1310
Keywords: ARDS; PEEP; hypoxemic respiratory failure; lung recruitment maneuver; mortality.
Introduction : The most beneficial positive end-expiratory pressure (PEEP) selection strategy in patients with acute respiratory distress syndrome (ARDS) is unknown, and current practice is variable.
Objectives: To compare the relative effects of different PEEP selection strategies on mortality in adults with moderate to severe ARDS
Méthode : We conducted a network meta-analysis using a Bayesian framework. Certainty of evidence was evaluated using grading of recommendations assessment, development and evaluation methodology
Résultats : We included 18 randomized trials (4,646 participants). Compared with a lower PEEP strategy, the posterior probability of mortality benefit from a higher PEEP without lung recruitment maneuver (LRM) strategy was 99% (risk ratio [RR], 0.77; 95% credible interval [CrI], 0.60-0.96, high certainty), the posterior probability of benefit of the esophageal pressure-guided strategy was 87% (RR, 0.77; 95% CrI, 0.48-1.22, moderate certainty), the posterior probability of benefit of a higher PEEP with brief LRM strategy was 96% (RR, 0.83; 95% CrI, 0.67-1.02, moderate certainty), and the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 77% (RR, 1.06; 95% CrI, 0.89-1.22, low certainty). Compared with a higher PEEP without LRM strategy, the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 99% (RR, 1.37; 95% CrI, 1.04-1.81, moderate certainty).
Conclusion : In patients with moderate to severe ARDS, higher PEEP without LRM is associated with a lower risk of death than lower PEEP. A higher PEEP with prolonged LRM strategy is associated with increased risk of death when compared with higher PEEP without LRM.
Conclusion (proposition de traduction) : Chez les patients atteints de SDRA modéré à sévère, une PEP plus élevée sans manœuvre de recrutement pulmonaire est associée à un risque de décès plus faible qu'une PEP plus faible. Une PEP plus élevée avec une stratégie de manœuvre de recrutement pulmonaire prolongée est associée à un risque accru de décès par rapport à une PEP plus élevée sans manœuvre de recrutement pulmonaire.
Association between Type of Fluid Received Prior to Enrollment, Type of Admission, and Effect of Balanced Crystalloid in Critically Ill Adults: A Secondary Exploratory Analysis of the BaSICS Clinical Trial.
Zampieri FG, Machado FR, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Lovato WJ, Amêndola CP, Serpa-Neto A, Paranhos JLR, Lúcio EA, Oliveira-Júnior LC, Lisboa TC, Lacerda FH, Maia IS, Grion CMC, Assunção MSC, Manoel ALO, Corrêa TD, Guedes MAVA, Azevedo LCP, Miranda TA, Damiani LP, Brandão da Silva N, Cavalcanti AB. | Am J Respir Crit Care Med. 2022 Jun 15;205(12):1419-1428
Keywords: balanced solutions; critical care; fluid challenge.
Introduction : The effects of balanced crystalloid versus saline on clinical outcomes for ICU patients may be modified by the type of fluid that patients received for initial resuscitation and by the type of admission.
Objectives: To assess whether the results of a randomized controlled trial could be affected by fluid use before enrollment and admission type.
Méthode : Secondary post hoc analysis of the BaSICS (Balanced Solution in Intensive Care Study) trial, which compared a balanced solution (Plasma-Lyte 148) with 0.9% saline in the ICU. Patients were categorized according to fluid use in the 24 hours before enrollment in four groups (balanced solutions only, 0.9% saline only, a mix of both, and no fluid before enrollment) and according to admission type (planned, unplanned with sepsis, and unplanned without sepsis). The association between 90-day mortality and the randomization group was assessed using a hierarchical logistic Bayesian model.
Résultats : A total of 10,520 patients were included. There was a low probability that the balanced solution was associated with improved 90-day mortality in the whole trial population (odds ratio [OR], 0.95; 89% credible interval [CrI], 0.66-10.51; probability of benefit, 0.58); however, probability of benefit was high for patients who received only balanced solutions before enrollment (regardless of admission type, OR, 0.78; 89% CrI, 0.56-1.03; probability of benefit, 0.92), mostly because of a benefit in unplanned admissions due to sepsis (OR, 0.70; 89% CrI, 0.50-0.97; probability of benefit, 0.96) and planned admissions (OR, 0.79; 89% CrI, 0.65-0.97; probability of benefit, 0.97).
Conclusion : There is a high probability that balanced solution use in the ICU reduces 90-day mortality in patients who exclusively received balanced fluids before trial enrollment.
Conclusion (proposition de traduction) : Il existe une forte probabilité que l'utilisation de solutions équilibrées dans l'unité de soins intensifs réduise la mortalité à 90 jours chez les patients qui ont reçu exclusivement des liquides équilibrés avant leur inclusion dans l'essai.
Commentaire : Jackson KE and al; SMART Investigators and the Pragmatic Critical Care Research Group. Effect of Early Balanced Crystalloids Before ICU Admission on Sepsis Outcomes. Chest. 2021 Feb;159(2):585-595 .
Guidelines for the management of patients with severe acute pancreatitis, 2021.
Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, De Jong A. | Anaesth Crit Care Pain Med. 2022 Jun;41(3):101060
Keywords: Acute respiratory distress syndrome; Critical care; Guidelines; Intensive care unit; Sepsis; Severe acute pancreatitis.
Introduction : To provide guidelines for the management of the intensive care patient with severe acute pancreatitis.
Design: A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.
Méthode : The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.
Résultats : The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations.
Conclusion : There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.
Conclusion (proposition de traduction) : Les experts se sont mis d'accord sur 24 recommandations visant à améliorer les pratiques de prise en charge des patients en soins intensifs atteints de pancréatite aiguë sévère.
Guidelines for the choice of intravenous fluids for vascular filling in critically ill patients, 2021.
Joannes-Boyau O, Le Conte P, Bonnet MP, Cesareo E, Chousterman B, Chaiba D, Douay B, Futier E, Harrois A, Huraux C, Ichai C, Meaudre Desgouttes E, Mimoz O, Muller L, Oberlin M, Peschanski N, Quintard H, Rousseau G, Savary D, Tran-Dinh A, Villoing B, Chauvin A, Weiss E. | Anaesth Crit Care Pain Med. 2022 Jun;41(3):101058
DOI: https://doi.org/10.1016/j.accpm.2022.101058 | Télécharger l'article au format
Keywords: Acute brain failure; Fluid therapy; Guidelines; Haemorrhagic shock; Sepsis or septic shock.
Introduction : To provide recommendations for the appropriate choice of fluid therapy for resuscitation of critically ill patients.
Design: A consensus committee of 24 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were left ungraded.
Méthode : Four fields were defined: patients with sepsis or septic shock, patients with haemorrhagic shock, patients with acute brain failure, and patients during the peripartum period. For each field, the panel focused on two questions: (1) Does the use of colloids, as compared to crystalloids, reduce morbidity and mortality, and (2) Does the use of some specific crystalloids effectively reduce morbidity and mortality. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE methodology.
Résultats : The SFAR/SFMU guideline panel provided nine statements on the appropriate choice of fluid therapy for resuscitation of critically ill patients. After two rounds of rating and various amendments, strong agreement was reached for 100% of the recommendations. Out of these recommendations, two have a high level of evidence (Grade 1 +/-), six have a moderate level of evidence (Grade 2 +/-), and one is based on expert opinion. Finally, no recommendation was formulated for two questions.
Conclusion : Substantial agreement among experts has been obtained to provide a sizable number of recommendations aimed at optimising the choice of fluid therapy for resuscitation of critically ill patients.
Conclusion (proposition de traduction) : Un accord substantiel entre experts a été obtenu pour fournir un nombre important de recommandations visant à optimiser le choix du remplissage vasculaire pour la réanimation des patients gravement malades.
Prehospital trauma flowcharts - Concise and visual cognitive aids for prehospital trauma management from the French Society of Emergency Medicine (SFMU) and the French Society of Anaesthesia and Intensive Care Medicine (SFAR).
Tazarourte K, Ageron FX, Avondo A, Barnard E, Bobbia X, Cesareo E, Chollet-Xemard C, Curac S, Desmettre T, Khoury CEL, Gauss T, Gil-Jardine C, Harris T, Heidet M, Lapostolle F, Pradeau C, Renard A, Sapir D, Tourtier JP, Travers S. | Anaesth Crit Care Pain Med. 2022 Jun;41(3):101070
DOI: https://doi.org/10.1016/j.accpm.2022.101070 | Télécharger l'article au format
Keywords: Airway Management; Cognitive aid; Damage Control; EMS; Guideline; HEMS; Mass Casualty; Prehospital; Rapid Sequence Intubation; Sedation; Shock; Trauma; Traumatic Brain injury; Traumatic Cardiac Arrest.
Editorial : The present corpus of cognitive aids (CA) for trauma management, trauma flowcharts, provides comprehensive and visual guidelines for trauma clinicians for the prehospital setting. These flowcharts are structured along a timeline and all essential action carry a specific time stamp. The flowcharts aspire to be an easy-to-use real-time support for clinicians, as well as to be used as a reference for training and education. The flowcharts are the result of a close cooperation of the French Society of Emergency Medicine (Société française de médecine d’urgence, SFMU) and the French Society of Anaesthesia and Intensive Care Medicine (Société française d’anesthésie et de réanimation, SFAR).
Conclusion : The flowcharts were developed according to a specific methodology. Every flowchart was composed by two collaborators along a pre-established template and existing clinical guidelines. All flowcharts underwent peer review from a panel of 42 experts from SFAR and the SFMU. After extensive review, the entire panel of experts voted on the entire corpus of flowcharts. The vote was performed according to a scale from 1 to 9 (1 3 = no agreement; 4 6 = indetermined, new vote; 7 9 = strong agreement). A flowchart was approved, if more than 75% of panel members expressed a strong agreement. The final version was reviewed and validated by the clinical guideline committee of the SFMU. An electronic, interactive smartphone-based application is available in French language (https://sfar.org/lappli-des-anesthesistes-reanimateurs ).
Conclusion (proposition de traduction) : Les algorithmes ont été développés selon une méthodologie spécifique. Chaque algorithme a été composé par deux collaborateurs à partir d'un modèle préétabli et des recommandations cliniques existantes. Tous les algorithmes ont fait l'objet d'une évaluation par un panel de 42 experts de la SFAR et de la SFMU. Après un examen approfondi, le panel d'experts a voté sur l'ensemble du corpus des algorithmes. Le vote a été effectué selon une échelle de 1 à 9 (1 3 = aucun accord ; 4 6 = indéterminé, nouveau vote ; 7 9 = fort accord). Un algorithme était approuvé si plus de 75 % des membres du panel exprimaient un accord fort. La version finale a été revue et validée par le comité des directives cliniques de la SFMU. Une application électronique interactive sur smartphone est disponible en langue française (https://sfar.org/lappli-des-anesthesistes-reanimateurs ).
Intrahospital trauma flowcharts — Cognitive aids for intrahospital trauma management from the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society of Emergency Medicine (SFMU).
Gauss T, Quintard H, Bijok B, Bouhours G, Clavier T, Cook F, de Courson H, David JS, Duracher-Gout C, Garrigue D, Geeraerts T, Hamada S, Joannes-Boyau O, Jouffroy R, Lamblin A, Langeron O, Lanot P, Lasocki S, Leone M, Mirek S, Muller L, Pasquier P, Prunet B, Perbet S, Raux M, Richards J, Roger C, Roquilly A, Weiss E, Bouzat P, Pottecher J. | Anaesth Crit Care Pain Med. 2022 Jun;41(3):101069
DOI: https://doi.org/10.1016/j.accpm.2022.101069 | Télécharger l'article au format
Keywords: Cognitive aid; Damage Control; Guideline; Resuscitation; Shock; Trauma; Traumatic Brain Injury.
Editorial : Trauma care is best provided along concise and evidence-based guidelines. Yet despite considerable improvement in trauma outcome over the last ten years, mortality and morbidity remain high and low guideline compliance seems associated with increased mortality. Often conventional guideline formats are too cumbersome and not user-friendly enough to be consulted on scene or in the resuscitation room. Easy-to-use cognitive aids enhance guideline compliance and ultimately improve patient outcome.
Conclusion : The flowcharts were developed according to a distinct methodology. Every flowchart was composed by two collaborators along a pre-established template and existing clinical guidelines. All flowcharts were submitted to peer review from a college composed of 42 members from SFAR and the SFMU. After extensive review, the entire college of experts voted on the entire corpus of flowcharts. The vote was performed according to a scale from 1 to 9 (1–3 = no agreement; 4–6 = indetermined, new vote; 7–9 = strong agreement). A flowchart was adopted, if more than 75% of college members expressed a strong agreement. The final version was reviewed and validated by the clinical guideline committee of the French Society of Anaesthesia and Intensive Care Medicine (SFAR). An electronic, interactive smartphone-based application is available in French language
Conclusion (proposition de traduction) : Les algorithmes ont été développés selon une méthodologie distincte. Chaque algorithme a été composé par deux collaborateurs à partir d'un modèle préétabli et des directives cliniques existantes. Tous les algorithmes ont été soumis à un examen par les pairs d'un collège composé de 42 membres de la SFAR et de la SFMU. Après un examen approfondi, le collège d'experts a voté sur l'ensemble du corpus des algorithmes. Le vote a été effectué selon une échelle de 1 à 9 (1-3 = pas d'accord ; 4-6 = indéterminé, nouveau vote ; 7-9 = fort accord). Un algorithme a été adopté si plus de 75% des membres du collège ont exprimé un fort accord. La version finale a été revue et validée par le comité des recommandations cliniques de la Société française d'anesthésie et de réanimation (SFAR). Une application électronique interactive sur smartphone est disponible en langue française.
A review of literature on phosphorus burns .
Lacroix G, Martinot-Duquennoy V, Ngo B, Knipper P, Pasquesoone L. | Ann Burn Fire Disasters. 2022 June;35(2):152-9
DOI: NV | Télécharger l'article au format
Keywords: burns; phosphorus; assessment; care; review
Editorial : Entre septembre et novembre 2020, l’Arménie et l’Azerbaïdjan se sont affrontés dans le Haut- Karabagh. Plusieurs missions chirurgicales ont été organisées par l’Assistance Publique – Hôpitaux de Paris pour aider à la prise en charge des blessés de guerre arméniens. Ces missions avaient notamment pour objectif l’évaluation de soldats victimes de brûlures suspectes d’être causées par du phosphore. Confrontés lors de ces missions à cette étiologie peu fréquente de brûlures, nous nous sommes intéressés à leur physiopathologie, leur prise en charge et leurs complications. Des actualisations itératives sont nécessaires pour guider de la meilleure façon la prise en charge des brûlures au phosphore. Dans ce but, nous avons réalisé une revue de la littérature en recherchant dans Pubmed les mots-clés «phosphorus», «burns» en Mesh Terms sans limite de date de parution des articles. Il ressort de cette revue que les brûlures au phosphore sont profondes, exten- sives et peuvent être responsables d’une toxicité systémique avec notamment une hypocalcémie pouvant être responsable de troubles du rythme cardiaque et de mort subite. En aigu, les brûlures doivent être lavées abon- damment au sérum physiologique ou à l’eau stérile puis bénéficier d’une décontamination mécanique de l’en- semble des particules de phosphore blanc. Il ne faut pas effectuer de pansement gras en raison du caractère liposoluble du phosphore blanc. Par la suite, un ou plusieurs parages sont nécessaires avant de commencer la couverture des pertes de substance induites. Cette couverture fait appel à l’ensemble des techniques de chi- rurgie plastique. Les brûlures au phosphore sont rares mais graves. Elles sont surtout rencontrées sur des théâtres de guerre et doivent ainsi être connues de tous les soignants qui interviennent dans ces circonstances.
Conclusion (proposition de traduction) : Les brûlures au phosphore blanc sont rares mais graves. Elles sont surtout rencontrées dans un contexte de guerre mais peuvent se voir en milieu civil. Elles sont le plus souvent profondes, de cicatrisation difficile et peuvent s’accompagner de manifestations générales dont des troubles du rythme cardiaque, même pour des surfaces cutanées brûlées faibles. Une prise en charge urgente est nécessaire et consiste en premier lieu en une irrigation abondante au sérum physiologique et un isolement des brûlures de l’air, au moyen d’un ligne humide notamment. Les pansements gras sont proscrits. Il faut ensuite réaliser un débridement avec retrait des particules de phosphore et des parages multiples jusqu’à obtenir un sous-sol viable. La couverture cutanée fait appel à l’ensemble des techniques de chirurgie plastique. Notre expérience lors du conflit au Haut-Karabagh, nous amène à proposer d’évoquer systématiquement ces brûlures au phosphore blanc dans les conflits armés et d’enseigner leur prise en charge aux soignants intervenant en zone de guerre.
Managing Posterior Hip Dislocations.
Gottlieb M | Ann Emerg Med. 2022 Jun;79(6):554-559
Editorial : Hip dislocations are an important condition presenting to the emergency department (ED), requiring rapid evaluation and management.1 More than 90% of hip dislocations are posterior, and the most common mechanism for native hip dislocation is a motor vehicle collision causing a high-energy load on a flexed hip. In contrast, prosthetic hips can become dislocated with minor activities, such as tying shoes or sitting in a low seat. Once dislocated, it is important to reduce the native hip as quickly as possible to reduce the risk of avascular necrosis. One study reported a 5% incidence among hips reduced within 6 hours of the injury versus 53% among hips reduced after 6 hours. Indications for an open reduction in the operating room include open dislocations, ipsilateral femoral neck fracture, and failed reduction after several attempts at closed reduction. Many emergency medicine clinicians have developed significant experience in caring for these patients. This paper is not intended to be a comprehensive review of all the aspects of the evaluation and management of adult patients with hip dislocation; instead, this seeks to distill key facets of management based upon the current literature and years of practice.
Conclusion : Orthopedic surgery consultation should be considered depending on institutional protocols. Most patients with successful reduction of a prosthetic hip can be discharged with outpatient orthopedic surgeon follow-up. Due to the significant force involved in a native hip dislocation, it is important to ensure that there are no other major injuries before discharge. One study found that 71% of patients with traumatic hip dislocations had significant associated injuries. Strict immobilization is not recommended, and experts generally recommend early active and passive range of motion exercises with either no weight-bearing or toe-touch weight-bearing (5-10 pounds) for the first several weeks. While commonly used, abduction braces remain controversial and have not been demonstrated to reduce the risk of recurrent dislocations in patients with prosthetic hips. However, patients should be advised to avoid flexing their hip beyond 90°, avoid any twisting motions, and avoid crossing their leg past midline.
Conclusion (proposition de traduction) : Une consultation en chirurgie orthopédique doit être envisagée en fonction des protocoles institutionnels. La plupart des patients dont la réduction d'une prothèse de hanche est réussie peuvent sortir de l'hôpital avec un suivi ambulatoire par un chirurgien orthopédiste. En raison de la force significative impliquée dans une luxation native de la hanche, il est important de s'assurer qu'il n'y a pas d'autres blessures majeures avant la sortie. Une étude a révélé que 71 % des patients ayant subi une luxation traumatique de la hanche présentaient des blessures associées importantes. L'immobilisation stricte n'est pas recommandée, et les experts recommandent généralement des exercices d'amplitude de mouvement actifs et passifs précoces, sans port de poids ou avec port de poids sur les orteils (2,2 à 5,5 kg) pendant les premières semaines. Bien qu'elles soient couramment utilisées, les orthèses d'abduction restent controversées et il n'a pas été démontré qu'elles réduisent le risque de luxations récurrentes chez les patients porteurs de prothèses de hanche. Cependant, il faut conseiller aux patients d'éviter de fléchir leur hanche au-delà de 90°, d'éviter tout mouvement de torsion et d'éviter de croiser leur jambe au-delà de la ligne médiane.
Performance of the Simple Clinical Score (SCS) and the Rapid Emergency Medicine Score (REMS) to predict severity level and mortality rate among patients with sepsis in the emergency department.
Chatchumni M, Maneesri S, Yongsiriwit K. | Australas Emerg Care. 2022 Jun;25(2):121-125
DOI: https://doi.org/10.1016/j.auec.2021.09.002 | Télécharger l'article au format
Keywords: Assessment; Emergency service; Hospital; Predict; Sepsis; Tools.
Editorial : Nurses play a key role as the first line of service for patients with medical conditions and injuries in the emergency department (ED), which includes assessing patients for sepsis. The researchers evaluated tools to examine the performance of the Simple Clinical Score (SCS) and the Rapid Emergency Medicine Score (REMS) to predict sepsis severity and mortality among sepsis patients in the ED. A retrospective survey was performed, selecting participants by using a purposive sampling method, and including the medical records of all patients diagnosed with sepsis admitted to the ED at Singburi Hospital, Thailand. Data were analysed using the ROC curve and the Area Under Curve (AUC) to calculate the accuracy of each patient's mortality prediction. A total of 225 patients diagnosed with sepsis was identified, with a mortality rate of 59.11% after admission to the medical service and intensive care unit. The AUC analysis showed that the accuracy of the model generated from the REMS (88.6%) was higher than that of the SCS (76.7%). The authors also recommend that key variables identified in this research should be used to develop screening and assessment tools for sepsis in the context of the ED.
Conclusion : Regarding nursing practice, the establishment of an emergency screening system is recommended. The five predominant assessment tools were shown to share some variables, including (1) use of the Glasgow Coma Scale or other assessment of consciousness/coma, (2) respiratory rate, (3) blood oxygen concentration, (4) abnormal ECG, and (5) a portion of time spent in bed prior to current illness.
Our results indicated great variability between the SCS and REMS assessments, and also identified and ranked parameters that are important for the detection of sepsis. The REMS calculation is an important mortality predictor in patients with sepsis. These variousables could be developed as a tool for screening patients diagnosed with sepsis among the Thai population. Promptly and effectively assessing the severity of sepsis is crucial to saving these patients’lives.
Conclusion (proposition de traduction) : En ce qui concerne la pratique infirmière, la mise en place d'un système de dépistage en urgence est conseillée. Il a été démontré que les cinq outils d'évaluation prédominants partagent certaines variables, notamment (1) l'utilisation de l'échelle de coma de Glasgow ou une autre évaluation de la conscience/du coma, (2) la fréquence respiratoire, (3) la concentration d'oxygène dans le sang, (4) un ECG anormal et (5) une partie du temps passé au lit avant la maladie actuelle.
Nos résultats ont révélé une grande variabilité entre les évaluations du SCS et du REMS, et ont également permis d'identifier et de classer les paramètres qui sont importants pour la détection du sepsis. Le calcul du REMS est un important prédicteur de mortalité chez les patients atteints de sepsis. Ces différentes variables pourraient être développées comme un outil de dépistage des patients ayant un diagnostic de sepsis dans la population thaïlandaise. Une évaluation rapide et efficace de la gravité de la septicémie est cruciale pour sauver la vie de ces patients.
The experience of patients at high risk of difficult peripheral intravenous cannulation: An Australian prospective observational study.
Sweeny A, Archer-Jones A, Watkins S, Johnson L, Gunter A, Rickard C. | Australas Emerg Care. 2022 Jun;25(2):140-146
Keywords: Emergency; Peripheral intravenous cannulation; Ultrasound.
Introduction : Peripheral intravenous cannulation (PIVC) insertion is challenging for some patients, leading to delays in care and workflow. A few easy-to-identify risk factors can differentiate difficult to cannulate (DIVA) patients.
Méthode : A prospective observational study of adults undergoing PIVC was undertaken. Nursing and medical staff inserted PIVC using their usual practices. Patient, PIVC characteristics, number of attempts and staff characteristics were captured. Indicators of high-risk-for-DIVA were: no vein seen, and/or no vein palpable, and/or a history of difficult PIVC. The experience and outcomes for high-risk-for-DIVA patients were compared to non-DIVA.
Résultats : 1084 adults with PIVCs inserted were observed; with (378 (34.9%)) qualifying as high-risk-for-DIVA. First attempt success was achieved for 831 (76.7%) patients overall, with high-risk-for-DIVA significantly less likely to require one attempt (61.1% vs 85.0%, p<0.001). High-risk-for-DIVA were more likely to have: PIVC aborted, multiple attemptors, ultrasound -guidance, smaller gauge PIVC, and wrist or hand placement.
Conclusion : Simple predictors for difficult PIVC are known, and were present in about one-third of adults in this cohort. Earlier identification and escalation of these patients to more experienced cannulators, those experienced with US, and/or placement in the wrist/hand with a small gauge PIVC, may assist in avoiding unnecessary cannulation attempts and delays.
Conclusion (proposition de traduction) : Les critères prédictifs simples d'une perfusion intraveineuse périphérique difficile sont connus et étaient présents chez environ un tiers des adultes de cette cohorte. L'identification précoce et le recours à des opérateurs plus expérimentés, ayant l'expérience de l'échographie et/ou du ponctionnement au poignet ou à la main avec une perfusion intraveineuse périphérique de petit calibre, peuvent contribuer à éviter des tentatives de perfusion inutiles et des retards.
Effectiveness of high-flow nasal cannula for tracheal intubation in the emergency department.
Mitsuyama Y, Nakao S, Shimazaki J, Ogura H, Shimazu T. | BMC Emerg Med. 2022 Jun 23;22(1):115
DOI: https://doi.org/10.1186/s12873-022-00674-w | Télécharger l'article au format
Keywords: Emergency department; High-flow nasal cannula; Tracheal intubation.
Introduction : Tracheal intubation in the emergency department (ED) can cause serious complications. Available evidence on the use of a high-flow nasal cannula (HFNC) during intubation in the ED is limited. This study evaluated the effect of oxygen therapy by HFNC on oxygen desaturation during tracheal intubation in the ED.
Méthode : This was a single-center before-and-after study designed to compare two groups that received oxygen therapy during intubation: one received conventional oxygen, and the other received oxygen therapy using HFNC. We included non-trauma patients who required tracheal intubation in the ED. Linear regression analysis was performed to evaluate the relationship between oxygen therapy using HFNC and the lowest peripheral oxygen saturation (SpO2) during intubation in the conventional and HFNC groups.
Résultats : The study population included 87 patients (conventional group, n = 67; HFNC group, n = 20). The median lowest SpO2 in the HFNC group was significantly higher than that in the conventional group (94% [84-99%] vs. 85% [76-91%], p = 0.006). The percentage of cases with oxygen desaturation to < 90% during the intubation procedure in the HFNC group was significantly lower than that in the conventional group (40% vs. 63.8%, p = 0.037). The use of HFNC was significantly associated with the lowest SpO2, and the use of HFNC increased the lowest SpO2 during intubation procedures by 3.658% (p = 0.048).
Conclusion : We found that the use of HFNC during tracheal intubation was potentially associated with a higher lowest SpO2 during the procedure in comparison to conventional oxygen administration in non-trauma patients in the ED.
Conclusion (proposition de traduction) : Nous avons constaté que l'utilisation de l'oxygénothérapie nasale à haut débit pendant l'intubation trachéale était potentiellement associée à une SpO2 minimale plus élevée pendant la procédure par rapport à l'administration conventionnelle d'oxygène chez les patients non traumatisés aux urgences.
Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study.
Birrenbach T, Bühlmann F, Exadaktylos AK, Hautz WE, Müller M, Sauter TC. | BMC Emerg Med. 2022 Jun 21;22(1):113
DOI: https://doi.org/10.1186/s12873-022-00671-z | Télécharger l'article au format
Keywords: Anxiety; Emergency department; Pain management; Telehealth; Telemedicine; Virtual reality simulation; e-Health.
Introduction : Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce. The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2-5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0-10).
Méthode : Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales.
Résultats : Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute (< 24 h) (n = 16, 30.8%) or subacute (> 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3-7) vs. median post-VR simulation 3 (IQR 2-5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2-5) vs. median post-VR simulation 2 (IQR 0-3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen's d estimate for pain reduction = 0.59 (95% CI 0.19-0.98), for anxiety level on NRS = 0.75 (95% CI 0.34-1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high.
Conclusion : Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization.
Conclusion (proposition de traduction) : L'analgésie par réalité virtuelle pour la réduction de la douleur et de l'anxiété dans le cadre très fréquenté d'un service d'urgence est faisable, efficace, et la satisfaction des utilisateurs est élevée. D'autres études randomisées et contrôlées sont nécessaires pour mieux caractériser son impact sur la perception de la douleur et l'utilisation des ressources.
Temporal changes in blood pressure following prehospital rapid sequence intubation.
Fouche PF, Meadley B, StClair T, Winnall A, Stein C, Jennings PA, Bernard S, Smith K. | Emerg Med J. 2022 Jun;39(6):451-456
Keywords: airway; anaesthesia; paramedics.
Introduction : Rapid Sequence intubation (RSI) is an airway procedure that uses sedative and paralytic drugs to facilitate endotracheal intubation. It is known that RSI could impact blood pressure in the peri-intubation period. However, little is known about blood pressure changes in longer time frames. Therefore, this analysis aims to describe the changes in systolic blood pressure in a large cohort of paramedic-led RSI cases over the whole prehospital timespan.
Méthode : Intensive Care Paramedics in Victoria, Australia, are authorised to use RSI in medical or trauma patients with a Glasgow Coma Scale <10. This retrospective cohort study analysed data from patientcare records for patients aged 12 years and above that had received RSI, from 1 January 2008 to 31 December 2019. This study quantifies the systolic blood pressure changes using regression with fractional polynomial terms. The analysis is further stratified by high versus Low Shock Index (LSI). The shock index is calculated by dividing pulse rate by systolic blood pressure.
Résultats : During the study period RSI was used in 8613 patients. The median number of blood pressure measurements was 5 (IQR 3-8). Systolic blood pressure rose significantly by 3.4 mm Hg (p<0.001) and then returned to baseline in the first 5 min after intubation for LSI cases. No initial rise in blood pressure is apparent in High Shock Index (HSI) cases. Across the whole cohort, systolic blood pressure decreased by 7.1 mm Hg (95% CI 7.9 to 6.3 mm Hg; p<0.001) from the first to the last blood pressure measured.
Conclusion : Our study shows that in RSI patients a small transient elevation in systolic blood pressure in the immediate postintubation period is found in LSI, but this elevation is not apparent in HSI. Blood pressure decreased over the prehospital phase in RSI patients with LSI, but increased for HSI cases.
Conclusion (proposition de traduction) : Notre étude montre que chez les patients ayant bénéficié d'une intubation à séquence rapide (ISR), une légère élévation transitoire de la pression artérielle systolique au cours de la période post-intubation immédiate est observée dans les cas à faible indice de choc, mais cette élévation n'est pas constatée dans les cas à indice de choc élevé. La pression artérielle a diminué au cours de la phase préhospitalière chez les patients ayant bénéficié d'une ISR et présentant un faible indice de choc, mais a augmenté dans les cas d'indice de choc élevé.
Commentaire : Un facteur important dans la variation de la pression artérielle post-induction est l'indice de choc pré-intubation d'un patient. Miller et al ont démontré que les patients à faible indice de choc (LSI) présentaient une augmentation de la pression artérielle dans les minutes suivant l'ISR, alors que les patients à indice de choc élevé (HSI) ne présentaient pas une augmentation initiale similaire.
L'étude de Miller a montré que la pression artérielle peut varier en fonction de l'état de choc et du moment de la mesure de la pression artérielle. L'objectif de l'étude était de quantifier les changements de la pression artérielle chez les patients ayant bénéficié d'un ISR paramédical, et d'énumérer ces changements en fonction de l'indice de choc.
Miller M, Kruit N, Heldreich C, et al. Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index. Ann Emerg Med 2016;68:181–8 .
Understanding burn injuries in children—A step toward prevention and prompt first aid.
D'cunha A, Rebekah G, Mathai J, Jehangir S. | Burns. 2022 Jun;48(4):762-766
Keywords: Attitude; Burn awareness; Burn prevention; Burns first aid; Knowledge; Practice.
Editorial : This study was designed to examine knowledge, attitude and practices with regards to burns prevention and first aid in the Indian community. A total of 83 caregivers aged 19 and 40 years (mean 29 years) participated in survey. Sixty-one percent of those who responded to the survey had some knowledge of first aid, mostly through health education at schools (59%). Very few (2%) received first aid education from health workers. Approximately 2/3 of responders (66-70%) were aware of applying cool running water to a burn and to stop drop and roll in case of a flame burn. However, the same number also listed a myriad of household remedies that they would use as first aid. 66-71% responders were aware of some situational risks in the home and community but only 27% considered young children to be at greater risk. 31% responders had an enclosed kitchen and 16% were still cooking on the floor. A large percentage (83%) cooked outside on a traditional wooden open fire. A quarter of the responders still used oil lamps on the floor and had little regard for the flammability of clothes. There was a weak positive correlation between knowledge and attitude (r-square 0.379) and attitude and practice (r-square 0.373), but no correlation between knowledge and practice (r-square 0.089). Our survey suggests that many responders have limited knowledge of effective first-aid techniques and live in high-risk environments. The major sources of first aid information were from school-based health education, social and electronic media. These resources can be utilized to further disseminate knowledge on first aid and practical prevention techniques.
Conclusion : Our survey suggests that many responders have limited knowledge of effective first-aid techniques and live in high-risk environments. The major sources of first aid information were from school-based health education, social and electronic media. These resources can be utilized to further disseminate knowledge on first aid and practical prevention techniques.
Conclusion (proposition de traduction) : Notre enquête suggère que de nombreux intervenants ont une connaissance limitée des techniques de premiers secours efficaces et vivent dans des environnements à haut risque. Les principales sources d'information sur les premiers secours provenaient de l'éducation sanitaire en milieu scolaire et des médias sociaux et électroniques. Ces ressources peuvent être utilisées pour diffuser davantage les connaissances sur les premiers secours et les techniques de prévention pratiques.
A simple mnemonic, B.U.R.N.S., for burns first aid.
Tan HMG, Chung L, Chong XY, Joethy J, Chong SJ. | Burns. 2022 Jun;48(4):841-845
Keywords: B.U.R.N.S.; Burns first aid; Burns mnemonic; Education.
Introduction : Burn injuries remain common in the world, with an average of more than thousands of cases requiring medical attention each year. Singapore sees an average of 220 burns admissions annually. Given the high number of burn cases in Singapore, the authors identified that there is a need for more public awareness on first aid burn treatment. Acute management of burns can improve eventual patient outcome. The authors devised a simple mnemonic that can be used in burns education for first aid treatment, intended to be taught to trained personnel, who will have the first contact with these burn patients. The aim of the study was to assess the viability of implementing this mnemonic, B.U.R.N.S, to facilitate first aid education for burns.
Méthode : In this study, we presented this mnemonic as a poster to 30 full-time burn care medical professionals. Feedback was then obtained from this group of medical professionals and used to revise the mnemonic. The mnemonic was then subsequently taught to 400 medical professionals, who are predominantly involved in the pre-hospital management of burns. They are then asked to reiterate the mnemonic to test the ease of remembering the mnemonic. Objective feedback was obtained with a 5-point scoring system.
Résultats : The results indicated a significant improvement in burn first aid knowledge after the implementation of the mnemonic, from a score of 3.67-4.77, The content was deemed as appropriate and easy to understand and recall, and participants were able to reiterate the content, and will recommend this mnemonic to be used for burns teaching for first aid.
Conclusion : The study results suggest that this B.U.R.N.S. mnemonic and visual aid is simple and easy to apply, especially for uniformed personnel, as these individuals may have the first contact with the burns victims, and it is important for them to render the appropriate burns first aid treatment. Overall, burns first aid awareness and education can be improved with the implementation of this mnemonic and poster. Moving forward, we aim to integrate the B.U.R.N.S. into educational programmes in professional institutions involved in responding to burns (medical and nursing schools of Singapore), as well as in schools and public institutions, for educational purpose to raise public awareness. We wish to also be able to do so on an international level when courses are conducted.
Conclusion (proposition de traduction) : Les résultats de l'étude suggèrent que ce mnémonique et cette aide visuelle B.U.R.N.S. sont simples et faciles à appliquer, en particulier pour le personnel en tenue, car ces personnes peuvent être le premier contact avec les victimes de brûlures, et il est important pour elles de prodiguer les premiers soins appropriés aux brûlés. Dans l'ensemble, la sensibilisation et l'éducation aux premiers secours en cas de brûlures peuvent être améliorées par la mise en œuvre de ce moyen mnémotechnique et de ce message. Pour l'avenir, nous souhaitons intégrer le B.U.R.N.S. dans les programmes éducatifs des institutions professionnelles impliquées dans la réponse aux brûlures (écoles de médecine et d'infirmières de Singapour), ainsi que dans les écoles et les institutions publiques, à des fins éducatives pour sensibiliser le public. Nous souhaitons également être en mesure de le faire au niveau international lorsque des cours sont organisés.
Early or late booster for basic life support skill for laypeople: a simulation-based randomized controlled trial.
Boet S, Waldolf R, Bould C, Lam S, Burns JK, Moffett S, McBride G, Ramsay T, Bould MD. | CJEM. 2022 Jun;24(4):408-418
Keywords: Education; Heart arrest; Patient simulation; Resuscitation.
Introduction : Retention of skills and knowledge has been shown to be poor after resuscitation training. The effect of a "booster" is controversial and may depend on its timing. We compared the effectiveness of an early versus late booster session after Basic Life Support (BLS) training for skill retention at 4 months.
Méthode : We performed a single-blind randomized controlled trial in a simulation environment. Eligible participants were adult laypeople with no BLS training or practice in the 6 months prior to the study. We provided participants with formal BLS training followed by an immediate BLS skills post-test. We then randomized participants to one of three groups: control, early booster, or late booster. Based on their group allocation, participants attended a brief BLS refresher at either 3 weeks after training (early booster), at 2 months after training (late booster), or not at all (control). All participants underwent a BLS skills retention test at 4 months. We measured BLS skill performance according to the Heart and Stroke Foundation's skills testing checklist for adult CPR and the use of an automated external defibrillator.
Résultats : A total of 80 laypeople were included in the analysis (control group, n = 28; early booster group, n = 23; late booster group, n = 29). The late booster group achieved better skill retention (mean difference in checklist score at retention compared to the immediate post-test = - 0.8 points out of 15, [95% CI - 1.7, 0.2], P = 0.10) compared to the early booster (- 1.3, [- 2.6, 0.0], P = 0.046) and control group (- 3.2, [- 4.7, - 1.8], P < 0.001).
Conclusion : A late booster session improves BLS skill retention at 4 months in laypeople.
Conclusion (proposition de traduction) : Une session de rappel tardive améliore le maintien des compétences de Basic Life Support (BLS) à 4 mois chez les non-professionnels.
Setting and Titrating Positive End-Expiratory Pressure.
Millington SJ, Cardinal P, Brochard L. | Chest. 2022 Jun;161(6):1566-1575
Keywords: ARDS; critical care; mechanical ventilation.
How I Do It
Editorial : Although maintaining some amount of positive end-expiratory pressure (PEEP) seems essential, selecting and titrating a specific level for patients with ARDS remains challenging despite extensive research on the subject. Although an "open lung" approach to ventilation is popular and has some degree of biological plausibility, it is not without risk. Furthermore, there is no clear evidence-based guidance regarding initial PEEP settings or how to titrate them early in the course of the illness. Many busy clinicians use a "one-size-fits-all" approach based on local medical culture, but an individualized approach has the potential to offer significant benefit. Here we present a pragmatic approach based on simple measurements available on all ventilators, focused on achieving balance between the potential risks and benefits of PEEP. Acknowledging "best PEEP" as an impossible goal, we aim for a straightforward method to achieve "better PEEP."
Conclusion : Finding the “best” PEEP for a patient with ARDS is impossible with current technology, and the path to “better” PEEP is far from straightforward. We present a pragmatic protocol with three main principles: (1) choose a safe starting PEEP; (2) consider the harms of higher PEEP, specifically hemodynamic compromise and overdistention; and (3) consider the benefits of higher PEEP, specifically better oxygenation and less atelectrauma (when the lung is indeed recruitable). Our approach will be correctly criticized as a dramatic oversimplification but should be viewed through a lens of harm reduction in considering the number of patients with ARDS who currently receive a blind PEEP prescription with no attempt at individualization. Here, the imperfect should be embraced: “Give them the third best to go on with; the second best comes too late, the best never comes.”
Conclusion (proposition de traduction) : Trouver la "meilleure" PEP pour un patient souffrant de SDRA est impossible avec la technologie actuelle, et le chemin vers une "meilleure" PEP est loin d'être simple. Nous présentons un protocole pragmatique comportant trois grands principes : (1) choisir une PEP de départ sûre ; (2) prendre en compte les inconvénients d'une PEP plus élevée, notamment le compromis hémodynamique et la surdistention ; et (3) prendre en compte les avantages d'une PEP plus élevée, notamment une meilleure oxygénation et moins d'atélectraumatisme (lorsque le poumon est effectivement recrutable). Notre approche sera à juste titre critiquée pour sa simplification excessive, mais elle doit être considérée dans une optique de réduction des dommages, compte tenu du nombre de patients atteints de SDRA qui reçoivent actuellement une prescription de PEP en aveugle, sans tentative d'individualisation. Dans ce cas, l'imparfait doit être adopté : "Donnez-leur le troisième meilleur pour continuer ; le deuxième meilleur arrive trop tard, le meilleur n'arrive jamais".
Rapid Exclusion of Acute Myocardial Injury and Infarction With a Single High-Sensitivity Cardiac Troponin T in the Emergency Department: A Multicenter United States Evaluation.
Sandoval Y, Lewis BR, Mehta RA, Ola O, Knott JD, De Michieli L, Akula A, Lobo R, Yang EH, Gharacholou SM, Dworak M, Crockford E, Rastas N, Grube E, Karturi S, Wohlrab S, Hodge DO, Tak T, Cagin C, Gulati R, Jaffe AS. | Circulation. 2022 Jun 7;145(23):1708-1719
Keywords: myocardial infarction; myocardial ischemia; troponin T.
Original Research Article
Introduction : There are good data to support using a single high-sensitivity cardiac troponin T (hs-cTnT) below the limit of detection of 5 ng/L to exclude acute myocardial infarction. Per the US Food and Drug Administration, hs-cTnT can only report to the limit of quantitation of 6 ng/L, a threshold for which there are limited data. Our goal was to determine whether a single hs-cTnT below the limit of quantitation of 6 ng/L is a safe strategy to identify patients at low risk for acute myocardial injury and infarction.
Méthode : The efficacy (proportion identified as low risk based on baseline hs-cTnT<6 ng/L) of identifying low-risk patients was examined in a multicenter (n=22 sites) US cohort study of emergency department patients undergoing at least 1 hs-cTnT (CV Data Mart Biomarker cohort). We then determined the performance of a single hs-cTnT<6 ng/L (biomarker alone) to exclude acute myocardial injury (subsequent hs-cTnT >99th percentile in those with an initial hs-cTnT<6 ng/L). The clinically intended rule-out strategy combining a nonischemic ECG with a baseline hs-cTnT<6 ng/L was subsequently tested in an adjudicated cohort in which the diagnostic performance for ruling out acute myocardial infarction and safety (myocardial infarction or death at 30 days) were evaluated.
Résultats : A total of 85 610 patients were evaluated in the CV Data Mart Biomarker cohort, among which 24 646 (29%) had a baseline hs-cTnT<6 ng/L. Women were more likely than men to have hs-cTnT<6 ng/L (38% versus 20%, P<0.0001). Among 11 962 patients with baseline hs-cTnT<6 ng/L and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% (95% CI, 98.6-99.0) and sensitivity of 99.6% (95% CI, 99.5-99.6). In the adjudicated cohort, a nonischemic ECG with hs-cTnT<6 ng/L identified 33% of patients (610/1849) as low risk and resulted in a negative predictive value and sensitivity of 100% and a 30-day rate of 0.2% for myocardial infarction or death.
Conclusion : A single hs-cTnT below the limit of quantitation of 6 ng/L is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction.
Conclusion (proposition de traduction) : Un seul dosage de troponine T cardiaque ultra-sensible, inférieur à la limite de quantification de 6 ng/L, est une méthode sûre et rapide pour identifier un nombre important de patients présentant un risque très faible de lésion myocardique aiguë et d'infarctus.
Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries.
Ter Avest E, Carenzo L, Lendrum RA, Christian MD, Lyon RM, Coniglio C, Rehn M, Lockey DJ, Perkins ZB. | Crit Care. 2022 Jun 20;26(1):184
DOI: https://doi.org/10.1186/s13054-022-04052-7 | Télécharger l'article au format
Keywords: Helicopter emergency medical services (HEMS); Interventions; Penetrating injuries; Pre-hospital.
Editorial : Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.
Conclusion : Pre-hospital resuscitation of patients in extremis due to NCH from non-ballistic injuries is dependent on available resources. Although minimizing scene time is important, several advanced pre-hospital interventions can be provided to a select group of exsanguinating patients in the pre-hospital setting in order to improve their chances of survival. Research studies as well as the experience gained from the adoption of these advanced resuscitation interventions by some pre-hospital services provide guidance on the future resuscitation of this patient group.
Conclusion (proposition de traduction) : La réanimation pré-hospitalière des patients in extremis en raison d'une hémorragie non compressible due à des blessures non balistiques dépend des ressources disponibles. Bien qu'il soit important de minimiser le temps passé sur les lieux, plusieurs interventions préhospitalières avancées peuvent être pratiquées sur un groupe sélectionné de patients en exsanguination dans le cadre préhospitalier afin d'améliorer leurs chances de survie. Les études de recherche ainsi que l'expérience acquise par l'adoption de ces interventions avancées de réanimation par certains services préhospitaliers fournissent des indications sur la réanimation future de ce groupe de patients.
Andexanet alfa versus four-factor prothrombin complex concentrate for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage: a propensity score-overlap weighted analysis.
Costa OS, Connolly SJ, Sharma M, Beyer-Westendorf J, Christoph MJ, Lovelace B, Coleman CI. | Crit Care. 2022 Jun 16;26(1):180
DOI: https://doi.org/10.1186/s13054-022-04043-8 | Télécharger l'article au format
Keywords: Andexanet alfa; Direct factor Xa inhibitor reversal; Four-factor prothrombin complex concentrate; Intracranial hemorrhage.
Introduction : Andexanet alfa is approved (FDA "accelerated approval"; EMA "conditional approval") as the first specific reversal agent for factor Xa (FXa) inhibitor-associated uncontrolled or life-threatening bleeding. Four-factor prothrombin complex concentrates (4F-PCC) are commonly used as an off-label, non-specific, factor replacement approach to manage FXa inhibitor-associated life-threatening bleeding. We evaluated the effectiveness and safety of andexanet alfa versus 4F-PCC for management of apixaban- or rivaroxaban-associated intracranial hemorrhage (ICH).
Méthode : This two-cohort comparison study included andexanet alfa patients enrolled at US hospitals from 4/2015 to 3/2020 in the prospective, single-arm ANNEXA-4 study and a synthetic control arm of 4F-PCC patients admitted within a US healthcare system from 12/2016 to 8/2020. Adults with radiographically confirmed ICH who took their last dose of apixaban or rivaroxaban < 24 h prior to the bleed were included. Patients with a Glasgow Coma Scale (GCS) score < 7, hematoma volume > 60 mL, or planned surgery within 12 h were excluded. Outcomes were hemostatic effectiveness from index to repeat scan, mortality within 30 days, and thrombotic events within five days. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated using propensity score-overlap weighted logistic regression.
Résultats : The study included 107 andexanet alfa (96.6% low dose) and 95 4F-PCC patients (79.3% receiving a 25 unit/kg dose). After propensity score-overlap weighting, mean age was 79 years, GCS was 14, time from initial scan to reversal initiation was 2.3 h, and time from reversal to repeat scan was 12.2 h in both arms. Atrial fibrillation was present in 86% of patients. Most ICHs were single compartment (78%), trauma-related (61%), and involved the intracerebral and/or intraventricular space(s) (53%). ICH size was ≥ 10 mL in volume (intracerebral and/or ventricular) or ≥ 10 mm in thickness (subdural or subarachnoid) in 22% of patients and infratentorial in 15%. Andexanet alfa was associated with greater odds of achieving hemostatic effectiveness (85.8% vs. 68.1%; OR 2.73; 95% CI 1.16-6.42) and decreased odds of mortality (7.9% vs. 19.6%; OR 0.36; 95% CI 0.13-0.98) versus 4F-PCC. Two thrombotic events occurred with andexanet alfa and none with 4F-PCC.
Conclusion : In this indirect comparison of patients with an apixaban- or rivaroxaban-associated ICH, andexanet alfa was associated with better hemostatic effectiveness and improved survival compared to 4F-PCC.
Conclusion (proposition de traduction) : Dans cette comparaison indirecte de patients présentant une hémorragie intracrânienne associée à l'apixaban ou au rivaroxaban, l'andexanet alfa a été associé à une meilleure efficacité hémostatique et à une meilleure survie par rapport aux concentrés de complexe prothrombique à quatre facteurs.
Early intubation and patient-centered outcomes in septic shock: a secondary analysis of a prospective multicenter study.
Mellado-Artigas R, Ferrando C, Martino F, Delbove A, Ferreyro BL, Darreau C, Jacquier S, Brochard L, Lerolle N. | Crit Care. 2022 Jun 7;26(1):163
DOI: https://doi.org/10.1186/s13054-022-04029-6 | Télécharger l'article au format
Keywords: Mechanical ventilation; Outcomes; Septic shock; Tracheal intubation.
Introduction : Despite the benefits of mechanical ventilation, its use in critically ill patients is associated with complications and had led to the growth of noninvasive techniques. We assessed the effect of early intubation (first 8 h after vasopressor start) in septic shock patients, as compared to non-early intubated subjects (unexposed), regarding in-hospital mortality, intensive care and hospital length of stay.
Méthode : This study involves secondary analysis of a multicenter prospective study. To adjust for baseline differences in potential confounders, propensity score matching was carried out. In-hospital mortality was analyzed in a time-to-event fashion, while length of stay was assessed as a median difference using bootstrapping.
Résultats : A total of 735 patients (137 intubated in the first 8 h) were evaluated. Propensity score matching identified 78 pairs with similar severity and characteristics on admission. Intubation was used in all patients in the early intubation group and in 27 (35%) subjects beyond 8 h in the unexposed group. Mortality occurred in 35 (45%) and in 26 (33%) subjects in the early intubation and unexposed groups (hazard ratio 1.44 95% CI 0.86-2.39, p = 0.16). ICU and hospital length of stay were not different among groups [9 vs. 5 (95% CI 1 to 7) and 14 vs. 16 (95% CI - 7 to 8) days]. All sensitivity analyses confirmed the robustness of our findings.
Conclusion : An early approach to invasive mechanical ventilation did not improve outcomes in this matched cohort of patients. The limited number of patients included in these analyses out the total number included in the study may limit generalizability of these findings.
Conclusion (proposition de traduction) : Une approche précoce de la ventilation mécanique invasive n'a pas amélioré les résultats dans cette cohorte appariée de patients. Le nombre limité de patients inclus dans ces analyses par rapport au nombre total de patients inclus dans l'étude peut limiter la généralisation de ces résultats.
Early intubation and decreased in-hospital mortality in patients with coronavirus disease 2019.
Yamamoto R, Kaito D, Homma K, Endo A, Tagami T, Suzuki M, Umetani N, Yagi M, Nashiki E, Suhara T, Nagata H, Kabata H, Fukunaga K, Yamakawa K, Hayakawa M, Ogura T, Hirayama A, Yasunaga H, Sasaki J; J-RECOVER study group. | Crit Care. 2022 May 6;26(1):124
DOI: https://doi.org/10.1186/s13054-022-03995-1 | Télécharger l'article au format
Keywords: Coronavirus infection; Critical care; Oxygen; Pulmonary function; Respiratory failure; Timing of intubation.
Introduction : Some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage particularly in the early phase of pandemic. We aimed to elucidate whether early intubation is associated with decreased in-hospital mortality among patients with novel coronavirus disease 2019 (COVID-19) who required intubation.
Méthode : A multicenter, retrospective, observational study was conducted at 66 hospitals in Japan where patients with moderate-to-severe COVID-19 were treated between January and September 2020. Patients who were diagnosed as COVID-19 with a positive reverse-transcription polymerase chain reaction test and intubated during admission were included. Early intubation was defined as intubation conducted in the setting of ≤ 6 L/min of oxygen usage. In-hospital mortality was compared between patients with early and non-early intubation. Inverse probability weighting analyses with propensity scores were performed to adjust patient demographics, comorbidities, hemodynamic status on admission and time at intubation, medications before intubation, severity of COVID-19, and institution characteristics. Subgroup analyses were conducted on the basis of age, severity of hypoxemia at intubation, and days from admission to intubation.
Résultats : Among 412 patients eligible for the study, 110 underwent early intubation. In-hospital mortality was lower in patients with early intubation than those with non-early intubation (18 [16.4%] vs. 88 [29.1%]; odds ratio, 0.48 [95% confidence interval 0.27-0.84]; p = 0.009, and adjusted odds ratio, 0.28 [95% confidence interval 0.19-0.42]; p < 0.001). The beneficial effects of early intubation were observed regardless of age and severity of hypoxemia at time of intubation; however, early intubation was associated with lower in-hospital mortality only among patients who were intubated later than 2 days after admission.
Conclusion : Early intubation in the setting of ≤ 6 L/min of oxygen usage was associated with decreased in-hospital mortality among patients with COVID-19 who required intubation. Trial Registration None.
Conclusion (proposition de traduction) : L'intubation précoce dans le cadre d'une utilisation ≤ 6 L/min d'oxygène a été associée à une diminution de la mortalité hospitalière chez les patients atteints de COVID-19 qui ont dû être intubés.
Protocol for balanced versus saline trialists: living systematic review and individual patient data meta-analysis of randomised controlled trials (BEST-Living study).
Zampieri FG, and al.. | Crit Care Resusc. 2022; 24 (2): 128-36
DOI: https://doi.org/10.51893/2022.2.OA3 | Télécharger l'article au format
Introduction : It remains unclear whether balanced solutions improve patient-centred outcomes in critically ill patients overall and whether the treatment effect is heterogeneous, with evidence that some populations of patients may be helped and others harmed. To provide the most up-to-date and comprehensive assessment of the totality of the evidence, we will perform an ongoing living systematic review with aggregated and individual patient data meta-analysis (IPDMA) comparing the use of balanced solutions with saline in critically ill adults.
Méthode : We will include randomised controlled trials in adults treated in an intensive care unit that allocated individuals or clusters of patients to a balanced crystalloid solution or 0.9% saline for intravenous fluid therapy. Studies that used colloids as part of the intervention or that recruited only elective surgical patients will be excluded. The primary endpoint will be in-hospital mortality. The key secondary endpoint will be survival at longest follow-up for each trial. Data will be synthesised using both a random effect Bayesian meta-analysis and using hierarchical Bayesian models for individual patient data.
Conclusion : The use of balanced crystalloid solutions may reduce mortality and improve other outcomes in some critically ill patients. We will assess the totality of current and future evidence by performing an ongoing living systematic review with aggregated data and IPDMA.
Conclusion (proposition de traduction) : L'utilisation de solutions cristalloïdes balancées peut réduire la mortalité et améliorer d'autres résultats chez certains patients gravement malades. Nous évaluerons l'ensemble des preuves actuelles et futures en réalisant une revue systématique vivante en cours avec des données agrégées et une méta-analyse de données individuelles de patients.
Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact.
De Monnin K, Terian E, Yaegar LH, Pappal RD, Mohr NM, Roberts BW, Kollef MH, Palmer CM, Ablordeppey E, Fuller BM. | Crit Care Med. 2022 Jun 1;50(6):986-998
Introduction : Data suggest that low tidal volume ventilation (LTVV) initiated in the emergency department (ED) has a positive impact on outcome. This systematic review and meta-analysis quantify the impact of ED-based LTVV on outcomes and ventilator settings in the ED and ICU.
titre_eData sourcesn_plus: We systematically reviewed MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, references, conferences, and ClinicalTrials.gov.
Méthode : Randomized and nonrandomized studies of mechanically ventilated ED adults were eligible.
Data extraction: Two reviewers independently screened abstracts. The primary outcome was mortality. Secondary outcomes included ventilation duration, lengths of stay, and occurrence rate of acute respiratory distress syndrome (ARDS). We assessed impact of ED LTVV interventions on ED and ICU tidal volumes.
Résultats : The search identified 1,023 studies. Eleven studies (n = 12,912) provided outcome data and were meta-analyzed; 10 additional studies (n = 1,863) provided descriptive ED tidal volume data. Overall quality of evidence was low. Random effect meta-analytic models revealed that ED LTVV was associated with lower mortality (26.5%) versus non-LTVV (31.1%) (odds ratio, 0.80 [0.72-0.88]). ED LTVV was associated with shorter ICU (mean difference, -1.0; 95% CI, -1.7 to -0.3) and hospital (mean difference, -1.2; 95% CI, -2.3 to -0.1) lengths of stay, more ventilator-free days (mean difference, 1.4; 95% CI, 0.4-2.4), and lower occurrence rate (4.5% vs 8.3%) of ARDS (odds ratio, 0.57 [0.44-0.75]). ED LTVV interventions were associated with reductions in ED (-1.5-mL/kg predicted body weight [PBW] [-1.9 to -1.0]; p < 0.001) and ICU (-1.0-mL/kg PBW [-1.8 to -0.2]; p = 0.01) tidal volume.
Conclusion : The use of LTVV in the ED is associated with improved clinical outcomes and increased use of lung protection, recognizing low quality of evidence in this domain. Interventions aimed at implementing and sustaining LTVV in the ED should be explored.
Conclusion (proposition de traduction) : L'utilisation de la ventilation à petit volume courant aux urgences est associée à de meilleurs résultats cliniques et augment l'usage de la protection pulmonaire, tout en reconnaissant la faible qualité des preuves dans ce domaine. Les interventions visant à mettre en œuvre et à maintenir la ventilation à faible volume courant aux urgences devraient être étudiées.
How technology can save lives in cardiac arrest.
Scquizzato T, Gamberini L, Semeraro F. | Curr Opin Crit Care. 2022 Jun 1;28(3):250-255
Introduction : Technology is being increasingly implemented in the fields of cardiac arrest and cardiopulmonary resuscitation. In this review, we describe how recent technological advances have been implemented in the chain of survival and their impact on outcomes after cardiac arrest. Breakthrough technologies that are likely to make an impact in the future are also presented.
Résultats : Technology is present in every link of the chain of survival, from prediction, prevention, and rapid recognition of cardiac arrest to early cardiopulmonary resuscitation and defibrillation. Mobile phone systems to notify citizen first responders of nearby out-of-hospital cardiac arrest have been implemented in numerous countries with improvement in bystanders' interventions and outcomes. Drones delivering automated external defibrillators and artificial intelligence to support the dispatcher in recognising cardiac arrest are already being used in real-life out-of-hospital cardiac arrest. Wearables, smart speakers, surveillance cameras, and artificial intelligence technologies are being developed and studied to prevent and recognize out-of-hospital and in-hospital cardiac arrest.
Conclusion : This review highlights the importance of technology applied to every single step of the chain of survival to improve outcomes in cardiac arrest. Further research is needed to understand the best role of different technologies in the chain of survival and how these may ultimately improve outcomes.
Conclusion (proposition de traduction) : Cette étude souligne l'importance de la technologie appliquée à chaque étape de la chaîne de survie pour améliorer les résultats en cas d'arrêt cardiaque. Des recherches supplémentaires sont nécessaires pour comprendre le meilleur rôle des différentes technologies dans la chaîne de survie et comment celles-ci peuvent finalement améliorer les résultats.
Hypofibrinogenaemia and hypocalcaemia in adult trauma patients receiving pre-hospital packed red blood cell transfusions: Potential for supplementary pre-hospital therapeutic interventions.
Bodnar D, Stevens Z, Williams S, Handy M, Rashford S, Brown NJ. | Emerg Med Australas. 2022 Jun;34(3):333-340
Keywords: calcium; coagulopathy; fibrinogen; pre-hospital care; trauma.
Introduction : To report the arrival ionised calcium (iCa) and fibrinogen concentrations in trauma patients treated with packed red blood cells by the road-based high-acuity response units of a metropolitan ambulance service.
Méthode : A retrospective review of trauma patients treated with packed red blood cells by high-acuity response units between January 2012 and December 2016. Patients were identified from databases at southeast Queensland adult trauma centres, Pathology Queensland Central Transfusion Laboratory, Gold Coast University Hospital blood bank and the Queensland Ambulance Service. Patient characteristics, results of laboratory tests within 30 min of ED arrival were analysed.
Résultats : A total of 164 cases were analysed. The median injury severity score was 33.5 (interquartile range 22-41), with blunt trauma the commonest mechanism of injury (n = 128, 78.0%). Fifty-eight of the 117 patients (24.4%) with fibrinogen measured had a fibrinogen concentration ≤1.5 g/L; 79 of the 123 patients (64.2%) with an international normalised ratio (INR) measurement had an INR >1.2; 97 of 148 patients (63.8%) with an iCa measured, had an iCa below the Pathology Queensland reference range of 1.15-1.32 mmol/L. Arrival fibrinogen concentration ≤1.5 g/L and arrival iCa ≤1.00 were associated with in-hospital mortality with odds ratio 11.90 (95% confidence interval 4.50-31.65) and odds ratio 4.97 (95% confidence interval 1.42-17.47), respectively.
Conclusion : Hypocalcaemia and hypofibrinogenaemia on ED arrival were common in this cohort. Future work should evaluate whether outcomes improve by correction of these deficits during the pre-hospital phase of trauma care.
Conclusion (proposition de traduction) : L'hypocalcémie et l'hypofibrinogénémie à l'arrivée aux urgences étaient courantes dans cette cohorte. Les travaux futurs devraient évaluer si les résultats s'améliorent en corrigeant ces déficits pendant la phase pré-hospitalière des soins de traumatologie.
Association between intravenous fluid resuscitation and outcome among patients with suspected infection and sepsis: A retrospective cohort study.
Kabil G, Liang S, Delaney A, Macdonald S, Thompson K, Saavedra A, Suster C, Moscova M, McNally S, Frost S, Hatcher D, Shetty A. | Emerg Med Australas. 2022 Jun;34(3):361-369
Keywords: emergency service; fluid resuscitation; sepsis; septic shock.
Introduction : To investigate the association between timing and volume of intravenous fluids administered to ED patients with suspected infection and all-cause in-hospital mortality.
Méthode : Retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia, between October 2018 and May 2019. Patients over 16 years of age with suspected infection who received intravenous fluids within 24 h of presentation were included.
Résultats : During the study period, 7533 patients with suspected infection received intravenous fluids. Of these, 1996 (26.5%) and 231 (3.1%) had suspected sepsis and septic shock, respectively. Each 1000 mL increase in intravenous fluids administered was associated with a reduction in risk of in-hospital mortality (adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.76-0.99). This association was stronger in patients with septic shock (AOR 0.66, 95% CI 0.49-0.89), and those admitted to intensive care unit (ICU) (AOR 0.74, 95% CI 0.56-0.96). Patients with suspected sepsis and septic shock who received a total volume of >3600 mL had lower in-hospital mortality (AOR 0.44, 95% CI 0.22-0.91; AOR 0.16, 95% CI 0.05-0.57) compared to those administered <3600 mL within the first 24 h of presenting to the ED. There was no association between the time of initiation of fluids and in-hospital mortality among survivors and non-survivors (2.3 vs 2.5 h, P = 0.50).
Conclusion : We observed a reduction in risk of in-hospital mortality for each 1000 mL increase in intravenous fluids administered in patients with septic shock or admitted to ICU suggesting illness severity to be a likely effect modifier.
Conclusion (proposition de traduction) : Nous avons observé une réduction du risque de mortalité à l'hôpital pour chaque augmentation de 1000 ml de liquides intraveineux administrés chez les patients en choc septique ou admis en soins intensifs, suggérant que la gravité de la maladie est un facteur de modification probable de l'effet.
Whole body CT for trauma reduces emergency department time for patients with lower extremity fractures.
Smith T, Weger K, Steenburg S. | Emerg Radiol. 2022 Jun;29(3):449-454
Keywords: CT angiography; Extremity trauma; Whole body CT.
Introduction : Whole body CT in the setting of trauma has been shown to improve patient outcomes and decrease mortality in the emergency department (ED). Our institutional WBCT protocol allows for easy inclusion of the lower extremities, circumventing the need for diagnostic radiographs of the lower extremities. We hypothesized that this WBCT protocol would decrease time in the ED, reduce time to ED discharge, and decrease the number of lower extremity radiographs obtained in this patient population.
titre_en_plusx: To assess patient throughput in the ED by determining total time in the ED, number of lower extremity radiographs, cost of radiographs, and total cost of imaging before and after the implementation of a WBCT protocol for trauma.
Méthode : The trauma registry from an urban level 1 trauma center was searched for blunt trauma patients 6 months before and 6 months after the implementation of a WBCT protocol for trauma. Time between admission and discharge from the ED, total number of radiographs, total radiographs cost, total cost of ED imaging, and radiation dose estimations before and after WBCT implementation were calculated.
Résultats : There was a statistically significant decrease in time in the ED (76 min, p = 0.033) and number of lower extremity radiographs (decreased by 2 per patient, p < 0.01) following the implementation of the WBCT for trauma protocol. The cost of radiographs was decreased by 28.5% (p = 0.013) but the total cost of ED imaging was increased by approximately 4 × (p < 0.0001). Calculated effective radiation dose to the lower extremities increased by a factor of 1.9 × after implementation of WBCT for trauma.
Conclusion : Implementation of a WBCT protocol for trauma resulted in statistically significant decreased time in the ED and decreased the number of radiographs at the expense of increased imaging costs and radiation exposure.
Conclusion (proposition de traduction) : La mise en œuvre d'un protocole de scanner corps entier dans les traumatismes a entraîné une réduction statistiquement significative du temps passé aux urgences et une diminution du nombre de radiographies, au prix d'une augmentation des coûts en imagerie et de l'exposition aux rayonnements.
Association between the corrosion of ingested lithium button battery in the esophagus and its complications in pediatric patients.
Hosokawa T, Tanami Y, Sato Y, Yoshida M, Ebana R, Hara T, Nambu R, Iwama I, Oguma E. | Emerg Radiol. 2022 Jun;29(3):455-460
Keywords: Children; Foreign body ingestion; Lithium button battery; Pediatric; Radiograph.
Introduction : The incidence of lithium button battery ingestion has been increasing recently, which results in severe complications. We aimed to demonstrate the association between the corrosion of lithium button batteries in the esophagus on radiographs and their complications.
Méthode : The nine pediatric patients included in this study were classified into two groups based on the presence of severe complications. The presence and degree of corrosion on plain radiographs were evaluated. The degree of corrosion was classified into the following three grades; none: 0%; moderate: 1-50%; severe: 51-100%. Fisher's exact test was used for statistical analyses.
Résultats : Of the nine patients, five showed complications. The number of patients who had grade none, moderate, and severe degrees of corrosion was three, four, and two, respectively. The incidence of severe complications differed significantly between the incidence of lithium button batteries' contour (without vs. with severe complications [presence/absence of corrosion] = 1/3 vs. 5/0, respectively; P = 0.0476). In cases with "none" degree of corrosion, all three cases had no complication, and in cases with a "severe" degree of corrosion, all two cases had complications.
Conclusion : The cases with the presence of corrosion of lithium button batteries had a higher tendency to have severe complications. Therefore, physicians should anticipate the presence of severe complications in pediatric patients with corrosion more than those without corrosion.
Conclusion (proposition de traduction) : Les cas présentant une corrosion causée par des piles boutons au lithium avaient davantage tendance à présenter des complications graves. Par conséquent, les médecins doivent anticiper la présence de complications graves chez les patients pédiatriques présentant une corrosion plus que chez ceux qui n'en présentent pas.
Can Acute Care Biomarkers Change Patient’s Management in Sepsis?.
Di Somma S, Crisanti L. | Eurasian J Emerg Med . 2022 June; 21: 79-85
DOI: https://doi.org/10.4274/eajem.galenos.2022.21.2.1 | Télécharger l'article au format
Keywords: Acute care biomarkers; Sepsis; Emergency
Editorial : Sepsis and septic shock have an enormous burden on healthcare systems, having more than 30 million people worldwide suffering from those diseases. As emergency providers we must be able to immediately recognize the presence of sepsis to improve the management of this disease and reduce its burden on patient’s lives and on the emergency departments. Biomarkers can play an important role in this attempt. Laboratory tests could help both to identify the presence of sepsis at patients’ arrival and to stratify the risk of progression to septic shock. A new biomarker in that regard is represented by Bioactive Adrenomedullin (BioADM), which mirrors vascular integrity, and is able to detect the physio pathological deterioration of the patients with sepsis that will progress into septic shock. Now, thanks to point-of-care testing devices, we are able to measure BioADM in whole blood in less than twenty minutes, which will help the physician making faster and more adequate therapeutical decisions beside patient’s bed. The good news is that BioADM will also serve as a target for a monoclonal antibody that will counteract the vascular disfunction in septic shock. In conclusion, coupling BioADM with other biomarkers already routinely used such as procalcitonin and lactate we can immediately change patient’s management in Sepsis improving our decision making and patient outcome
Conclusion : ince every hour of delay in diagnosing of sepsis and septic shock in the emergency room is going to be linked with high mortality rates, we need new biomarkers for early detection of sepsis, beyond lactate. Bioactive Adrenomedullin (BioADM), that could also be measured by point of care tests devices on whole blood in 20 minutes, seems to be a very good new biomarker now available to reduce the burden of septic shock in the emergency room.
Finally, we would recommend using biomarkers in the emergency room really with care, since we do not need to treat the number, we need to treat the patients.
Conclusion (proposition de traduction) : Étant donné que chaque heure de retard dans le diagnostic de la septicémie et du choc septique aux urgences est liée à des taux de mortalité élevés, nous avons besoin de nouveaux biomarqueurs pour la détection précoce de la septicémie, au-delà du lactate. Le Bioactive Adrenomedullin (BioADM), qui pourrait également être mesurée par des dispositifs de tests au point de soins sur sang total en 20 minutes, semble être un très bon nouveau biomarqueur maintenant disponible pour réduire le volume de chocs septiques aux urgences.
Enfin, nous recommandons d'utiliser les biomarqueurs aux urgences avec beaucoup de précaution, car il ne s'agit pas de traiter le nombre, mais les patients.
Short-Term Prognosis of Patients with Hyperpotassemia in the Emergency Department.
YıldırımR, Günsoy E, Eray O. | Eurasian J Emerg Med. 2022; 21: 100-105
DOI: https://doi.org/10.4274/eajem.galenos.2021.60243 | Télécharger l'article au format
Keywords: Hyperpotassemia; Hyperkalemia; Emergency department
Introduction : Although hyperkalemia is a common encountered electrolyte disorder in the emergency room, there is little information in the literature regarding its clinical results. In this study, the short-term prognoses of patients who applied to the emergency department for any reason and were found to have hyperkalemia were investigated.
Méthode : This retrospective cohort study was carried out in a tertiary care university hospital emergency department by using the data provided by a hospital information management system (HIMS) in a year period. The 1th week and 28th day survivals of the patients who applied to the emergency department for any reason and were found to have hyperpotassemia (K >5.11 mg/dL) were evaluated. The relationship between potassium values at the first admission of patients with hyperkalemia and hospitalization or intensive care admissions, age, gender, hemodialysis needs, chronic kidney disease (CKD) and acute kidney injury (AKI), and survival were investigated.
Résultats : In the study, the results of 18,582 serum potassium samples were evaluated. Among the 2,715 hyperkalemia samples, 532 (19.5%) false potassium elevations and 363 (9%) repeat patients were measured. These samples were excluded from evaluation. Information of seven patients could not be reached and they were excluded from the study. Hyperpotassemia results of 1934 patients were included in the final analysis. It was found that 130 (6.7%) of the patients died within seven days, and 245 (12.7%) died within 28 days. In the study, 7-day and 28- day day mortality of patients who developed AKI, needed hemodialysis, who were hospitalized or located in intensive care unit were found to be significantly higher (p<0.001 for each). There was no statistical difference at 7th and 28th days between patients with CKD and those without CKD. It was found that AKI for patients, hyperpotassemia was associated with hospitalization, death and hemodialysis.
Conclusion : Patients with hyperkalemia accompanying AKI carry a risk in terms of mortality and other adverse prognoses. This risk has been found to be weaker in CKD. Hyperkalemia creates a serious risk even in hyperpotassemia close to normal value.
Conclusion (proposition de traduction) : Les patients présentant une hyperkaliémie accompagnant une lésion rénale aiguë présentent un risque en termes de mortalité et d'autres pronostics défavorables. Ce risque s'est avéré plus faible en cas de maladie rénale chronique. L'hyperkaliémie crée un risque sérieux même en cas de taux de potassium élevé proche de la valeur normale.
Dispatching citizens as first responders to out-of-hospital cardiac arrests: a systematic review and meta-analysis.
Scquizzato T, Belloni O, Semeraro F, Greif R, Metelmann C, Landoni G, Zangrillo A. | Eur J Emerg Med. 2022 Jun 1;29(3):163-172
Introduction : Mobile phone technologies to alert citizen first responders to out-of-hospital cardiac arrests (OHCAs) were implemented in numerous countries. This systematic review and meta-analysis aim to investigate whether activating citizen first responders increases bystanders' interventions and improves outcomes. We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to 24 November 2021, for studies comparing citizen first responders' activation versus standard emergency response in the case of OHCA. The primary outcome was survival at hospital discharge or 30 days. Secondary outcomes were discharge with favourable neurological outcome, bystander-initiated cardiopulmonary resuscitation (CPR), and the use of automated external defibrillators (AEDs) before ambulance arrival. Evidence certainty was evaluated with GRADE. Our search strategy yielded 1215 articles. After screening, we included 10 studies for a total of 23 351 patients. OHCAs for which citizen first responders were activated had higher rates of survival at hospital discharge or 30 days compared with standard emergency response [nine studies; 903/9978 (9.1%) vs. 1104/13 247 (8.3%); odds ratio (OR), 1.45; 95% confidence interval (CI), 1.21-1.74; P < 0.001], return of spontaneous circulation [nine studies; 2575/9169 (28%) vs. 3445/12 607 (27%); OR, 1.40; 95% CI, 1.07-1.81; P = 0.01], bystander-initiated CPR [eight studies; 5876/9074 (65%) vs. 6384/11 970 (53%); OR, 1.75; 95% CI, 1.43-2.15; P < 0.001], and AED use [eight studies; 654/9132 (7.2%) vs. 624/14 848 (4.2%); OR, 1.82; 95% CI, 1.31-2.53; P < 0.001], but similar rates of neurological intact discharge [three studies; 316/2685 (12%) vs. 276/2972 (9.3%); OR, 1.37; 95% CI, 0.81-2.33; P = 0.24]. Alerting citizen first responders to OHCA patients is associated with higher rates of bystander-initiated CPR, use of AED before ambulance arrival, and survival at hospital discharge or 30 days.
Conclusion : The use of mobile phone systems to alert citizens as first responders in case of OHCA is associated with higher rates of bystander CPR and defibrillation before EMS arrival, and with higher rates of ROSC and survival to discharge or 30 days, but with similar survival with good neurological outcome. High-quality randomized studies are needed to confirm our findings and provide more insights on the role of citizen first responders.
Conclusion (proposition de traduction) : L'utilisation de systèmes de téléphonie mobile pour alerter les citoyens en tant que premiers intervenants en cas d'OHCA est associée à des taux plus élevés de RCP et de défibrillation initiées par des secouristes avant l'arrivée du SAMU, et à des taux plus élevés de ROSC et de survie à la sortie de l'hôpital ou à 30 jours, mais à une survie similaire avec un bon résultat neurologique. Des études randomisées de haute qualité sont nécessaires pour confirmer nos résultats et fournir plus d'informations sur le rôle des citoyens premiers intervenants.
Myocardial dysfunction after cardiac arrest: tips and pitfalls.
Ortuno S, Geri G, Bouguoin W, Cariou A, Aissaoui N. | Eur J Emerg Med. 2022 Jun 1;29(3):188-194
Editorial : Postcardiac arrest shock (PCAS) is defined by hemodynamic instability occurring in the first hours after cardiac arrest (CA) and is a major cause of mortality among patients hospitalized after CA. It includes vasoplegia and myocardial dysfunction. This postcardiac arrest myocardial dysfunction is supposed to recover within the 3 days. However, there are many unknowns regarding its definition, its prognosis value and its management. In this review dedicated to emergency physicians, we choose to address tips and pitfalls they should know regarding this prevalent syndrome.
Conclusion : Even if there is no consensual definition, we can retain that PCAMD occurred in the first hours after CA and is characterized by an LVEF dysfunction below 40%. Its pathophysiological is related to ischemia-reperfusion phenomenon, uncontrol systemic inflammatory response and catecholamine overload. Monitoring is mandatory, and management has no specificity. Mechanical hemodynamic support might be useful. This myocardial dysfunction recovers by 2–3 days, but entire recovery could take longer. Many questions remain regarding the prognostic value and the long-term outcome.
Conclusion (proposition de traduction) : Même s'il n'existe pas de définition consensuelle, on peut retenir que la dysfonction myocardique post arrêt cardiaque survient dans les premières heures après l'arrêt cardiaque et se caractérise par une dysfonction de la fraction d'éjection du ventricule gauche inférieure à 40%. Sa physiopathologie est liée au phénomène d'ischémie-reperfusion, à une réponse inflammatoire systémique incontrôlée et à une surcharge en catécholamines. La surveillance est obligatoire, et la prise en charge n'a pas de spécificité. Un soutien hémodynamique mécanique peut être utile. Cette dysfonction myocardique se rétablit en 2 ou 3 jours, mais la récupération complète peut prendre plus de temps. De nombreuses questions demeurent quant à la valeur pronostique et à l'issue à long terme.
The association of biological sex and long-term outcomes in patients with acute dyspnea at the emergency department.
Vaittinada Ayar P, Motiejūnaitė J, Čerlinskaitė K, Deniau B, Blet A, Kavoliūnienė A, Mebazaa A, Čelutkienė J, Azibani F. | Eur J Emerg Med. 2022 Jun 1;29(3):195-203
Introduction : Marked differences have been described between women and men in disease prevalence, clinical presentation, response to treatment and outcomes. However, such data are scarce in the acutely ill. An awareness of differences related to biological sex is essential for the success of clinical care and outcomes in patients presenting with acute dyspnea, the most frequent cause of emergency department (ED) admission.
Objectives: The aim of the present study was to assess the effect of biological sex on 1-year all-cause mortality in patients presenting with acute dyspnea to the ED.
Méthode : Consecutive adult patients presenting with acute dyspnea in two Lithuanian EDs were included. Clinical characteristics, laboratory data and medication use at discharge were collected. Follow-up at 1 year was performed via national data registries.
Outcomes measure and analysis: The primary outcome of the study was 1-year all-cause mortality. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model, with and without adjustment for the following confounders: age, systolic blood pressure, creatinine, sodium and hemoglobin.
Résultats : A total of 1455 patients were included. Women represented 43% of the study population. Compared to men, women were older [median (interquartile range [IQR]) age 74 (65-80) vs. 68 (59-77) years, P < 0.0001]. The duration of clinical signs before admission was shorter for women [median (IQR) duration 4 (1-14) vs. 7(2-14) days, P = 0.006]. Unadjusted 1-year all-cause mortality was significantly lower in women (21 vs. 28%, P = 0.001). Adjusted HR of 1-year all-cause mortality was lower in women when compared to men [HR 0.68 (0.53-0.88), P = 0.0028]. Additional sensitivity analyses confirmed the survival benefit for women in subgroups including age greater and lower than 75 years, the presence of comorbidities and causes of dyspnea (cardiac or noncardiac).
Conclusion : Women have better 1-year survival than men after the initial ED presentation for acute dyspnea. Understanding the biological sex-related differences should lead toward precision medicine, and improve clinical decision-making to promote gender equality in health.
Conclusion (proposition de traduction) : Les femmes ont une meilleure survie à un an que les hommes après la première admission aux urgences pour dyspnée aiguë. La compréhension des différences biologiques liées au sexe devrait conduire à une médecine de précision et améliorer la prise de décision clinique afin de promouvoir l'égalité des sexes en matière de santé.
Commentaire : Des différences marquées ont été décrites entre les femmes et les hommes en ce qui concerne la prévalence des maladies, la présentation clinique, la réponse au traitement et les résultats. Cependant, ces données sont rares chez les malades aigus. La prise en compte des différences liées au sexe biologique est essentielle pour le succès des soins cliniques et des résultats chez les patients présentant une dyspnée aiguë, la cause la plus fréquente d'admission aux urgences.
Effect of sodium bicarbonate on functional outcome in patients with out-of-hospital cardiac arrest: a post-hoc analysis of a French and North-American dataset.
Touron M, Javaudin F, Lebastard Q, Baert V, Heidet M, Hubert H, Leclere B, Lascarrou JB; RéAC Network. | Eur J Emerg Med. 2022 Jun 1;29(3):210-220
Introduction : No large randomised controlled trial has assessed the potential benefits on neurologic outcomes of prehospital sodium bicarbonate administration in patients with nontraumatic out-of-hospital cardiac arrest (OHCA).
Objective: To obtain information of assistance in designing a randomised controlled trial of bicarbonate therapy after OHCA in specific patient subgroups.
Méthode : We conducted two, separate, simultaneous, retrospective studies of two distinct, unlinked datasets.
Setting and participants: One dataset was a French nationwide population-based registry (RéAC Registry, French dataset) and the other was a randomised controlled trial comparing continuous to interrupted chest compressions in North America (ROC-CCC trial, North-American dataset).
Intervention: We investigated whether prehospital bicarbonate administration was associated with better neurologic outcomes.
Outcome measures and analyses: The main outcome measure was the functional outcome at hospital discharge. To adjust for potential confounders, we conducted a nested propensity-score-matched analysis with inverse probability-of-treatment weighting.
Résultats : In the French dataset, of the 54 807 patients, 1234 (2.2%) received sodium bicarbonate and 450 were matched. After propensity-score matching, sodium bicarbonate was not associated with a higher likelihood of favourable functional outcomes on day 30 [adjusted odds ratio (aOR), 0.912; 95% confidence interval (95%CI), 0.501-1.655]. In the North-American dataset, of the 23 711 included patients, 4902 (20.6%) received sodium bicarbonate and 1238 were matched. After propensity-score matching, sodium bicarbonate was associated with a lower likelihood of favourable functional outcomes at hospital discharge (aOR, 0.45; 95% CI, 0.34-0.58).
Conclusion : In patients with OHCA, prehospital sodium bicarbonate administration was not associated with neurologic outcomes in a French dataset and was associated with worse neurologic outcomes in a North-American dataset. Given the considerable variability in sodium bicarbonate use by different prehospital care systems and the potential resuscitation-time bias in the present study, a large randomised clinical trial targeting specific patient subgroups may be needed to determine whether sodium bicarbonate has a role in the prehospital management of prolonged OHCA.
Conclusion (proposition de traduction) : Chez les patients victimes d'un arrêt cardiaque extrahospitalier, l'administration préhospitalière de bicarbonate de sodium n'a pas été associée à des résultats neurologiques dans un ensemble de données françaises et a été associée à de plus mauvais résultats neurologiques dans un ensemble de données nord-américaines. Étant donné la variabilité considérable de l'utilisation du bicarbonate de sodium par les différents systèmes de soins préhospitaliers et le biais potentiel lié au temps de réanimation dans la présente étude, un vaste essai clinique randomisé ciblant des sous-groupes de patients spécifiques pourrait être nécessaire pour déterminer si le bicarbonate de sodium a un rôle à jouer dans la prise en charge préhospitalière des arrêts cardiaques extrahospitaliers prolongés.
Neurofilament light chain in patients with a concussion or head impacts: a systematic review and meta-analysis.
Karantali E, Kazis D, McKenna J, Chatzikonstantinou S, Petridis F, Mavroudis I. | Eur J Trauma Emerg Surg. 2022 Jun;48(3):1555-1567
Keywords: Biomarker; Concussion; Head impacts; Meta-analysis; Mild TBI; Neurofilament light chain.
Introduction : Traumatic brain injury is one of the leading causes of disability worldwide. Mild traumatic brain injury (TBI) is the most common and benign form of TBI, usually referred to by the medical term "concussion". The purpose of our systematic review and meta-analysis was to explore the role of serum and CSF neurofilament light chain (NfL) as a potential biomarker in concussion.
Méthode : We systematically searched PubMed, Web of Science, and Cochrane databases using specific keywords. As the primary outcome, we assessed CSF or serum NfL levels in patients with concussion and head impacts versus controls. The role of NfL in patients with concussion and head impacts compared to healthy controls was also assessed, as well as in sports-related and military-related conditions.
Résultats : From the initial 617 identified studies, we included 24 studies in our qualitative analysis and 14 studies in our meta-analysis. We found a statistically significant increase of serum NfL in patients suffering from a concussion or head impacts compared to controls (p = 0.0023), highlighting its potential role as a biomarker. From our sub-group analyses, sports-related concussion and mild TBI were mostly correlated with increased serum NfL values. Compared to controls, sports-related concussion was significantly associated with higher NfL levels (p = 0.0015), while no association was noted in patients suffering from head impacts or military-related TBI.
Conclusion : Serum NfL levels are higher in all patients suffering from concussion compared to healthy controls. The sports-related concussion was specifically associated with higher levels of NfL. Further studies exploring the use of NfL as a diagnostic and prognostic biomarker in mild TBI and head impacts are needed.
Conclusion (proposition de traduction) : Les niveaux sériques de chaîne légère des neurofilaments sont plus élevés chez tous les patients souffrant d'une commotion cérébrale par rapport aux témoins sains. La commotion liée au sport était spécifiquement associée à des niveaux plus élevés de chaîne légère de neurofilament. D'autres études explorant l'utilisation de la chaîne légère des neurofilaments comme biomarqueur diagnostique et pronostique dans les cas de traumatisme cérébral léger et de commotion cérébrale sont nécessaires.
The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury.
van Wessem KJP, Jochems D, Leenen LPH. | Eur J Trauma Emerg Surg. 2022 Jun;48(3):1589-1599
DOI: https://doi.org/10.1007/s00068-021-01827-5 | Télécharger l'article au format
Keywords: Morbidity; Mortality; Polytrauma; TBI; Tranexamic acid.
Introduction : Tranexamic acid (TXA) has shown to be beneficial in selected patients with hemorrhagic shock. Recently, TXA has gained interest in isolated traumatic brain injury (TBI) patients with variable results. There are limited data on TXA in polytrauma with associated TBI. This study investigated the role of TXA in severely injured patients with associated severe TBI.
Méthode : A 7.5-year prospective cohort study was performed to investigate the relation between prehospital TXA and mortality in consecutive trauma patients with associated severe TBI (Abbreviated Injury Scale (AIS)head ≥ 3) admitted to a Level-1 Trauma Center ICU. Indication for prehospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation, and outcomes were prospectively collected.
Résultats : Two hundred thirty-four patients (67% males) with median age of 49 years and ISS 33 (98% blunt injuries) were included. Thirteen patients (6%) developed thromboembolic complications; mortality rate was 24%. Fifty-one percent of patients received prehospital TXA. TXA patients were younger, had more deranged physiology on arrival, and received more crystalloids and blood products ≤ 24 h. There was, however, no difference in overall outcome between TXA patients and no-TXA patients.
Conclusion : Despite having a more deranged physiology TXA patients had similar outcome compared to no-TXA patients who were much older. Thromboembolic complication rate was low. Prehospital tranexamic acid has no evident effect on outcome in polytrauma patients with associated critical brain injury.
Conclusion (proposition de traduction) : Malgré une physiologie plus perturbée, les patients sous acide tranexamique ont eu des résultats similaires aux patients sans acide tranexamique qui étaient beaucoup plus âgés. Le taux de complication thromboembolique était faible. L'acide tranexamique préhospitalier n'a pas d'effet évident sur le devenir des patients polytraumatisés présentant une lésion cérébrale grave associée.
Efficacy of tracheal tube introducers and stylets for endotracheal intubation in the prehospital setting: a systematic review and meta-analysis.
Tollman J, Ahmed Z. | Eur J Trauma Emerg Surg. 2022 Jun;48(3):1723-1735
DOI: https://doi.org/10.1007/s00068-021-01762-5 | Télécharger l'article au format
Keywords: Bougie; Endotracheal intubation; Prehospital; Stylet; Tracheal tube introducer.
Introduction : Tracheal tube introducers and stylets remain some of the most widely used devices for aiding practitioners in performing endotracheal intubation (ETI). The purpose of this systematic review is to evaluate the efficacy of tracheal tube introducers and stylets for ETI in the prehospital setting.
Méthode : A literature search was conducted on the 2nd of March 2021 across PubMed, Embase (Ovid) and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify relevant studies. Included studies had their data extracted and both a quality assessment and statistical analysis were performed.
Résultats : The summary estimate of prehospital studies with video technology showed a statistically significant increase in first pass ETI success in favour of bougies (RR 1.15, CI 1.10-1.21, p < 0.0001). The summary estimates of prehospital studies without video technology and simulation studies with and without video technology showed no statistical difference between methods for first pass or overall ETI success. Some of the highest success rates were recorded by devices that incorporated video technology. Stylets lead to a shorter time to ETI while bougies were easier to use. Neither device was associated with a higher rate of ETI complications than the other.
Conclusion : Both tracheal tube introducers and stylets function as efficacious aids to intubation in the prehospital environment. Where video technology is available, bougies could offer a statistically significant advantage in terms of first pass ETI success. Where video technology is unavailable, a combination of clinical scenario, practitioner expertise and personal preference might ultimately guide the choice of device.
Conclusion (proposition de traduction) : Les guides et mandrins pour sondes trachéales sont tous deux des aides efficaces à l'intubation dans l'environnement préhospitalier. Lorsque la technologie vidéo est disponible, les mandrins longs béquillés pourraient offrir un avantage statistiquement significatif en termes de réussite de la première intubation orotrachéale. Lorsque la technologie vidéo n'est pas disponible, une combinaison de scénario clinique, d'expertise du praticien et de préférence personnelle pourrait finalement guider le choix du dispositif.
Epidemiology and predictors of traumatic spine injury in severely injured patients: implications for emergency procedures.
Häske D, Lefering R, Stock JP, Kreinest M; TraumaRegister DGU. | Eur J Trauma Emerg Surg. 2022 Jun;48(3):1975-1983
DOI: https://doi.org/10.1007/s00068-020-01515-w | Télécharger l'article au format
Keywords: Immobilization; Prehospital; Risk; Trauma.
Introduction : This study aimed to identify the prevalence and predictors of spinal injuries that are suitable for immobilization.
Méthode : Retrospective cohort study drawing from the multi-center database of the TraumaRegister DGU®, spinal injury patients ≥ 16 years of age who scored ≥ 3 on the Abbreviated Injury Scale (AIS) between 2009 and 2016 were enrolled.
Résultats : The mean age of the 145,833 patients enrolled was 52.7 ± 21.1 years. The hospital mortality rate was 13.9%, and the mean injury severity score (ISS) was 21.8 ± 11.8. Seventy percent of patients had no spine injury, 25.9% scored 2-3 on the AIS, and 4.1% scored 4-6 on the AIS. Among patients with isolated traumatic brain injury (TBI), 26.8% had spinal injuries with an AIS score of 4-6. Among patients with multi-system trauma and TBI, 44.7% had spinal injuries that scored 4-6 on the AIS. Regression analysis predicted a serious spine injury (SI; AIS 3-6) with a prevalence of 10.6% and cervical spine injury (CSI; AIS 3-6) with a prevalence of 5.1%. Blunt trauma was a predictor for SI and CSI (OR 4.066 and OR 3.640, respectively; both p < 0.001) and fall > 3 m for SI (OR 2.243; p < 0.001) but not CSI (OR 0.636; p < 0.001). Pre-hospital shock was predictive for SI and CSI (OR 1.87 and OR 2.342, respectively; both p < 0.001), and diminished or absent motor response was also predictive for SI (OR 3.171) and CSI (OR 7.462; both p < 0.001). Patients over 65 years of age were more frequently affected by CSI.
Conclusion : In addition to the clinical symptoms of pain, we identify '4S' [spill (fall) > 3 m, seniority (age > 65 years), seriously injured, skull/traumatic brain injury] as an indication for increased attention for CSIs or indication for spinal motion restriction.
Conclusion (proposition de traduction) : En plus des symptômes cliniques de la douleur, nous identifions les "4S" [chute > 3 m, ancienneté (âge > 65 ans), blessé grave, traumatisme crânien/cerveau] comme une indication d'une attention accrue en cas de blessure de la colonne cervicale ou comme une indication de restriction des mouvements de la colonne.
A retrospective data analysis on the induction medications used in trauma rapid sequence intubations and their effects on outcomes.
Kuza CM, To J, Chang A, Mert M, Yau A, Singh M, Choi KJ, Huang S, Wier J, Inaba K, Hirji SA, Spencer D, Albertson S, Grigorian A, Nahmias JT. | Eur J Trauma Emerg Surg. 2022 Jun;48(3):2275-2286
DOI: https://doi.org/10.1007/s00068-021-01759-0 | Télécharger l'article au format
Keywords: Induction agents; Rapid sequence intubation; Trauma.
Introduction : Rapid sequence intubation (RSI) in trauma patients is common; however, the induction agents used have been debated. We determined which induction medications were used most frequently for adult trauma RSIs and their associations with hemodynamics and outcomes. We hypothesized that etomidate is the most commonly used induction agent and has similar outcomes to other induction agents.
Méthode : This retrospective review at two U.S. level I trauma centers evaluated adult trauma patients undergoing RSI within 24 h of admission, between 01/01/2016 and 12/31/2017. We compared patient characteristics and outcomes by induction agent. Comparisons on the primary outcome of in-hospital mortality and secondary outcomes of peri-intubation hypotension, hospital and ICU length of stay (LOS), ventilator days, and complications used logistic regression or negative binomial regression. Regression models adjusted for hospital site, age, patient severity measures, and intubation location.
Résultats : Among 1303 trauma patients undergoing RSI within 24 h of admission, 948 (73%) were intubated in the emergency department (ED) and 325 (25%) in the operating room (OR). The most common induction agents were etomidate (68%), propofol (17%), and ketamine (11%). In-hospital mortality was highest in the etomidate group (25.5%), followed by ketamine (17%), and propofol (1.8%).
Conclusion : Etomidate was most commonly used in ED intubations; propofol was most used in the OR. Compared to propofol, patients induced with etomidate had higher mortality and complication rates. Findings should be interpreted with caution given limited generalizability and residual confounding by indication.
Conclusion (proposition de traduction) : L'étomidate était le plus souvent utilisé dans les intubations aux urgences ; le propofol était le plus utilisé au bloc opératoire. Comparativement au propofol, les patients induits à l'étomidate présentaient des taux de mortalité et de complication plus élevés. Les résultats doivent être interprétés avec prudence étant donné la généralisation limitée et la confusion résiduelle par l'indication.
"Double Maisonneuve fracture": an unknown fracture pattern.
Kašper Š, Bartoníček J, Rammelt S, Kamin K, Tuček M. | Eur J Trauma Emerg Surg. 2022 Jun;48(3):2433-2439
DOI: https://doi.org/10.1007/s00068-021-01786-x | Télécharger l'article au format
Keywords: Ankle fractures; Anterior malleolus; Maisonneuve fracture; Posterior malleolus; Tibiofibular syndesmosis; Trimalleolar fractures.
Introduction : The aim of this study was to describe pathoanatomy and to raise awareness of a fracture of the lateral malleolus combined with a high subcapital fracture of the fibula caused by a dislocation mechanism.
Méthode : The study comprised 11 patients, 5 men and 6 women, with the mean age of 57 years (range, 21-87), with a "Double Maisonneuve fracture". Individual lesions of ankle structures were described on the basis of radiographs, CT, and intraoperative findings.
Résultats : The distal fibular fracture was classified as Weber type B in 1 case and Weber type C in 10 cases. The proximal fibular fracture was described as a subcapital oblique spiral fracture with metadiaphyseal involvement in nine cases and a high short oblique fracture with fibular head involvement in two cases. Injury to the deltoid ligament was revealed in six cases; a bicollicular fracture of the medial malleolus was found in five patients. Posterior malleolar fractures were classified as type 1 in eight cases and type 2 in three cases. Avulsion of the Chaput tubercle was detected in four cases. Injury to the interosseous tibiofibular ligament was assessed in nine patients.
Conclusion : Double Maisonneuve fracture is a rare but probably underreported injury that must be taken into consideration during examination, as it may be easily overlooked. The essential part of diagnosis is a careful clinical examination and radiological assessment of the lower leg with additional CT examination of the ankle.
Conclusion (proposition de traduction) : La double fracture de Maisonneuve est une blessure rare mais probablement sous-estimée qui doit être prise en considération lors de l'examen, car elle peut facilement passer inaperçue. L'élément essentiel du diagnostic est un examen clinique minutieux et une évaluation radiologique de la partie inférieure de la jambe avec un examen tomodensitométrique supplémentaire de la cheville.
The pace of a trauma resuscitation: experience matters.
Maarseveen OECV, Ham WHW, Huijsmans RLN, Leenen LPH. | Eur J Trauma Emerg Surg. 2022 Jun;48(3):2503-2510
DOI: https://doi.org/10.1007/s00068-021-01838-2 | Télécharger l'article au format
Keywords: Leadership; Resuscitation; Resuscitation time; Trauma team.
Introduction : Resuscitation quality and pace depend on effective team coordination, which can be facilitated by adequate leadership. Our primary aim was to assess the influence of trauma team leader experience on resuscitation pace. Second, we investigated the influence of injury severity on resuscitation pace.
Méthode : The trauma team leaders were identified (Staff trauma surgeon vs Fellow trauma surgeon) and classified from video analysis during a 1-week period. Resuscitations were assessed for time to the treatment plan, total resuscitation time, and procedure time. Furthermore, patient and resuscitation characteristics were assessed and compared: age, gender, Injury Severity Score, Glasgow Coma Scale < 9, and the number (and duration) of surgical procedures during initial resuscitation. Correlations between total resuscitation time, Injury Severity Score, and time to treatment plan were calculated.
Résultats : After adjustment for the time needed for procedures, the time to treatment plan and total resuscitation time was significantly shorter in resuscitations led by a Staff trauma surgeon compared to a Fellow trauma surgeon (median 648 s (IQR 472–813) vs 852 s (IQR 694–1256); p 0.01 resp. median 1280 s (IQR 979–1494) vs 1535 s (IQR 1247–1864), p 0.04). Surgical procedures were only performed during resuscitations led by Staff trauma surgeons (4 thorax drains, 1 endotracheal intubation, 1 closed fracture reduction). Moreover, a significant negative correlation (r: – 0.698, p < 0.01) between Injury Severity Score and resuscitation time was found.
Conclusion : Experienced trauma team leaders may positively influence the pace of the resuscitation. Moreover, we found that the resuscitation pace increases when the patient is more severely injured.
Conclusion (proposition de traduction) : Les chefs d'équipe de traumatologie expérimentés peuvent influencer positivement sur le rythme de la réanimation. De plus, nous avons constaté que le rythme de la réanimation augmente lorsque le patient est plus gravement blessé.
Are home environment injuries more fatal in children and the elderly?.
Banerjee N, Sharma N, Soni KD, Bansal V, Mahajan A, Khajanchi M, Gerdin Wärnberg M, Roy N. | Injury. 2022 Jun;53(6):1987-1993
DOI: https://doi.org/10.1016/j.injury.2022.03.050 | Télécharger l'article au format
Keywords: Home injury; Injury at home; Trauma mortality; Trauma outcome; Unintentional injuries at home.
General Trauma Section
Introduction : 'In-home injuries' are those that occur within the house or its immediate surroundings. The literature on the prevalence and magnitude of home injuries is sparse. This study was designed to characterize the mechanisms of 'in-home' injuries and compare their outcomes with 'outside home injuries'.
Méthode : The Australia-India Trauma Systems Collaboration (AITSC) Project created a multicentric registry consisting of trauma patients admitted at four urban tertiary care hospitals in India from April 2016 to March 2018. This registry data was analysed for this study. All admitted patients except for dead on arrival were included. Patients were categorised into 'in-home' and 'outside home' cohorts based on the place where the trauma occurred. The outcome measures were 30 day in-hospital mortality and the length of hospital stay. Two subgroup analyses were performed, the first comprised pediatric patients (<15 years) and the second elderly patients >64 years).
Résultats : Among 9354 patients in the AITSC data registry, 8398 patients were included in the study. Out of these, 29 percent were in-home injuries, whereas the rest occurred outside home. The 30 day in-hospital mortality was 10.6 percent in the 'in-home' cohort, as compared to 13.7 percent in the 'outside home' cohort. This difference although significant on univariable analysis (p <0.01), there was no significant difference on multivariable regression analysis, after adjusting for age and injury severity score (OR = 0.88, 95% CI = 0.73-1.04; p = 0.15). The length of hospital stay was shorter in the home injuries group (median = 5 days; IQR = 3-12 days) compared to the outside-home group (median = 7 days; IQR = 4-14 days) (p < 0.01). In the pediatric and the elderly, on multivariable regression analysis, in-home injuries were associated with higher mortality than outside home injuries.
Conclusion : There was no significant difference in the 30 day in-hospital mortality amongst admitted trauma patients sustaining injuries at home or outside the home. However, in pediatric and elderly patients the chances of mortality was significantly higher when injured at home.
Conclusion (proposition de traduction) : Il n'y avait pas de différence significative dans la mortalité à l'hôpital à 30 jours parmi les patients admis en traumatologie et ayant subi des blessures à domicile ou en dehors du domicile. Cependant, chez les enfants et les personnes âgées, le risque de mortalité était significativement plus élevé en cas de blessure à domicile.
Management of moderate to severe traumatic brain injury: an update for the intensivist.
Meyfroidt G, Bouzat P, Casaer MP, Chesnut R, Hamada SR, Helbok R, Hutchinson P, Maas AIR, Manley G, Menon DK, Newcombe VFJ, Oddo M, Robba C, Shutter L, Smith M, Steyerberg EW, Stocchetti N, Taccone FS, Wilson L, Zanier ER, Citerio G. | Intensive Care Med. 2022 Jun;48(6):649-666
DOI: https://doi.org/10.1007/s00134-022-06702-4 | Télécharger l'article au format
Keywords: Traumatic brain injury, Intracranial pressure, Cerebral perfusion pressure, Intensive care unit, Neuromonitoring, Pre-hospital management
Editorial : Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical manage- ment and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit.
Conclusion : TBI management has changed over the past decade, from a dogmatic approach where ICP control in isolation was confused with TBI management, to a more multimodal approach, in which pathophysiological derangements are detected and treated accordingly. Further research into these pathophysiological mechanisms is still needed, quantifying temporal relations and depend- encies. Also, addressing the systemic complications of TBI, such as hypercoagulation or malnutrition, is now part of standard management protocols. Unfortunately, evidence from randomized clinical trials is still lacking for many of the recommended interventions. However, the Seattle Brain Injury Consen- sus Conference guidelines (SIBICC) guidelines now provide a clear standard of therapy where novel interventions can be added or be compared to.
Conclusion (proposition de traduction) : La prise en charge des lésions cérébrales traumatiques a évolué au cours de la dernière décennie, passant d'une approche dogmatique où le contrôle de la pression intracrânienne isolément était confondu avec la prise en charge des lésions cérébrales traumatiques, à une approche plus multimodale, dans laquelle les troubles physiopathologiques sont détectés et traités en conséquence. Des recherches plus approfondies sur ces mécanismes physiopathologiques sont encore nécessaires, quantifiant les relations temporelles et les dépendances. En outre, la prise en charge des complications systémiques des lésions cérébrales traumatiques, telles que l'hypercoagulation ou la malnutrition, fait désormais partie des protocoles de prise en charge standard. Malheureusement, les preuves issues d'essais cliniques randomisés font encore défaut pour bon nombre des interventions recommandées. Cependant, les lignes directrices de la Conférence de consensus sur les lésions cérébrales de Seattle (SIBICC) fournissent maintenant une norme claire de thérapie à laquelle de nouvelles interventions peuvent être ajoutées ou comparées.
• Hawryluk GWJ and al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. 2019 Dec;45(12):1783-1794 .
• Chesnut R and al. A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. 2020 May;46(5):919-929. doi: 10.1007/s00134-019-05900-x .
Algorithme pour le traitement de la pression intracrânienne (ICP) (modifié de la Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC))
Partie A du graphique - Les patients dont la PIC est inférieure au seuil n'ont généralement pas besoin de traitement, sauf pour les conditions dans lesquelles une pression intracrânienne élevée est présente car cette condition est associée à de moins bons résultats.
Partie B du graphique - Algorithme basé sur le consensus pour la prise en charge des lésions cérébrales traumatiques graves avec hypoxie cérébrale et pression intracrânienne normale.
Partie C du graphique - Algorithme basé sur le consensus pour la prise en charge des lésions cérébrales traumatiques graves avec hypertension intracrânienne et hypoxie cérébrale.
Partie D du graphique - Algorithme basé sur le consensus pour la prise en charge des lésions cérébrales traumatiques graves avec hypertension intracrânienne et oxygénation cérébrale normale.
Meyfroidt G and al. Correction to: Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med. 2022 Jul;48(7):989-991. doi: 10.1007/s00134-022-06759-1. Erratum for: Intensive Care Med. 2022 Jun;48(6):649-666 .
Long-term mortality and health-related quality of life of lower versus higher oxygenation targets in ICU patients with severe hypoxaemia.
Crescioli E, Klitgaard TL, Poulsen LM, Brand BA, Siegemund M, Grøfte T, Keus F, Pedersen UG, Bäcklund M, Karttunen J, Morgan M, Ciubotariu A, Bunzel AG, Vestergaard SR, Jensen NM, Jensen TS, Kjær MN, Jensen AKG, Lange T, Wetterslev J, Perner A, Schjørring OL, Rasmussen BS. | Intensive Care Med. 2022 Jun;48(6):714-722
DOI: https://doi.org/10.1007/s00134-022-06695-0 | Télécharger l'article au format
Keywords: Intensive care units; Mortality; Oxygen inhalation therapy; Quality of life; Randomized controlled trial.
Introduction : We assessed outcomes after 1 year of lower versus higher oxygenation targets in intensive care unit (ICU) patients with severe hypoxaemia.
Méthode : Pre-planned analyses evaluating 1-year mortality and health-related quality-of-life (HRQoL) outcomes in the previously published Handling Oxygenation Targets in the ICU trial which randomised 2928 adults with acute hypoxaemia to targets of arterial oxygen of 8 kPa or 12 kPa throughout the ICU stay up to 90 days. One-year all-cause mortality was assessed in the intention-to-treat population. HRQoL was assessed using EuroQol 5 dimensions 5 levels (EQ-5D-5L) questionnaire and EQ visual analogue scale score (EQ-VAS), and analyses were conducted in both survivors only and the intention-to-treat population with assignment of the worst scores to deceased patients.
Résultats : We obtained 1-year vital status for 2887/2928 (98.6%), and HRQoL for 2600/2928 (88.8%) of the trial population. One year after randomisation, 707/1442 patients (49%) in the lower oxygenation group vs. 704/1445 (48.7%) in the higher oxygenation group had died (adjusted risk ratio 1.00; 95% confidence interval 0.93-1.08, p = 0.92). In total, 1189/1476 (80.4%) 1-year survivors participated in HRQoL interviews: median EQ-VAS scores were 65 (interquartile range 50-80) in the lower oxygenation group versus 67 (50-80) in the higher oxygenation group (p = 0.98). None of the five EQ-5D-5L dimensions differed between groups.
Conclusion : Among adult ICU patients with severe hypoxaemia, a lower oxygenation target (8 kPa) did not improve survival or HRQoL at 1 year as compared to a higher oxygenation target (12 kPa).
Conclusion (proposition de traduction) : Chez les patients adultes en USI souffrant d'hypoxémie sévère, un objectif d'oxygénation plus faible (8 kPa) n'a pas amélioré la survie ou la qualité de vie liée à la santé à 1 an par rapport à un objectif d'oxygénation plus élevé (12 kPa).
Lasting Legacy In Intensive Care Medicine
Editorial : A truly historical perspective on oxygen targets begins billions of years ago. In Earth’s early history, there was essentially no oxygen in the atmosphere. Evolution of cyanobacteria resulted in oxygen production through photosynthesis. However, initially, as Earth’s iron rusted, oxygen did not appreciably accumulate in the atmos- phere. Around 2 billion years ago oxygen in the atmos- phere rose to between 2 and 4%, where it remained for over a billion years. It was in this low oxygen environ- ment that the precursors to our mitochondria evolved.
Conclusion : For clinicians who want to know what to do now, the approaches to conservative and liberal oxygen therapy evaluated in recent RCTs can reasonably be implemented for most patients. For patient groups where one strategy or the other may be potentially preferable, clinicians may choose to implement that strategy while acknowledging that uncertainty remains. If a higher oxygenation target is used for a specific patient, it is important to measure PaO2 to prevent unintentional exposure pro- 2 nounced hyperoxaemia. Approaches to oxygen therapy that fall outside of the range tested in recent trials should be regarded as experimental and should not be used routinely.
Conclusion (proposition de traduction) : Pour les cliniciens qui veulent savoir quoi faire maintenant, les attitudes d'oxygénothérapie conservatrice et libérale évaluées dans de récents essais contrôlés randomisés peuvent raisonnablement être mises en œuvre pour la plupart des patients. Pour les groupes de patients où une stratégie ou l'autre peut être potentiellement préférable, les cliniciens peuvent choisir de mettre en œuvre cette stratégie tout en reconnaissant que l'incertitude demeure. Si une cible d'oxygénation plus élevée est utilisée pour un patient spécifique, il est important de mesurer la PaO2 pour éviter une exposition involontaire à une hyperoxémie prononcée. Les approches d'oxygénothérapie qui se situent en dehors de la plage testée lors d'essais récents doivent être considérées comme expérimentales et ne doivent pas être utilisées en routine.
Ten tips to optimize vasopressors use in the critically ill patient with hypotension.
Legrand M, Zarbock A. | Intensive Care Med. 2022 Jun;48(6):736-739
DOI: https://doi.org/10.1007/s00134-022-06708-y | Télécharger l'article au format
What’s new in intensive care
Editorial : Hypotension is very common in critically ill patients and is associated with an increased morbidity and mortality. Hypotension, defined as low arterial blood pressure with proven of suspected organ hypoperfusion, often requires a differentiated catecholamine therapy, including vaso- pressors and inotropes. We here discuss ten tips to opti- mize vasopressor use in critically ill patients.
Conclusion : 1. Set goals of mean or diastolic blood pressures
2. Individualize the arterial pressure targets goals
3. Vasopressors induce an endogenous fluid recruitment and may limit positive fluid balance
4. Reassess fluid status and cardiac output after initiation of vasopressors
5. Consider agents with a different mechanism of action as a second line agent
6. Consider adding hydrocortisone in patients on high doses of vasopressors
7. There is no maximal dose of vasopressors
8. Vasopressin in patients with right ventricular failure
9. Enteral tube feeding can be initiated while under vasopressors
10. Vasopressors can be safely administered through a peripheral catheter
Conclusion (proposition de traduction) : 1. Définir des objectifs de tension artérielle moyenne ou diastolique
2. Adapter les objectifs de pression artérielle à chaque patient
3. Les vasopresseurs induisent un recrutement de liquides endogènes et ne permettent pas d'éviter le remplissage vasculaire
4. Réévaluer l'état des liquides et le débit cardiaque après initiation des vasopresseurs
5. Envisagez des agents avec un mécanisme différent d'action en tant qu'agent de deuxième ligne
6. Envisagez d'ajouter de l'hydrocortisone chez les patients à fortes doses de vasopresseurs
7. Il n'y a pas de dose maximale de vasopresseurs
8. Utilisation de la vasopressine chez les patients présentant une insuffisance ventriculaire droite
9. L'alimentation par sonde entérale peut être initiée sous vasopresseurs
10. Les vasopresseurs peuvent être administrés en toute sécurité via un cathéter veineux périphérique
Effets hémodynamiques positifs et négatifs potentiels des vasopresseurs chez les patients de réanimation et facteurs à prendre en compte lors de l'utilisation de vasopresseurs chez les patients de réanimation.
Joannidis M, Wiedermann CJ, Ostermann M. Correction: Ten myths about albumin. Intensive Care Med. 2022 Jun;48(6):793. doi: 10.1007/s00134-022-06680-7. Erratum for: Intensive Care Med. 2022 May;48(5):602-605 .
Rhythm- or rate-control strategies according to 4S-AF characterization scheme and long-term outcomes in atrial fibrillation patients: the FAMo (Fibrillazione Atriale in Modena) cohort.
Malavasi VL, Vitolo M, Colella J, Montagnolo F, Mantovani M, Proietti M, Potpara TS, Lip GYH, Boriani G. | Intern Emerg Med. 2022 Jun;17(4):1001-1012. 2022 Jun;17(4):1001-1012
DOI: https://doi.org/10.1007/s11739-021-02890-x | Télécharger l'article au format
Keywords: 4S-AF; Atrial fibrillation; Classification scheme; Mortality; Outcomes; Rhythm Control.
IM - ORIGINAL
Editorial : The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] was recently proposed to characterize AF patients. In this post hoc analysis we evaluated the agreement between the therapeutic strategy (rate or rhythm control, respectively), as suggested by the 4S-AF scheme, and the actual strategy followed in a patients cohort. Outcomes of interest were as follows: all-cause death, a composite of all-cause death/any thromboembolism/acute coronary syndrome, and a composite of all-cause death, any thrombotic/ischemic event, and major bleeding (net clinical outcome). We enrolled 615 patients: 60.5% male, median age 74 [interquartile range (IQR) 67-80] years; median CHA2DS2VASc 4 and median HAS-BLED 2. The 4S-AF score would have suggested a rhythm-control strategy in 351 (57.1%) patients while a rate control in 264 (42.9%). The strategy adopted was concordant with the 4S-AF suggestions in 342 (55.6%) cases, and non-concordant in 273 (44.4%). After a median follow-up of 941 days (IQR 365-1282), 113 (18.4%) patients died, 158 (25.7%) had an event of the composite endpoint. On adjusted Cox regression analysis, when 4S-AF score suggested rate control, disagreement with that suggestion was not associated with a worse outcome. When 4S-AF indicated rhythm control, disagreement was associated with a higher risk of all-cause death (HR 7.59; 95% CI 1.65-35.01), and of the composite outcome (HR 2.69; 95% CI 1.19-6.06). The 4S-AF scheme is a useful tool to comprehensively evaluate AF patients and aid the decision-making process. Disagreement with the rhythm control suggestion of the 4S-AF scheme was associated with adverse clinical outcomes.
Conclusion : The 4S-AF scheme is a useful tool to comprehensively evaluate AF patients and aid the decision-making process. Disagreement with the rhythm control suggestion of the 4S-AF scheme was associated with adverse clinical outcomes. In real-world AF patients, appropriate application of the 4S-AF scheme may facilitate the application of a rhythm-control strategy.
Conclusion (proposition de traduction) : Le schéma 4S-AF est un outil utile pour évaluer de manière exhaustive les patients souffrant de fibrillation atriale et pour faciliter le processus décisionnel. Le désaccord avec la suggestion de contrôle du rythme du schéma 4S-AF était associé à des résultats cliniques défavorables. Dans le monde réel des patients souffrant de FA, une application appropriée du schéma 4S-AF peut faciliter l'application d'une stratégie de contrôle du rythme. Traduit avec www.DeepL.com/Translator (version gratuite)
Commentaire : Schéma 4S-AF : risque d'accident vasculaire cérébral, gravité des symptômes, gravité de la fibrillation atriale (FA), gravité du substrat.
Prognostic value of fibrinogen to albumin ratios among critically ill patients with acute kidney injury.
Li C, Yao X, Chen Y, Zhang Y, Hu H. | Intern Emerg Med. 2022 Jun;17(4):1023-1031
DOI: https://doi.org/10.1007/s11739-021-02898-3 | Télécharger l'article au format
Keywords: Acute kidney injury; Albumin; Fibrinogen; Prognosis.
IM - ORIGINAL
Editorial : Fibrinogen to albumin ratios (FAR) have shown to be a promising prognostic factor for improving the predictive accuracy in various diseases. This study explores FAR's prognostic significance in critically ill patients with acute kidney injury (AKI). All clinical data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care Database III version 1.4. All patients were divided into four groups based on FAR quartiles. The primary endpoint was in-hospital mortality. A generalized additive model was applied to explore a nonlinear association between FAR and in-hospital mortality. The Cox proportional hazards models were used to determine the association between FAR and in-hospital mortality. A total of 5001 eligible subjects were enrolled. Multivariate analysis demonstrated that higher FAR was an independent predictor of in-hospital mortality after adjusting for potential confounders (HR, 95% CI 1.23, 1.03-1.48, P = 0.025). A nonlinear relationship between FAR and in-hospital mortality was observed. FAR may serve as a potential prognostic biomarker in critically patients with AKI and higher FAR was associated with increased risk of in-hospital mortality among these patients.
Conclusion : We found a U-shaped relationship between the FAR and mortality and a higher level of FAR was associated with increased risk of in-hospital mortality in critically ill patients with AKI. However, our findings still need to be confirmed by large prospective studies with long follow-up.
Conclusion (proposition de traduction) : Nous avons trouvé une relation en forme de U entre les ratios Fibrinogène/albumine et la mortalité et un niveau plus élevé de ratios Fibrinogène/albumine était associé à un risque accru de mortalité à l'hôpital chez les patients gravement malades souffrant de lésions rénales aiguës. Cependant, nos résultats doivent encore être confirmés par de grandes études prospectives avec un long suivi.
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.
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 globale de l'échographie du point d'intervention, la concordance avec le diagnostic composite final et la réduction statistiquement significative du temps nécessaire pour formuler le diagnostic, l'échographie du point d'intervention est un outil de diagnostic initial très prometteur qui peut accélérer la prise de décision aux urgences pour une prise en charge et un traitement rapides des patients avec une précision fiable.
Is hypocapnia a risk factor for non-invasive ventilation failure in cardiogenic acute pulmonary edema?.
Carrillo-Aleman L, Carrasco-Gónzalez E, Araújo MJ, Guia M, Alonso-Fernández N, Renedo-Villarroya A, López-Gómez L, Higon-Cañigral A, Sanchez-Nieto JM, Carrillo-Alcaraz A. | J Crit Care. 2022 Jun;69:153991
Keywords: Heart failure; Hospital mortality; Hypocapnia; Intensive care unit; Noninvasive ventilation.
Introduction : The impact of hypocapnia in the prognosis of cardiogenic acute pulmonary edema (CAPE) has not been sufficiently studied. The aim of this study was to analyse whether hypocapnia is a risk factor for non-invasive ventilation (NIV) failure and hospital mortality, in CAPE patients CAPE.
Méthode : Retrospective observational study of all patients with CAPE treated with NIV. Patients were classified in three groups according to PaCO2 level (hypocapnic, eucapnic and hypercapnic). NIV failure was defined as the need for endotracheal intubation and/or death.
Résultats : 1138 patients were analysed, 390 (34.3%) of which had hypocapnia, 186 (16.3%) had normocapnia and 562 (49.4%) had hypercapnia. NIV failure was more frequent in hypocapnic (60 patients, 15.4%) than in eucapnic (16 pacientes, 8.6%) and hypercapnic group (562 pacientes, 10.7%), with statistical significance (p = 0.027), as well as hospital mortality, 73 (18.7%), 19(10.2%) and 83 (14.8%) respectively (p = 0.026). The predicted factors for NIV failure were the presence of do-not-intubate order, complications related to NIV, a lower left ventricular ejection fraction, higher SAPS II and SOFA score and a higher HACOR score at one hour of NIV initiation.
Conclusion : Hypocapnia in patients with CAPE is associated with NIV failure and a greater in-hospital mortality.
Conclusion (proposition de traduction) : L'hypocapnie chez les patients souffrant d'un œdème pulmonaire aigu cardiogénique est associée à l'échec de la VNI et à une plus grande mortalité à l'hôpital.
Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomized Clinical Trial.
Chalabi J, Rahmatullah AA, Duan E, Tsang JLY, Lewis K, Lauzier F, Centofanti J, Rochwerg B, Culgin S, Nelson K, Abdukahil SA, Fiest KM, Stelfox HT, Tlayjeh H, Meade MO, Perri D, Solverson K, Niven DJ, Lim R, Møller MH, Belley-Cote E, Thabane L, Tamim H, Cook DJ, Arabi YM; COVI-PRONE Trial Investigators and the Saudi Critical Care Trials Group. | JAMA. 2022 Jun 7;327(21):2104-2113
Introduction : The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19.
Objective: To evaluate the efficacy and adverse events of prone positioning in nonintubated adult patients with acute hypoxemia and COVID-19.
Méthode : Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021.
Intervention: Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195).
Main outcomes and measures: The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events.
Résultats : Among the 400 patients who were randomized (mean age, 57.6 years [SD, 12.83 years]; 117 [29.3%] were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 [95% CI, 0.59 to 1.12], P = .20; absolute difference, -6.37% [95% CI, -15.83% to 3.10%]). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 [95% CI, 0.62 to 1.40], P = .54; absolute difference, -1.15% [95% CI, -9.40% to 7.10%]) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients [6.34%]) and desaturation (2 of 205 patients [0.98%]). There were no reported adverse events in the control group.
Conclusion : In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit.
Conclusion (proposition de traduction) : Chez les patients présentant une insuffisance respiratoire hypoxémique aiguë due à la COVID-19, le décubitus ventral, par rapport aux soins habituels sans décubitus ventral, n'a pas réduit de manière significative les besoins d'intubation orotrachéale à 30 jours. Cependant, la taille de l'effet pour le résultat principal de l'étude était imprécise et n'exclut pas un avantage cliniquement important.
Severe upper digestive tract hemorrhage.
Séguier A | Prat Anesth Reanim. 2022 Juin:26(3):144-148
DOI: https://doi.org/10.1016/j.pratan.2022.04.004 | Télécharger l'article au format
Keywords: Digestive tract haemorrhage; Blood transfusion; Digestive tract endoscopy; Hemorrhagic shock
MISE AU POINT
Editorial : L’hémorragie digestive haute est une urgence fréquente dont le pronostic s’est amé- lioré. Les deux étiologies principales sont les érosions gastro-œsophagiennes et l’hypertension portale ; la première est plus fréquente et la seconde souvent plus grave. Le diagnostic repose sur l’endoscopie qui doit être effectuée sans délai si l’hémorragie est grave. Le traitement phar- macologique repose sur les inhibiteurs de la pompe à protons en cas de cause érosive et sur les vasoconstricteurs splanchniques en cas d’HTP. L’érythromycine facilite la vidange gastrique et les conditions d’examen. L’acide tranexamique n’a pas fait la preuve de son efficacité en termes de réduction du saignement. Le contrôle des voies aériennes supérieures par intubation orotrachéale en séquence rapide est recommandé. © 2022 Publi ́e par Elsevier Masson SAS
Conclusion (proposition de traduction) : L’anesthésiste réanimateur est un acteur essentiel de la prise en charge des hémorragies digestives hautes pour l’évaluation initiale, pour la mise en oeuvre des traitements pharmacologiques pré-endoscopiques et pour l’orientation des malades vers une structure de soins, adaptée. Une connaissance globale de cette pathologie permet de mieux cerner les patients à risque d’hémorragie réfractaire qui doivent être rapprochés d’une structure spécialisée avec surveillance continue. La gestion des voies aériennes demeure une question centrale, mais l’anesthésie générale avec intubation en séquence rapide est devenue la règle en cas d’hémorragie abondante avec retentissement hémodynamique. L’échographie gastrique par la mesure de la surface antrale offre une perspective d’évaluation supplémentaire intéressante en cas d’hémorragie digestive haute non active et préparée.
Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation.
Pehlivanturk-Kizilkan M, Ozsezen B, Batu ED. | Pediatr Emerg Care. 2022 Jun 1;38(6):264-268
Introduction : Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity.
Méthode : Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department.
Résultats : Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity.
Conclusion : Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.
Conclusion (proposition de traduction) : Les visites non urgentes constituent la majeure partie des admissions aux urgences pédiatriques. Plusieurs facteurs se sont avérés être associés aux visites non urgentes, soit en ayant un effet direct, soit en ayant un impact indirect sur la gravité perçue. Des interventions basées sur l'éducation à la santé, ciblant des symptômes courants comme la fièvre et surtout des groupes de parents plus jeunes, pourraient être bénéfiques pour réduire la charge des patients dans les services d'urgence pédiatriques.
Value of Temperature for Predicting Invasive Bacterial Infection in Febrile Infants: A Spanish Pediatric Emergency Research Group (RISeuP-SPERG) Study.
de la Torre M, Gómez B, Velasco R; Group for Study of Febrile Infant of Spanish Pediatric Emergency Research Group (RISeuP-SPERG). | Pediatr Emerg Care. 2022 Jun 1;38(6):e1294-e1297
Introduction : This study aimed to analyze the prevalence of invasive bacterial infection (IBI) among infants younger than 90 days with fever without source according to the degree of fever.
Méthode : We performed a secondary analysis of a multicenter study with 19 participating Spanish pediatric emergency departments that included 3401 febrile infants 90 days or younger.
Résultats : Prevalence of IBI was 3.2% (5.3% among infants <29 days old, 2.5% among those 29-60 days old, and 2.2% among those 61-90 days old). Prevalence of bacteremia increased with the degree of fever, meanwhile the prevalence of bacterial meningitis did not. No cutoff point was useful for ruling out an IBI safely. Overall, 46.7% of the IBIs were diagnosed in patients with temperature <38.6° (sensitivity, 53.3%; negative likelihood ratio, 0.81).
Conclusion : Performing blood tests should be recommended in infants 90 days or younger with temperature ≥38°C without source regardless of the degree of fever.
Conclusion (proposition de traduction) : La réalisation d'analyses sanguines doit être recommandée chez les nourrissons de 90 jours ou moins présentant une température ≥ 38° C sans source, quel que soit le degré de la fièvre.
The Outcome of Cerumen Removal in the Pediatric Emergency Department.
Tavor O, Schnapp Z, Soffer GP, DeRowe A, Rimon A. | Pediatr Emerg Care. 2022 Jul 1;38(7):e1369-e1371
Introduction : Cerumen obstructs the visualization of the tympanic membrane (TM) in up to 40% of children, sometimes posing a challenge to rule out the diagnosis of acute otitis media (AOM) as the source of otalgia (for verbal children), irritability, fever, and febrile seizures. We aim to determine the rate at which removing the cerumen from blocking the view of the TM could change the management of these patients in the pediatric emergency department (PED).
Méthode : We retrospectively investigated all medical records of patients who underwent cerumen removal in the PED at a tertiary children's hospital from 2018 to 2019. We analyzed the effect of the procedure on the subsequent workup during their PED visit.
Résultats : Of 482 children who presented to the PED with otalgia, irritability, fever, and/or febrile seizures and who were referred to an otolaryngologist for subsequent treatment after preliminary evaluation in the PED, 176 were included in the study group after having the cerumen removed from one or both ears. Seventy-three of them were given a diagnosis of AOM, 93 had a normal-appearing TM, and 10 had external otitis. Twenty-one percent of those with AOM and 46% of those with a normal TM ( P = 0.008) had blood drawn as part of their workup in their PED visit. The rate of chest x-rays was also significantly less for the AOM group (16% vs 30%, P = 0.03), and they also underwent fewer urine tests ( P = NS).
Conclusion : Cerumen removal changes the management of children in the PED who present with a possible diagnosis of an ear infection. Cerumen removal could avoid unnecessary laboratory and imaging studies, which could save time, costs, and suffering.
Conclusion (proposition de traduction) : Le retrait du cérumen modifie la prise en charge des enfants qui se présentent aux urgences pédiatriques avec un diagnostic possible d'infection de l'oreille. L'élimination du cérumen pourrait éviter des examens de laboratoire et d'imagerie inutiles, ce qui permettrait d'économiser du temps, des coûts et de la souffrance.
The Utilization of Handheld Ultrasound Devices in a Prehospital Setting.
Ienghong K, Cheung LW, Tiamkao S, Bhudhisawasdi V, Apiratwarakul K. | Prehosp Disaster Med. 2022 Jun;37(3):355-359
DOI: https://doi.org/10.1017/s1049023x22000644 | Télécharger l'article au format
Introduction : Prehospital ultrasounds can be considered a new form of diagnostic tool when taking into account their small structure and due to the fact that nowadays, they are used in the care of emergency patients. However, at present, there is no study regarding the advantage of ultrasound usage in prehospital settings in Thailand.
Study objective: This study aims to determine the sonographic characteristics recorded by handheld ultrasounds used in prehospital care and the diagnostic accuracy of ultrasounds for prehospital patients.
Méthode : A cross-sectional study was conducted on prehospital patients who underwent point-of-care ultrasound (POCUS) examination on Emergency Medical Service (EMS) operations at Srinagarind Hospital, Thailand from January 2021 through December 2021. The ultrasound images, the electronic emergency department medical records, and the EMS database were recorded and reviewed by a team of emergency physicians. The quality of prehospital ultrasound examinations was assessed by comparing the diagnoses at the scene with those taken at the hospital.
Résultats : One hundred sixty-nine prehospital patients who received POCUS examinations were examined over a one-year period. All (100.0%) of the scans were for medical cases. No ultrasound protocol was used in the prehospital care. Two hundred eight POCUS examinations were performed in this study. The most common POCUS indication was dyspnea (45.6%), followed by hypotension/shock (30.1%), and finally syncope (8.2%). The most common area where POCUS was performed was on the lung (37.0%), followed by the inferior vena cava (30.8%), and finally for cardiac cases (26.4%). This study found that 34.9% of sonographic findings could be considered abnormal. The diagnoses of prehospital patients were confirmed by using POCUS in 66 cases (39.1%) with the accuracy of prehospital diagnosis reaching a peak of 75.8%.
Conclusion : This study shows POCUS examinations can be effectively used in prehospital care. The prehospital diagnosis given by physicians administering treatment who used POCUS examinations correlated with the in-hospital diagnosis.
Conclusion (proposition de traduction) : Cette étude montre que les examens échographiques au point d'intervention peuvent être utilisés efficacement dans les soins préhospitaliers. Le diagnostic préhospitalier posé par les médecins qui ont utilisé l'échographie au point d'intervention est en corrélation avec le diagnostic hospitalier.
Non-Invasive Ventilation in the Prehospital Emergency Setting: A Systematic Review and Meta-Analysis.
Scquizzato T, Imbriaco G, Moro F, Losiggio R, Cabrini L, Consolo F, Landoni G, Zangrillo A. | Prehosp Emerg Care. 2022 Jun 22:1-9
Introduction : Noninvasive ventilation is a well-established treatment for acute respiratory failure, being increasingly applied in the prehospital setting. This systematic review and meta-analysis aims to investigate whether early prehospital initiation of noninvasive ventilation reduces mortality compared to standard oxygen therapy.
Méthode : We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 7th, 2022, for studies comparing prehospital noninvasive ventilation performed by emergency medical services versus standard oxygen therapy in patients with acute respiratory failure. The primary outcome was mortality at the longest follow-up available.
Résultats : We included ten randomized studies and two quasi-randomized studies for a total of 1485 patients. Prehospital treatment with noninvasive ventilation compared with standard oxygen therapy did not significantly reduce mortality at the longest follow-up available (107/810 [13%] vs 114/772 [15%]; RR = 0.89; 95% CI, 0.70-1.13; P = 0.34; I2=24%). The endotracheal intubation rate was reduced when receiving prehospital noninvasive ventilation (38/776 [4.9%] vs 81/743 [11%]; RR = 0.44; 95% CI, 0.31-0.63; P < 0.001; I2=0%; number needed to treat 17). The intensive care admission rate (114/532 [21%] vs 129/507 [25%]; RR = 0.85; 95% CI, 0.69-1.04; P = 0.11; I2=0%) and length of hospital stay (mean difference=-1.29 days; 95% CI, -3.35-0.77; P = 0.21; I2=82%) were similar between groups.
Conclusion : Adults with acute respiratory failure treated in the prehospital setting with noninvasive ventilation had a lower risk of intubation than those managed with standard oxygen therapy, with similar risk of death, intensive care admission, and length of hospital stay.
Conclusion (proposition de traduction) : Les adultes souffrant d'insuffisance respiratoire aiguë traités en milieu préhospitalier par ventilation non invasive avaient un risque d'intubation plus faible que ceux gérés par oxygénothérapie standard, avec un risque de décès, d'admission en soins intensifs et de durée d'hospitalisation similaires.
Intra-cardiac arrest transport and survival from out-of-hospital cardiac arrest: A nationwide observational study.
Holmberg MJ, Granfeldt A, Stankovic N, Andersen LW. | Resuscitation. 2022 Jun;175:50-56
Keywords: Cardiac Arrest; Emergency Medical Services; Prehospital; Resuscitation; Transport.
Introduction : To assess whether intra-cardiac arrest transport as compared to continued on-scene resuscitation was associated with improved clinical outcomes among out-of-hospital cardiac arrest patients in Denmark.
Méthode : This was an observational study using data from population-based registries in Denmark. Adults (aged ≥ 18 to ≤ 65 years) with an out-of-hospital cardiac arrest attended by Emergency Medical Services (EMS) between 2016 and 2018 were included. The primary outcome was survival to 30 days. Time-dependent propensity score matching was used to match patients transported to the hospital within 20 minutes of EMS arrival to patients with assumed on-scene resuscitation (with or without subsequent intra-cardiac arrest transport) at risk of being transported within the same minute.
Résultats : The full cohort included 2,873 cardiac arrests. The median age was 56 (quartiles: 48 to 62) years, 1987 (69%) were male, and 104 (4%) were transported within 20 minutes. A total of 87 transported patients were matched to 87 patients at risk of being transported based on the propensity score. Although not reaching statistical significance, in comparison with on-scene resuscitation, intra-cardiac arrest transport was associated with increased survival to 30 days (risk ratio, 1.55; 95%CI, 0.99-2.44; P = 0.06). Similar associations were observed for return of spontaneous circulation and survival to one year.
Conclusion : Among patients aged 18-65 years, intra-cardiac arrest transport was associated with a non-significant increase in survival within 20 minutes of EMS on-scene arrival. However, the results did not eliminate the potential for bias and the results should be interpreted carefully.
Conclusion (proposition de traduction) : Chez les patients âgés de 18 à 65 ans, le transport en cas d'arrêt d'origine cardiaque a été associé à une augmentation non significative de la survie dans les 20 minutes suivant l'arrivée du SAMU sur les lieux. Cependant, les résultats n'ont pas éliminé le risque de biais et les résultats doivent être interprétés avec prudence.
Etiologies of In-hospital cardiac arrest: A systematic review and meta-analysis.
Allencherril J, Lee PYK, Khan K, Loya A, Pally A. | Resuscitation. 2022 Jun;175:88-95
Keywords: Acute coronary syndrome; Cardiac arrest; Heart failure.
Introduction : Etiologies of in-hospital cardiac arrest (IHCA) in general wards may differ from etiologies of out-of-hospital cardiac arrest (OHCA) given the different clinical characteristics of these patient populations. An appreciation for the causes of IHCA may allow the clinician to appropriately target root causes of arrest.
Méthode : MEDLINE/PubMed, EMBASE, and Google Scholar were queried from inception until May 31, 2021. Studies reporting etiologies of IHCA were included. A random effects meta-analysis of extracted data was performed using Review Manager 5.4.
Résultats : Of 12,451 citations retrieved from the initial literature search, 9 were included in the meta-analysis. The most frequent etiologies of cardiac arrest were hypoxia (26.46%, 95% confidence interval [CI] 14.19-38.74%), acute coronary syndrome (ACS) (18.23%, 95% CI 13.91-22.55%), arrhythmias (14.95%, 95% CI 0-34.93%), hypovolemia (14.81%, 95% CI 6.98-22.65%), infection (14.36%, 95% CI 9.46-19.25%), and heart failure (12.64%, 95% CI 6.47-18.80%). Cardiac tamponade, electrolyte disturbances, pulmonary embolism, neurological causes, toxins, and pneumothorax were less frequent causes of IHCA. Initial rhythm was unshockable (pulseless electrical activity or asystole) in 69.83% of cases and shockable (ventricular tachycardia or ventricular fibrillation) in 21.75%.
Conclusion : The most prevalent causes of IHCA among the general wards population are hypoxia, ACS, hypovolemia, arrythmias, infection, heart failure, three of which (arrhythmia, infection, heart failure) are not part of the traditional "H's and T's" of cardiac arrest. Other causes noted in the "H's and T's" of advanced cardiac life support do not appear to be important causes of IHCA.
Conclusion (proposition de traduction) : Les causes les plus fréquentes d'arrêt cardiaque à l'hôpital dans la population générale sont l'hypoxie, le syndrome coronarien aigu, l'hypovolémie, les arythmies, l'infection, l'insuffisance cardiaque, dont trois (arythmie, infection, insuffisance cardiaque) ne font pas partie des "H et T" traditionnels de l'arrêt cardiaque. Les autres causes mentionnées dans les " H et T " de la réanimation cardiaque avancée ne semblent pas être des causes importantes d'arrêt cardiaque à l'hôpital.
« 4 H » :
• Hypoxie (« fausse route », noyade…)
• Hypo-hyperkaliémie (et autres troubles électrolytiques)
• Hypovolémie (par hémorragie dans le cadre d’un traumatisme grave par exemple)
« 4 T » :
• Pneumothorax sous tension
• Tamponnade (cardiaque)
• Thrombose (coronaire et pulmonaire = infarctus du myocarde et embolie pulmonaire)
• Toxiques (intoxication : monoxyde de carbone, médicamenteuses…)
Higher chance of survival in patients with out-of-hospital cardiac arrest attributed to poisoning.
Hüser C, Baumgärtel M, Ristau P, Wnent J, Suárez V, Hackl MJ, Gräsner JT, Seewald S. | Resuscitation. 2022 Jun;175:96-104
Keywords: Cardiopulmonary resuscitation; German Resuscitation Registry; Intoxication; Out-of-hospital cardiac arrest; Poisoning.
Introduction : Description and comparison of cohort characteristics and outcome of adult patients with out-of-hospital cardiac arrest (OHCA) attributed to poisoning (P-OHCA) versus patients with OHCA attributed to other medical causes (NP-OHCA).
Méthode : We included all patients who received cardiopulmonary resuscitation after OHCA between January 2011 and December 2020 from German emergency medical services with good data quality in the German Resuscitation Registry.
Exclusion criteria: patients < 18 years of age or OHCA attributed to trauma, drowning, intracranial bleeding or exsanguination.
Résultats : Patients with P-OHCA (n = 574) were significantly younger compared to NP-OHCA (n = 40,146) (median age of 43 (35-54) years vs. 73 (62-82) years; p < 0.001). Cardiac arrest in P-OHCA patients was significantly less often witnessed by bystanders (41.8 % vs. 66.2 %, p < 0.001). Asystole was the predominant initial rhythm in P-OHCA patients (73.5% vs. 53.7%, p < 0.001) while ventricular fibrillation (VF) and pulseless electrical activity (PEA) were less common (9.2% vs. 25.1% and 16.2 % vs. 20.5%, p < 0.001). P-OHCA had a higher chance of survival with good neurological outcome at hospital discharge (15.2 vs. 8.8 % p < 0.001) and poisoning was an independent protective prognostic factor in multivariate analysis (OR 2.47, 95%-CI [1.71-3.57]). P-OHCA patients with initial PEA survival with good neurological outcome was comparable to initial VF (34.3 % vs. 37.7%).
Conclusion : Patients in the P-OHCA group had a significantly higher chance of survival with good neurological outcome and PEA as initial rhythm was as favourable as initial VF. Therefore, in P-OHCA patients resuscitation efforts should be extended.
Conclusion (proposition de traduction) : Les patients du groupe arrêt cardiaque intoxiqué en dehors de l'hôpital avaient une chance de survie significativement plus élevée avec de bons résultats neurologiques et une activité électrique sans pouls car le rythme initial était aussi favorable que la fibrillation ventriculaire initiale. Par conséquent, chez les patients victimes d'un arrêt cardiaque empoisonné hors de l'hôpital, les efforts de réanimation doivent être prolongés.
Coronary angiography and percutaneous coronary intervention in cardiac arrest patients without return of spontaneous circulation.
Rob D, Kavalkova P, Smalcova J, Kral A, Kovarnik T, Zemanek D, Franěk O, Smid O, Havranek S, Linhart A, Belohlavek J. | Resuscitation. 2022 Jun;175:133-141
Keywords: Coronary angiography; Extracorporeal life support; Out of hospital cardiac arrest; Percutaneous coronary intervention; Return of spontaneous circulation.
Introduction : This study aimed to examine coronary angiography (CAG) findings, percutaneous coronary intervention (PCI) results and outcomes in out-of-hospital cardiac arrest patients (OHCA) without return of spontaneous circulation (ROSC) on admission to hospital.
Méthode : We analyzed the OHCA register and compared CAG, PCI, and outcome data in patients with and without ROSC on admission to hospital.
Résultats : Between January 2012 and December 2020, 697 OHCA patients were analyzed. Of these, 163 (23%) did not have ROSC at admission. Patients without ROSC were younger (59 vs. 61 years, p = 0.001) and had a longer resuscitation time (62 vs. 18 minutes, p < 0.001) than patients with ROSC. Significant coronary artery disease was highly prevalent in both groups (65% vs. 68%, p = 0.48). Patients without ROSC had higher rates of acute coronary occlusions (42% vs. 33%, p = 0.046), specifically affecting the left main stem (16% vs. 1%, p < 0.001). PCI was performed in 81 patients (50%) without ROSC and in 295 (55%) with ROSC (p = 0.21). The success rate was 86% in patients without ROSC and 90% in patients with ROSC (p = 0.33). Thirty-day survival was 24% in patients without ROSC and 70% in patients with ROSC.
Conclusion : OHCA patients without ROSC on admission to hospital had higher acute coronary occlusion rates than patients with prehospital ROSC. PCI is feasible with a high success rate in patients without ROSC. Despite prolonged resuscitation times, meaningful survival in patients admitted without ROSC is achievable.
Conclusion (proposition de traduction) : Les patients victimes d'un arrêt cardiaque sans retour à une activité circulatoire spontanée à l'admission à l'hôpital présentaient des taux d'occlusion coronaire aiguë plus élevés que les patients ayant bénéficié d'un retour à une activité circulatoire spontanée avant l'hospitalisationv. L'intervention coronarienne percutanée est réalisable avec un taux de réussite élevé chez les patients sans retour à une activité circulatoire spontanée. Malgré des temps de réanimation prolongés, il est possible d'obtenir une survie significative chez les patients admis sans retour à une activité circulatoire spontanée.
A new variant position of head-up CPR may be associated with improvement in the measurements of cranial near-infrared spectroscopy suggestive of an increase in cerebral blood flow in non-traumatic out-of-hospital cardiac arrest patients: A prospective interventional pilot study.
Kim DW, Choi JK, Won SH, Yun YJ, Jo YH, Park SM, Lee DK, Jang DH. | Resuscitation. 2022 Jun;175:159-166
Keywords: Cardiopulmonary resuscitation; Cerebral blood flow; Head up CPR.
Introduction : This study aimed to investigate the effect of the head-up position implemented during cardiopulmonary resuscitation (CPR) on cerebral blood flow (CBF) using near-infrared spectroscopy in out-of-hospital cardiac arrest patients.
Méthode : Baseline characteristics (age, sex, cerebral performance category before cardiac arrest, witnessed cardiac arrest, bystander CPR, first monitored rhythm, no-flow time, prehospital low-flow time, CPR duration in the emergency department (ED), and reason for stopping CPR in the ED) were recorded. The changes of CBF were derived from the optical oscillation waveform measured by near-infrared spectroscopy in adult patients with out-of-hospital cardiac arrest by alternating head-up and supine positions at 4-minute intervals while performing CPR. The CBF velocity according to the head position was also evaluated using the time derivative of the oscillation waveform.
Résultats : During the study period, 28 patients were enrolled. The median increase in CBF in the prefrontal area in the head-up position was 14.6% (Interquartile range, 8.8-65.0), more than that in the supine position. An increase in CBF was observed in the head-up position compared with the supine position in 83.3% of the patients included in the analysis.
Conclusion : CBF increased when the head-up position was used during CPR in non-traumatic out-of-hospital cardiac arrest patients.
Conclusion (proposition de traduction) : Le débit sanguin cérébral augmente lorsque la position tête surélevée est utilisée pendant la RCP chez les patients victimes d'un arrêt cardiaque non traumatique en dehors de l'hôpital.
Procédure utilisée pour maintenir la position tête haute pendant la réanimation cardio-pulmonaire au service des urgences. Pour alterner entre la position couchée et la position tête en haut pendant la réanimation cardio-pulmonaire, une cale de soutien d'une hauteur de 15 cm a été insérée et retirée à certains intervalles.
• Debaty G et al. Tilting for Perfusion: Head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87:38 .
• Moore JC et al. Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest. Resuscitations. 2017;121:195-200 .
• Moore JC et al. Head-up position lowers intracranial pressure in a human cadaver model of cardiopulmonary resuscitation. AHA Resuscitation Science Symposium and Scientific session. New Orleans 2016.
• Kim T et al. The effect of resuscitation position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary resuscitation in porcine cardiac arrest model. Resuscitation 2017;113:101-107 .
Copyright : Rhesus
Effect of vasopressin and methylprednisolone vs. placebo on long-term outcomes in patients with in-hospital cardiac arrest a randomized clinical trial.
Granfeldt A, Sindberg B, Isbye D, Kjærgaard J, Kristensen CM, Darling S, Zwisler ST, Fisker S, Schmidt JC, Kirkegaard H, Grejs AM, Rossau JRG, Larsen JM, Rasmussen BS, Riddersholm S, Iversen K, Schultz M, Nielsen JL, Løfgren B, Lauridsen KG, Sølling C, Pælestik K, Kjærgaard AG, Due-Rasmussen D, Folke F, Charlot MG, Jepsen RMHG, Wiberg S, Høybye M, Holmberg MJ, Andersen LW. | Resuscitation. 2022 Jun;175:67-71
Keywords: In-hospital cardiac arrest; Long-term; Methylprednisolone; Outcomes; Vasopressin.
Introduction : The primary results from the Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial have previously been reported. The objective of the current manuscript is to report long-term outcomes.
Méthode : The VAM-IHCA trial was a multicenter, randomized, double-blind, placebo-controlled trial conducted at ten hospitals in Denmark. Adult patients (age ≥ 18 years) were eligible for the trial if they had an in-hospital cardiac arrest and received at least one dose of epinephrine during resuscitation. The trial drugs consisted of 40 mg methylprednisolone (Solu-Medrol®, Pfizer) and 20 IU of vasopressin (Empressin®, Amomed Pharma GmbH) given as soon as possible after the first dose of epinephrine. This manuscript report outcomes at 6 months and 1 year including survival, survival with favorable neurological outcome, and health-related quality of life.
Résultats : 501 patients were included in the analysis. At 1 year, 15 patients (6.3%) in the intervention group and 22 patients (8.3%) in the placebo group were alive corresponding to a risk ratio of 0.76 (95% CI, 0.41-1.41). A favorable neurologic outcome at 1 year, based on the Cerebral Performance Category score, was observed in 14 patients (5.9%) in the intervention group and 20 patients (7.6%) in the placebo group (risk ratio, 0.78 [95% CI, 0.41-1.49]. No differences existed between groups for favorable neurological outcome and health-related quality of life at either 6 months or 1 year.
Conclusion : Administration of vasopressin and methylprednisolone, compared with placebo, in patients with in-hospital cardiac arrest did not improve long-term outcomes in this trial.
Conclusion (proposition de traduction) : L'administration de vasopressine et de méthylprednisolone, par rapport au placebo, chez les patients ayant subi un arrêt cardiaque à l'hôpital n'a pas amélioré les résultats à long terme dans cet essai.
Removal of the cervical collar from alpine rescue protocols? A biomechanical non-inferiority trial in real-life mountain conditions.
Grenier G, Despatis MA, Lebel K, Hamel M, Martin C, Boissy P. | Scand J Trauma Resusc Emerg Med. 2022 Jun 27;30(1):42
DOI: https://doi.org/10.1186/s13049-022-01031-3 | Télécharger l'article au format
Introduction : Alpine skiing rescues are challenging because of the mountainous environment and risks of cervical spine motion (CSM) induced during victims' extrications (EXs) and downhill evacuations (DEs). The benefits of applying a cervical collar (CC) over manual in-line stabilization without CC (MILS) in terms of spinal motion restriction during simulated alpine rescues are undocumented. Our hypothesis was that CSM recorded using MILS alone is non-inferior to CSM recorded with a CC according to a 10 degrees margin.
Méthode : A total of 32 alpine extrications and 4 downhill evacuations on different slope conditions were performed using a high fidelity mannequin designed with a motion sensors instrumented cervical spine. The primary outcome was the peak extrication 3D excursion angle (Peak 3D θEX,) of the mannequin's head. The secondary objectives were to describe the time to extrication completion (tEX) and to highlight which extrication manipulation is more likely to induce CSM.
Résultats : The median Peak 3D θ
Conclusion : For experienced ski patrollers, the biomechanical benefits of spinal motion restriction provided by CC over MILS during alpine skiing rescues appear to be marginal and CC use negatively affects rescue time.
Conclusion (proposition de traduction) : Pour les pisteurs expérimentés, les avantages biomécaniques de la limitation du mouvement de la colonne vertébrale apportée par le collier cervical par rapport à la stabilisation manuelle en ligne pendant les sauvetages en ski alpin semblent être mineurs et l'utilisation du collier cervical affecte négativement le temps de sauvetage.
The Differences of CPR duration between Shockable and Nonshockable Rhythms in Predicting the Benefit of Target Temperature Management.
Lin JJ, Huang CH, Chien YS, Hsu CH, Chiu WT, Wu CH, Wang CH, Tsai MS. | Shock. 2022 May 1;57(5):652-658
Introduction : Among cardiac arrest (CA) survivors, whether the combination of duration of cardiopulmonary resuscitation (CPR) and shockable/nonshockable rhythms during resuscitation can help predict the benefit of targeted temperature management (TTM) remains un-investigated.
Méthode : This multicenter retrospective cohort study enrolled 479 nontraumatic adult CA survivors with TTM and CPR duration < 60 min during January 2014 to June 2019 from the Taiwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry. The differences of CPR duration between shockable and nonshockable rhythms in predicting outcomes in the studied population was evaluated.
Résultats : We observed that 205 patients (42.8%) survived to hospital discharge and 100 patients (20.9%) presented favorable neurological outcomes at discharge. The enrolled patients were further re-classified into four groups according to shockable/nonshockable rhythms and CPR duration. Patients with shockable rhythms and shorter CPR duration had better survival-to-discharge (adjusted odds ratio [OR] = 2.729, 95% confidence interval [CI] = 1.384-5.383, P = 0.004) and neurological recovery (adjusted OR = 9.029, 95%CI = 3.263-24.983, P < 0.001) than did those with nonshockable rhythms and longer CPR duration.
Conclusion : The CPR duration for predicting outcomes differs between CA patients with shockable and nonshockable rhythms. The combination of shockable/nonshockable rhythms and CPR duration may help predict the prognosis in CA survivors undergoing TTM.
Conclusion (proposition de traduction) : La durée de la RCP pour prédire les résultats diffère entre les patients en arrêt cardiaque avec des rythmes choquables et non choquables. La combinaison des rythmes choquables/non choquables et de la durée de la RCP peut aider à prédire le pronostic chez les survivants d'un arrêt cardiaque soumis à une gestion ciblée de la température.
Effectiveness and Safety of Anticoagulation Therapy in Frail Patients With Atrial Fibrillation.
Kim D, Yang PS, Sung JH, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Lip GYH, Joung B. | Stroke. 2022 Jun;53(6):1873-1882
Keywords: Editorials; anticoagulant; atrial fibrillation; frailty; ischemic stroke; mortality.
Introduction : Frail patients with atrial fibrillation (AF) are less likely to receive anticoagulation than nonfrail patients with AF despite frailty being associated with poorer clinical outcomes including stroke. Using a population-based cohort, we sought to assess the effectiveness and safety of oral anticoagulants (OACs) in frail patients with AF.
Méthode : This retrospective cohort study analyzed 83 635 patients aged at least 65 years with AF and frailty (≥5 Hospital Frailty Risk Score) between January 1, 2013 and December 31, 2016 from the Korean National Health Insurance Service database. To account for the differences between patients receiving OAC or not and across different OAC regimens, propensity score-weighting was used. Net adverse clinical event, defined as the first event of ischemic stroke, major bleeding, or cardiovascular death, was compared. In addition, each individual outcome was examined separately.
Résultats : In the study population (57.1% women; mean age, 78.5±7.2 years), a total of 14 968 net adverse clinical event, 3718 ischemic stroke, 5536 major bleeding, and 6188 cardiovascular death occurred. In comparison with no OAC use, OAC use was associated with lower risks of net adverse clinical event (hazard ratio, 0.78 [95% CI, 0.75-0.82]), ischemic stroke (hazard ratio, 0.91 [95% CI, 0.86-0.97]), and cardiovascular death (hazard ratio, 0.52 [95% CI, 0.49-0.55]), but no difference was observed for major bleeding (hazard ratio, 1.02 [95% CI, 0.95-1.10]). Compared with warfarin, all four individual direct OAC were associated with decreased risks of net adverse clinical event, ischemic stroke, major bleeding, and cardiovascular death. The associations for OAC use (compared to no OAC use) or direct OAC use (compared to warfarin) with favorable outcomes were more prominent in individuals with a higher CHA2DS2-VASc score of at least 3.
Conclusion : Among frail patients with AF, OAC treatment was associated with a positive net clinical outcome. Direct OACs provided lower incidences of stroke, bleeding, and mortality, compared with warfarin.
Conclusion (proposition de traduction) : Chez les patients fragiles atteints de fibrillation atriale, le traitement par anticoagulants oraux est associé à un résultat clinique net positif. Les anticoagulants oraux directs ont permis de réduire l'incidence des accidents vasculaires cérébraux, des hémorragies et de la mortalité, par rapport à la warfarine.
Vitamin D Enhances Hematoma Clearance and Neurologic Recovery in Intracerebral Hemorrhage.
Liu J, Li N, Zhu Z, Kiang KM, Ng ACK, Dong CM, Leung GK. | Stroke. 2022 Jun;53(6):2058-2068
Keywords: cerebral hemorrhage; hormones; macrophages; monocytes; vitamin D.
Basic and Translational Sciences
Introduction : Erythrophagocytosis by reparative monocyte-derived macrophage contributes to hematoma clearance and neurological recovery after intracerebral hemorrhage (ICH). Vitamin D (VitD) is a neuroprotective hormone and regulates the differentiation of monocyte-derived macrophage from monocytes. In this study, we examined the effects of VitD supplementation on monocyte-derived macrophage and hematoma clearance in rodent with ICH.
Méthode : Neurobehavioral functions and hematoma volume were assessed using a collagenase injection model in both young- and middle-aged mice with or without VitD treatment given 2 hours post-ICH induction. We used flow cytometry to analyze CD36 expression and macrophage and undifferentiated monocyte cell numbers during in vivo erythrophagocytosis in collagenase and autologous blood injection models. Western blot analysis and immunofluorescence were used to assess the expression levels of the PPAR-γ (peroxisome proliferator-activated receptor γ)-CD36 axis and CD206. A macrophage differentiation study was conducted on murine bone marrow-derived monocytes.
Résultats : VitD promoted neurological recovery and facilitated hematoma clearance in both young- and middle-aged mice after ICH. Within the perihematomal region, mature macrophages, rather than undifferentiated monocytes, expressed higher levels of CD36 in driving erythrocyte clearance. VitD increased the macrophage number but decreased the monocyte number and elevated the levels of CD36 and PPAR-γ in the brain. In vitro, VitD accelerated the differentiation of reparative macrophages from bone marrow-derived monocytes.
Conclusion : VitD promotes reparative macrophage differentiation, facilitates hematoma clearance, and improves neurobehavioral performance in mice with ICH, suggesting that VitD should be further examined as a potentially promising treatment for ICH.
Conclusion (proposition de traduction) : La vitamine D favorise la différenciation des macrophages réparateurs, facilite la clairance de l'hématome et améliore les performances neurocomportementales chez les souris souffrant d'hémorragie intracérébrale, ce qui suggère que la vitamine D devrait être examinée plus avant en tant que traitement potentiellement prometteur de l'hémorragie intracérébrale.
High risk and low prevalence diseases: Ovarian torsion.
Bridwell RE, Koyfman A, Long B. | Am J Emerg Med. 2022 Jun;56:145-150
Keywords: Adnexal torsion; Gynecology; Ovarian torsion.
Introduction : Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity.
Méthode : This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence.
Discussion : Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED.
Conclusion : An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.
Conclusion (proposition de traduction) : Une compréhension de la torsion ovarienne peut aider les urgentistes à diagnostiquer et à gérer cette maladie.
Risk factors for inadequate sedation after endotracheal intubation in the pediatric emergency department.
Edmunds KJ, Byczkowski T, Frey M, Boyd S, Caruso M, Zhang Y, Kerrey BT, Timm N. | Am J Emerg Med. 2022 Jun;56:15-20
Editorial : Rapid sequence intubation (RSI) is performed for the majority of children undergoing emergency endotracheal intubation in pediatric emergency departments (PED) or pediatric intensive care units (PICU). RSI is defined as administration of a sedative and paralytic in rapid succession to facilitate efficient tracheal intubation. After RSI, additional sedation is typically necessary to avoid patient harm and discomfort.
Conclusion : Despite the use of an RSI checklist, 42% of children experienced inadequate post-intubation sedation. Though this is an improved proportion from the limited pediatric literature on this topic, there is certainly still improvement to be made. This study found that risk factors associated with inadequate sedation included succinylcholine use and a second paralytic given after successful intubation. We concluded that providers choosing to use medications for RSI should be mindful of these risk factors and the need for timely post intubation sedation when intubating pediatric patients. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors
Conclusion (proposition de traduction) : Malgré l'utilisation d'une liste de contrôle pour l'intubation à séquence rapide, 42 % des enfants ont subi une sédation insuffisante après l'intubation. Bien qu'il s'agisse d'une proportion plus élevée que dans la littérature pédiatrique limitée sur ce sujet, il y a certainement encore des améliorations à apporter. Cette étude a révélé que les facteurs de risque associés à une sédation insuffisante comprenaient l'utilisation de succinylcholine et l'administration d'un deuxième paralysant après une intubation réussie. Nous avons conclu que les soignants qui choisissent d'utiliser des médicaments pour l'intubation à séquence rapide devraient être conscients de ces facteurs de risque et de la nécessité d'une sédation post-intubation en temps voulu lorsqu'ils intubent des patients pédiatriques. Cette recherche n'a bénéficié d'aucune subvention spécifique de la part d'organismes de financement des secteurs public, commercial ou à but non lucratif.
Checklist pour l'intubation à séquence rapide.
NRB = masque haute concentration, CPAP = pression positive continue des voies aériennes, BMV = ventilation au BAVU, PEM = médecine d'urgence pédiatrique, EM = médecine d'urgence, SUX = succinylcholine, N/A = non applicable, PIC = pression intracrânienne, K = concentration de potassium sérique, ETCO2 = capnométrie, Storz = vidéo-laryngoscope Storz (Karl Storz GmbH & Co. KG, Tuttingen, Allemagne), ETT = tube orotrachéal.
Low initial in-hospital end-tidal carbon dioxide predicts poor patient outcomes and is a useful trauma bay adjunct.
Portelli Tremont JN, Caldas RA, Cook N, Udekwu PO, Moore SM. | Am J Emerg Med. 2022 Jun;56:45-50
Keywords: Capnography; Early trauma management; End tidal carbon dioxide; Predictive tool; Triage.
Introduction : Appropriate triage of the trauma patient is critical. Low end-tidal carbon dioxide (ETCO2) is associated with mortality and hemorrhagic shock in trauma, but the relationship between low ETCO2 and important clinical variables is not known. This study investigates the association of initial in-hospital ETCO2 and patient outcomes, as well as the utility of ETCO2 as a predictive aid for blood transfusion.
Méthode : Adult patients who presented to a Level One trauma center from 2019 to 2020 were eligible. Trauma bay ETCO2 measured by side-stream capnography was prospectively obtained for all trauma activations at time of initial evaluation. Using the Liu method of cut point estimation, patients were stratified as having low (≤29.5 mmHg) or normal ETCO2 (>29.5 mmHg). Multivariable regression was used to estimate the association of low ETCO2 with patient outcomes.
Résultats : A total of 955 patients underwent initial in-hospital ETCO2 measurement. Median time from arrival to ETCO2 measurement was 4 min. Among admitted patients (N = 493), 48.9% had low ETCO2. Compared to patients with normal ETCO2, those with low ETCO2 were older (median age 53 vs 46, p = 0.01) and more likely to have the highest trauma activation (27.4% vs 19.8%, p = 0.048). There was no difference in head injury. After adjustment, patients with low ETCO2 had greater odds of blood transfusion (OR 4.65, 95%CI 2.0-10.7), mortality (OR 5.10, 95%CI 1.1-24.9), inferior disposition (OR 1.64, 95%CI 1.1-2.6), and complications (OR 3.35, 95%CI 1.5-7.4). ETCO2 was more predictive of early blood transfusion than Shock Index (area under ROC = 67.6% vs 58.2%).
Conclusion : Low trauma bay ETCO2 remains significantly associated with inferior clinical outcomes after adjustment. In comparison to other triage tools, low ETCO2 values may be more predictive of the need for blood transfusion. Further studies are needed to evaluate the role of ETCO2 as a decision making tool for early trauma management.
Conclusion (proposition de traduction) : Une faible valeur d'ETCO2 dans le service de traumatologie reste significativement associée à des résultats cliniques inférieurs après ajustement. En comparaison avec d'autres outils de triage, des valeurs d'ETCO2 basses peuvent être plus prédictives de la nécessité d'une transfusion sanguine. D'autres études sont nécessaires pour évaluer le rôle de l'ETCO2 comme outil de décision pour la gestion précoce des traumatismes.
Utility of non-invasive synchronized intermittent mandatory ventilation in acute cardiogenic pulmonary edema.
Cekmen B, Bildik B, Bozan O, Atis SE, Dogan S, Kocak AO. | Am J Emerg Med. 2022 Jun;56:71-76
Keywords: Continuous positive airway pressure; Noninvasive ventilation; Pulmonary edema; Respiratory failure.
Introduction : Acute cardiogenic pulmonary edema (ACPE), one of the outcomes of acute heart failure (AHF), is a common reason in a critical condition with respiratory distress. Non-invasive synchronized intermittent mandatory ventilation(nSIMV) mode, which includes inspiratory pressure in addition to positive end expiratory pressure with/without pressure support provided in the non-invasive continuous positive airway pressure plus/pressure support(nCPAP/PS) mode can be effective in hypercarbia and the associated changes in consciousness. This study aimed to demonstrate the efficacy of nSIMV in ACPE.
Méthode : Patients who presented with clinical acute respiratory failure and were admitted to the critical care unit of the emergency department with the diagnosis of ACPE were included. Patients were placed on non-invasive mechanical ventilators with an oronasal mask under the nCPAP/PS and nSIMV modes. Pulse and respiratory rate, systolic and diastolic blood pressure and Glasgow Coma Scores(GCS), HACOR(heart rate, acidosis, consciousness, oxygenation and respiratory rate) scores, pH, PaCO2, PaO2/FiO2 and lactate at the time of admission and at 30 and 60 min were evaluated.
Résultats : Twenty-two patients were recruited, nCPAP/PS mode was 10 and nSIMV mode was 12. Although there was no statistically significant difference between the two groups in terms of the change in the relevant parameters from admission to 60 min, the decreases in PaCO2 and lactate levels (31.4% vs. 21.2%, p = 0.383; 68.8% vs. 47.1%, p = 0.224; respectively) and the increase in PaO2 and PaO2/FiO2 values (34% vs. 14.2%, p = 0.710 and 132.1% vs. 52.7%, p = 0.073; respectively) were higher in the nSIMV group.
Conclusion : The nSIMV mode is as effective as the nCPAP/PS mode in the treatment of patients with ACPE. We believe that the nSIMV mode can be preferable, particularly in patients with hypercarbia who have relatively lower GCS and oxygenation.
Conclusion (proposition de traduction) : Le mode nVACI est aussi efficace que le mode nCPAP ou ventilation en pression dans le traitement des patients présentant un œdème pulmonaire aigu cardiogénique. Nous pensons que le mode nVACI peut être préférable, en particulier chez les patients en hypercapnie qui ont un score de Glasgow et une oxygénation relativement faibles.
Comparison of supine and upright face-to-face cadaver intubation.
Julliard D, Vassiliadis J, Bowra J, Gillett M, Knipp R, Krishnamohan A, Fogg T. | Am J Emerg Med. 2022 Jun;56:87-91
Keywords: Difficult airway; Endotracheal intubation; Sitting position; Supine position; Video laryngoscopy.
Introduction : Optimal patient positioning during intubation improves laryngeal view and first pass success, as well as reducing incidence of hypoxia. In certain pre-hospital situations, it may be impractical or impossible for the operator to stand behind the patient.
Objective: We compared intubation in the supine and upright face-to-face positions, with regards to time to intubate and the view of the vocal cords obtained.
Méthode : This was a pilot comparison study. One investigator intubated 25 cadavers with the use of a bougie in the supine and upright face-to-face positions. Each attempt was recorded on a video laryngoscope. Recordings of each attempt were reviewed by five blinded emergency physicians, who allocated both a percentage of glottic opening (POGO) score and Cormack-Lehane (CL) grade. Time to insertion of the endotracheal tube (ETT) through the vocal cords was measured from the video.
Résultats : The median intubation time was 1 s longer for upright cadavers than for supine cadavers, with greater variation in intubation times for upright cadavers compared with supine cadavers (IQR 9.0 vs 3.5 excluding the outlier case). The mean POGO score (averaged across raters) was 4.7% lower for upright intubation attempts (excluding the outlier case) with a moderate-to-good degree of inter-rater reliability, however this difference was not statistically significant. The median CL grade (averaged across raters) was 0.2 higher for upright intubation attempts (excluding the outlier case) with a poor-to-moderate degree of inter-rater reliability, and this difference was also not statistically significant.
Conclusion : This pilot study suggests that upright, face-to-face intubation may be clinically similar to supine intubation in terms of time to intubation and difficulty. Further studies utilising a larger number of operators and cadaver types are indicated.
Conclusion (proposition de traduction) : Cette étude pilote suggère que l'intubation en position debout et face à face peut être cliniquement similaire à l'intubation en position couchée en termes de temps d'intubation et de difficulté. D'autres études utilisant un plus grand nombre d'opérateurs et de types de cadavres sont indiquées.
Early identified risk factors and their predictive performance of brain death in out-of-hospital cardiac arrest survivors.
Lee BK, Min JH, Park JS, Kang C, Lee BK. | Am J Emerg Med. 2022 Jun;56:117-123
Keywords: Brain death; Heart arrest; Neuron-specific enolase; Out-of-hospital cardiac arrest.
Introduction : Early prediction of brain death (BD) after the return of spontaneous circulation (ROSC) in patients with cardiac arrest would be useful for the proper distribution of good quality transplantable organs and medical resources. We aimed to early identify independent risk factors of BD and their predictive performance in out-of-hospital cardiac arrest (OHCA) survivors.
Méthode : This retrospective observational study included adult OHCA survivors from May 2018 to February 2021. Independent risk factors for progression to BD were identified by performing multivariate logistic regression analysis, including clinical, laboratory, biological parameters and prognostic factors, obtained within 6 h after ROSC. Neuron-specific enolase (NSE) level were categorized into quartile. The primary outcome was BD occurrence.
Résultats : Overall, 108 patients were included in this analysis, 31 (29%) of whom had BD. In multivariate logistic regression analysis, initial serum NSE levels in the fourth quartile compared to the first quartile (odds ratio [OR], 88.5; 95% confidence interval [CI]: 7.0-1113.6) and absence of pupil light reflex (PLR) (OR, 40.3; 95% CI: 3.8-430.3) were independently associated with BD. According to the receiver operating characteristic curve analysis, initial serum NSE levels and PLR showed good-to-excellent and fair-to-good prognostic performance, respectively (area under the curve [AUC], 0.90; 95% CI: 0.83-0.95 vs. 0.81; 95% CI: 0.72-0.88). Additionally, the combination of both the risk factors (AUC, 0.96; 95% CI: 0.90-0.99) showed significantly higher predictive performance for BD than when using them individually (P = 0.04 and P < 0.01, respectively).
Conclusion : High levels of initial serum NSE and PLR obtained within 6 h after ROSC may help early predict progression to BD in OHCA survivors. A large prospective multicenter study should be conducted to confirm these results.
Conclusion (proposition de traduction) : Des niveaux élevés de NSE sérique de départ et de réflexe pupillaire lumineux obtenus dans les 6 heures suivant le retour à une activité circulatoire spontanée peuvent aider à prédire précocement la évolution vers la mort cérébrale chez les survivants d'un arrêt cardiaque extrahospitalier. Une grande étude prospective multicentrique devrait être menée pour confirmer ces résultats.
Association between prehospital shock index and mortality among patients with COVID-19 disease.
Jouffroy R, Brami E, Scannavino M, Daniel Y, Bertho K, Abriat A, Salomé M, Lemoine S, Jost D, Prunet B, Travers S. | Am J Emerg Med. 2022 Jun;56:133-136
DOI: https://doi.org/10.1016/j.ajem.2022.03.059 | Télécharger l'article au format
Introduction : There exists a need for prognostic tools for the early identification of COVID-19 patients requiring intensive care unit (ICU) admission andmortality. Herewe investigated the association between a clinical (initial prehospital shock index (SI)) and biological (initial prehospital lactatemia) tool and the ICU admission and 30-day mortality among COVID-19 patients cared for in the prehospital setting.
Méthode : We retrospectively analysed COVID-19 patients initially cared for by a Paris Fire Brigade advanced (ALS) or basic life support (BLS) team in the prehospital setting between 2020, March 08th and 2020, May 30th. We assessed the association between prehospital SI and prehospital lactatemia and ICU admission and mortality using logistic regression model analysis after propensity score matching with Inverse Probability Treatment Weighting (IPTW) method. Covariates included in the IPTW propensity analysis were: age, sex, body mass index (BMI), initial respiratory rate (iRR), initial pulse oximetry without (SpO2i) andwith oxygen supplementation (SpO2i.O2), initial Glasgow coma scale (GCSi) value, initial prehospital SI and initial prehospital lactatemia.
Résultats : We analysed 410 consecutive COVID-19 patients [254 males (62%); mean age, 64 ± 18 years].
Fifty-seven patients (14%) deceased on the scene, of whom 41 (72%) were male and were significantly older (71 ± 12 years vs. 64 ± 19 years; P 〈10−3).
Fifty-three patients (15%) were admitted in ICU and 39 patients (11%) were deceased on day-30. The mean prehospital SI value was 1.5 ± 0.4 and the mean prehospital lactatemia was 2.0 ± 1.7 mmol.l−1. Multivariate logistic regression analysis on matched population after IPTWpropensity analysis reported a significant association between ICU admission and age (adjusted Odd-Ratio (aOR), 0.90; 95% confidence interval (95% CI): 0.93–0.98;p = 10−3), SpO2i.O2 (aOR, 1.10; 95%CI: 1.02–1.20;p = 0.002) and BMI (aOR, 1.09; 95% CI: 1.03–1.16;p = 0.02). 30-day mortality was significantly associated with SpO2i.O2 (aOR, 0.92; 95% CI: 0.87–0.98;p = 0.01 P < 10−3) and GCSi (aOR, 0.90; 95% CI: 0.82–0.99;p=0.04).
Neither prehospital SI nor prehospital lactatemia were associated with ICU admission and 30-day mortality.
Conclusion : Neither prehospital initial SI nor lactatemiawere associated with ICU admission and 30-daymortality among COVID-19 patients initially cared for by a Paris Fire Brigade BLS or ALS team. Further prospective studies are needed to confirm these preliminary results.
Conclusion (proposition de traduction) : Ni le shock index préhospitalier initial ni la lactatémie n'ont été associés à l'admission en unité de soins intensifs et à la mortalité à 30 jours chez les patients atteints de la maladie COVID-19 initialement pris en charge par une équipe de réanimation de base ou de réanimation avancée de la Brigade des sapeurs-pompiers de Paris. D'autres études prospectives sont nécessaires pour confirmer ces résultats préliminaires.
Effects of Smart Advanced Life Support protocol implementation including CPR coaching during out-of-hospital cardiac arrest.
Kim GW, Moon HJ, Lim H, Kim YJ, Lee CA, Park YJ, Lee KM, Woo JH, Cho JS, Jeong WJ, Choi HJ, Kim CS, Choi HJ, Choi IK, Heo NH, Park JS, Lee YH, Park SM, Jeong DK. | Am J Emerg Med. 2022 Jun;56:211-217
DOI: https://doi.org/10.1016/j.ajem.2022.03.050 | Télécharger l'article au format
Keywords: Advanced cardiac life support; Emergency medical dispatch; Out-of-hospital cardiac arrest.
Introduction : The aim of this study was to compare out-of-hospital cardiac arrest (OHCA) outcomes before and after implementation of Smart Advanced Life Support (SALS) protocol incorporating changes in cardiopulmonary resuscitation (CPR) assistance and coaching by physicians via real-time video calls.
Méthode : A prospective before-and-after multi-regional observational study was conducted between January 2014 and December 2018. In January 2016, emergency medical service (EMS) providers adopted an integrated CPR coaching by physicians via real-time video call via SALS to treat patients with OHCA focusing on high-quality cardiopulmonary resuscitation. Propensity score matching was performed to match patients. Patients' outcomes using conventional protocol were then compared with those of patients using the SALS protocol.
Résultats : Among 26,349 OHCA cases, 2351 patients and 7261 patients were enrolled during the pre-intervention and the post-intervention periods, respectively. Multivariate analysis showed that SALS was independently associated with favorable neurological outcomes [odds ratio (OR): 2.20; 95% confidence interval (CI): 1.62-2.99]. A total of 2096 patients were propensity score-matched and the two groups were well balanced. In the matched cohort, the use of SALS protocol was still associated with increased prehospital return of spontaneous circulation (ROSC) (OR: 3.83, 95% CI: 2.80-5.26), survival to discharge (OR: 1.68; 95% CI: 1.20-2.34), and favorable neurological outcomes (OR: 1.83; 95% CI: 1.19-2.82).
Conclusion : A multidisciplinary SALS protocol for the resuscitation of patients with OHCA was associated with increased prehospital ROSC, survival to discharge, and good neurologic outcomes compared with traditional resuscitation protocol.
Conclusion (proposition de traduction) : Un protocole multidisciplinaire Smart Advanced Life Support pour la réanimation des patients ayant subi un arrêt cardiaque en dehors de l'hôpital a été associé à une augmentation du retour à une activité circulatoire spontanée, de la survie jusqu'à la sortie de l'hôpital et de bons résultats neurologiques par rapport au protocole de réanimation traditionnel.
Commentaire : Les Smart Device (appareils intelligent)s, sont devenus une référence dans le monde du connecté. Il s’agit d’appareils intelligents qui se connectent à d’autres appareils de différentes manières afin de faciliter le transfert des données.
Comparative evaluation of the effectiveness of intravenous paracetamol, dexketoprofen and ibuprofen in acute low back pain.
Dogan C, Yilmaz A, Ozen M, Seyit M, Oskay A, Kemanci A, Uluturk M, Turkcuer I. | Am J Emerg Med. 2022 Jun;56:223-227
DOI: https://doi.org/10.1016/j.ajem.2022.04.017 | Télécharger l'article au format
Keywords: Dexketoprofen; Emergency department; Ibuprofen; Low back pain; Paracetamol.
Introduction : Non-traumatic back pain constitutes roughly 5% of the admissions to emergency departments. This study seeks to compare the efficacy of intravenously administered paracetamol, dexketoprofen, and ibuprofen in patients with non-traumatic acute low back pain.
Méthode : This study was designed as a randomized, double-blinded investigation and carried out at a tertiary hospital. 210 eligible patients without trauma who presented with low back pain were recruited for the study and randomized into paracetamol (n = 71), dexketoprofen (n = 70), and ibuprofen (n = 69) groups. The measurements at 0, 15, 30 and 60 min were noted down by using a 100 mm VAS, and the relevant comparisons were made.
Résultats : The VAS scores at 0 and 60 min in the paracetamol, dexketoprofen, and ibuprofen groups decreased on average by 40 mm, 42 mm, and 43 mm, respectively. The baseline and final pain scores of each drug group differed significantly (p < 0.05), though the between-group analysis revealed no significant difference (p > 0.05).
Conclusion : Given the obtained data, we did not note a significant difference between intravenous paracetamol, dexketoprofen and ibuprofen with respect to pain efficacy in non-traumatic acute low back pain. Based on the patients' clinical conditions and histories, we concluded that the choice of medication might not change the efficacy of the treatment and patient comfort.
Conclusion (proposition de traduction) : Au vu des données obtenues, nous n'avons pas noté de différence significative entre le paracétamol intraveineux, le dexkétoprofène et l'ibuprofène en ce qui concerne l'efficacité sur la douleur dans la lombalgie aiguë non traumatique. Sur la base des conditions cliniques et des antécédents des patients, nous avons conclu que le choix du médicament pouvait ne pas modifier l'efficacité du traitement et le confort du patient.
Commentaire : Le dexkétoprofène (Ketesse®, Laboratoires Menarini) est un anti-inflammatoire non stéroïdien analgésique, anti-inflammatoire et antipyrétique. Il est utilisé pour traiter la douleur d'intensité légère à modérée, telles que les douleurs musculaires, les règles douloureuses (dysménorrhées), les douleurs dentaires. La posologie recommandée est fonction de la nature et la sévérité de la douleur; elle est généralement de 12,5 mg toutes les 4 à 6 heures, ou 25 mg toutes les 8 heures. La dose totale journalière ne doit pas dépasser 75 mg. I est disponible en comprimé pelliculé de 12,5 mg et 5 mg, en solution injectable 50 mg/2 ml et granulés pour solution buvable en sachet.
Il n'apporte apparemment rien de plus par rapport au kétoprofène.
Retrospective study comparing success rates of lumbar puncture positions in infants.
Bhagat RP, Amlicke M, Steele F, Fishbein J, Kusulas M. | Am J Emerg Med. 2022 Jun;56:228-231
DOI: https://doi.org/10.1016/j.ajem.2022.04.013 | Télécharger l'article au format
Keywords: Infant; Lateral recumbent; Lumbar puncture; Position; Sitting; Success.
Introduction : A lumbar puncture (LP) is performed in the emergency room for diagnostic purposes; unsuccessful or traumatic LPs can complicate decision making. The sitting position has a larger interspinous process compared to lateral recumbent and is safer in sick neonates at risk for cardiac and respiratory instability.
Purpose: Our study aims to determine which position (lateral recumbent or sitting) is associated with a greater likelihood of successful lumbar puncture in infants <3 months when performed in the emergency room.
Méthode : This is a retrospective chart review in infants aged <3 months who had a LP performed in a pediatric emergency room. The primary outcome was the rate of successful LPs, defined as obtaining adequate CSF to send for all studies. The secondary outcome was the proportion of atraumatic LPs by position, defined as <500 RBCs or < 10,000 RBCs.
Résultats : A total of 557 charts were reviewed with 116 in the sitting position and 441 in the lateral recumbent position. The primary outcome of adequate CSF fluid collection was not significantly different between groups (63% sitting position versus 58% lateral recumbent position; p = 0.22). In addition, the proportion of atraumatic LPs showed no significant difference regardless of RBC cutoff (<500 RBCs p = 0.83, <10,000 RBCs p = 0.60).
Conclusion : This study found no evidence that there is a difference in rate of LP success nor the proportion of traumatic LP in infants less than 3 months of age when positioned in the sitting position compared to the lateral recumbent position.
Conclusion (proposition de traduction) : Cette étude n'a trouvé aucune preuve qu'il y ait une différence dans le taux de réussite de la ponction lombaire ni dans la proportion de ponction lombaire traumatique chez les nourrissons de moins de 3 mois lorsqu'ils sont placés en position assise par rapport à la position couchée latérale.
Ultrasound-guided interscalene block versus intravenous analgesia and sedation for reduction of first anterior shoulder dislocation.
Yao L, Dong W, Wu Z, Zhao Q, Mao H. | Am J Emerg Med. 2022 Jun;56:232-235
DOI: https://doi.org/10.1016/j.ajem.2022.03.047 | Télécharger l'article au format
Keywords: General anesthesia; Interscalene block; Reduction; Shoulder dislocation.
Introduction : This study aims to compare the efficacy of ultrasound-guided interscalene block (US-ISB) with that of intravenous analgesia and sedation (IVAS) in reducing first shoulder dislocation.
Méthode : A prospective study was performed in 66 patients with first anterior shoulder dislocation in emergency department. The patients were divided into a US-ISB (n = 32) group and an IVAS (IVAS n = 34) group. The procedure time (anesthesia, reduction, and hospital times), pain score (before, during, and after reduction), reduction attempts, complications, and patient satisfaction were recorded and compared between the two groups.
Résultats : The anesthesia time (P < 0.01) and reduction time (P < 0.01) were shorter and the hospital time (P < 0.01) was longer in the IVAS group than in the US-ISB group. No significant differences in preoperative (P = 0.18) and postoperative (P = 0.27) pain scores were found between the two groups, but the intraoperative score of the US-ISB group was significantly higher than that of the IVAS group. More reduction attempts (P < 0.01) were recorded in the US-ISB group than that in the IVAS group. Complications (P < 0.01) such as nausea, vomiting, headache, and hypoxia occurred more frequently in the IVAS group than in the US-ISB group. No significant difference in patient satisfaction was observed between two groups (P = 0.96).
Conclusion : Compared with IVAS group, US-ISB group reduces the time to discharge and achieves lesser complication. The pain score and reduction attempt are lower in the IVAS group than in the US-ISB group.
Conclusion (proposition de traduction) : Comparé au groupe analgésie intraveineuse et sédation, le groupe bloc interscalénique échoguidé réduit le temps de sortie et présente moins de complications. Le score de douleur et la tentative de réduction sont plus faibles dans le groupe analgésie intraveineuse et sédation que dans le groupe bloc interscalénique échoguidé.
Commentaire : Vierula1 M, Robert J, Wong P, McVicar J. Le Bloc Interscalénique Échoguidé. (19 March 2019) ATOTW 400 tutorials .
Tranexamic acid - A narrative review for the emergency medicine clinician.
Wang K, Santiago R. | Am J Emerg Med. 2022 Jun;56:33-44
DOI: https://doi.org/10.1016/j.ajem.2022.03.027 | Télécharger l'article au format
Introduction : Over the last decade, tranexamic acid (TXA) has been incorporated into treatment algorithms for a multitude of emergent conditions and the evidence surrounding its role in emergency medicine continues to evolve.
Méthode : The objective of this literature review is to provide an evidence-based approach to the utilization of TXA in the emergency department.
Discussion : The most robust trials suggest TXA may offer a modest improvement in mortality in patients at risk of significant bleeding from trauma, but is not beneficial in spontaneous intracranial hemorrhage or gastrointestinal bleeding. The role of TXA in other clinical scenarios is less clear and requires clinical judgment.
Conclusion : Tranexamic acid appears to be a reasonable adjunct for the emergency medicine clinician to consider in the management of many hemorrhagic conditions and angiotensin converting enzyme inhibitor-induced angioedema. Additional high-quality research in these areas is needed to further identity patients who may benefit most from TXA
Conclusion (proposition de traduction) : L'acide tranexamique semble être un adjuvant raisonnable à envisager pour le praticien en médecine d'urgence dans la prise en charge de nombreuses affections hémorragiques et de l'œdème de Quincke induit par l'inhibiteur de l'enzyme de conversion de l'angiotensine. Des recherches supplémentaires de haute qualité dans ces domaines sont nécessaires pour mieux identifier les patients qui pourraient bénéficier le plus de l'acide tranexamique.
Analgesic efficacy of nitrous oxide in adults in the emergency department: A meta-analysis of randomized controlled trials.
Xing Y, Zhou L, Yu J, Wang Z, Ding Z, Xie C, Li Y, Wang F, Tang L. | Am J Emerg Med. 2022 Jun;56:92-99
DOI: https://doi.org/10.1016/j.ajem.2022.03.028 | Télécharger l'article au format
Keywords: Analgesia; Emergency department; Meta-analysis; Nitrous oxide.
Introduction : Nitrous oxide (N2O) has a rapidly analgesic effect, but evidence regarding its role in managing pain in adults in the emergency department (ED) is conflicting. The purpose of this meta-analysis is to investigate the analgesic efficacy and safety of N2O in adults in ED.
Méthode : We systematically searched PubMed, the Cochrane Library, Embase, Web of science, China National Knowledge Infrastrusture (CNKI) and Wanfang Database up to August 10th, 2021. Randomized controlled trials (RCTs) were included if they compared N2O/O2 to placebo or other analgesic methods for management of pain in adults in ED or prehospital. The primary outcome was the analgesic efficacy of N2O. Secondary outcomes included adverse events, satisfaction of patients and the duration of procedure.
Résultats : 14 RCTs with 1751 patients were included. Pooled analysis suggested that N2O had better analgesia than placebo in the pain score (WMD = -3.00, 95% CI = -3.99 to -2.02, P < 0.00001, I2 = 91%) and the number of patients with pain relief (OR = 6.18, 95% CI = 3.22 to 11.85, P < 0.00001, I2 = 0%), while there were no significant difference in the pain score (WMD = 0.93, 95% CI = -1.09 to 2.95, P = 0.37, I2 = 97%) or the number of patients with pain relief (OR = 0.07, 95% CI = 0.00 to 3.47, P = 0.18, I2 = 86%) between the N2O group and the other analgesic method group. Although N2O did not increase nausea (OR = 1.52, 95% CI = 0.44 to 5.21, P = 0.50, I2 = 54%) or satisfaction of patients (OR = 1.06, 95% CI = 0.16 to 7.18, P = 0.96, I2 = 81%), it was associated with higher tendency of vomiting (OR = 6.50, 95% CI = 2.07 to 20.42, P = 0.001, I2 = 29%) and dizziness (OR = 4.54, 95% CI = 2.27 to 9.09, P < 0.0001, I2 = 26%), and shorter procedure time (WMD = -5.73 min, 95% CI = -10.14 min to -1.32 min, P = 0.01, I2 = 98%).
Conclusion : The present meta-analysis suggested that N2O could provide better analgesia than placebo and similar analgesia to other methods with more vomiting and dizziness in adults in ED.
Conclusion (proposition de traduction) : La présente méta-analyse suggère que le protoxyde d'azote pourrait fournir une meilleure analgésie que le placebo et une analgésie similaire à d'autres méthodes avec plus de vomissements et de vertiges chez les adultes aux urgences.
High risk and low prevalence diseases: Ovarian torsion.
Bridwell RE, Koyfman A, Long B. | Am J Emerg Med. 2022 Jun;56:145-150
DOI: https://doi.org/10.1016/j.ajem.2022.03.046 | Télécharger l'article au format
Keywords: Adnexal torsion; Gynecology; Ovarian torsion.
Introduction : Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity.
Méthode : This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence.
Discussion : Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED.
Conclusion : An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.
Conclusion (proposition de traduction) : Une bonne compréhension de la torsion ovarienne peut aider les praticiens des urgences à diagnostiquer et à gérer cette maladie.
Clinical update on COVID-19 for the emergency and critical care clinician: Medical management.
Long B, Chavez S, Carius BM, Brady WJ, Liang SY, Koyfman A, Gottlieb M. | Am J Emerg Med. 2022 Jun;56:158-170
DOI: https://doi.org/10.1016/j.ajem.2022.03.036 | Télécharger l'article au format
Keywords: COVID-19; Coronavirus-2019; SARS-CoV-2; Severe acute respiratory syndrome coronavirus 2.
Introduction : Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved.
Méthode : This is the second part in a series on COVID-19 updates providing a focused overview of the medical management of COVID-19 for emergency and critical care clinicians.
Résultats : COVID-19, caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality worldwide. A variety of medical therapies have been introduced for use, including steroids, antivirals, interleukin-6 antagonists, monoclonal antibodies, and kinase inhibitors. These agents have each demonstrated utility in certain patient subsets. Prophylactic anticoagulation in admitted patients demonstrates improved outcomes. Further randomized data concerning aspirin in outpatients with COVID-19 are needed. Any beneficial impact of other therapies, such as colchicine, convalescent plasma, famotidine, ivermectin, and vitamins and minerals is not present in reliable medical literature. In addition, chloroquine and hydroxychloroquine are not recommended.
Conclusion : This review provides a focused update of the medical management of COVID-19 for emergency and critical care clinicians to help improve care for these patients.
Conclusion (proposition de traduction) : Cette revue fournit une mise à jour ciblée de la gestion médicale de la COVID-19 pour les urgentistes et les réanimateurs afin de contribuer à améliorer les traitements de ces patients.
Ultrasound-Guided vs. Landmark Method for Subclavian Vein Catheterization in an Academic Emergency Department.
Subramony R, Spann R, Medak A, Campbell C. | J Emerg Med. 2022 Jun;62(6):760-768
Keywords: catheterization; emergency; procedures; subclavian; ultrasound.
Introduction : Ultrasound guidance has been shown to decrease complication rates and improve success for internal jugular and femoral vein catheterization in the emergency department (ED). However, the current data on the efficacy and safety of ultrasound-guided subclavian vein catheterization has failed to provide support for similar conclusions.
Objective: To determine if ultrasound-guided subclavian vein catheterization is safer and more efficacious than the traditional landmark method in an ED setting.
Méthode : A prospective randomized trial was conducted from April 2004 through June 2009 in an urban tertiary care academic ED with an annual census of >50,000 patients. Four primary data endpoints were calculated: 1) overall success for both resident and attending physicians; 2) number of attempts by each group of providers; 3) complication rate with each method; and 4) time to which the subclavian line was obtained.
Résultats : Eighty-five patients were enrolled in the study. The ultrasound method was more successful in obtaining subclavian catheter placement when compared with the landmark method. When comparing successful cannulation attempts in both groups, the ultrasound group showed a statistically significant longer time to success when compared with the landmark group. There was no difference in the success or complication rates between residents and attending physicians. There was no significant difference in complications rates between ultrasound-guided and landmark methods.
Conclusion : Ultrasound-guided subclavian vein catheterization was found to be associated with a higher overall success rate compared with the landmark method with no significant difference with respect to complication rate in an ED setting.
Conclusion (proposition de traduction) : Le cathétérisme de la veine sous-clavière guidé par échographie s'est avéré être associé à un taux de réussite global plus élevé que la méthode du repère, sans différence significative en ce qui concerne le taux de complications dans un service d'urgence.
Commentaire : Société française d'anesthésie et de réanimation (Sfar). Recommandations sur l’utilisation de l’échographie lors de la mise en place des accès vasculaires. Anesth Reanim. 2015; 1: 183–189 .
La mise en place d’un cathéter dans une veine de gros calibre est parfois nécessaire à l’administration des traitements ou à la surveillance. Les anesthésistes-réanimateurs sont, par leur formation et leur pratique, parmi les plus compétents pour réaliser ce geste. Celui-ci peut être néanmoins associé à des complications lors de sa réalisation, comme la ponction d’une artère adjacente avec formation éventuelle d’un hématome ou la ponction de la plèvre avec décollement du poumon. Ces complications peuvent être favorisées par des variations de l’anatomie. L’utilisation de l’échographie permet la visualisation des vaisseaux, de ses structures adjacentes et de l’aiguille de ponction tout au long de son trajet. Cette technique dite échoguidée permet de réduire significativement les complications et devrait être utilisée par défaut.
Is Tranexamic Acid (TXA) Effective Compared with Anterior Nasal Packing (ANP) in Achieving Cessation of Bleeding in Patients with Anterior Epistaxis?.
Torres E, Johnson MY, Seebald K, Kachhi P. | J Emerg Med. 2022 Jun;62(6):820-825
Keywords: Anterior nasal packing; Bleeding; Emergency department; Epistaxis; Nose bleed; TXA; Tranexamic acid.
Editorial : Question: In a patient presenting with anterior epistaxis, is tranexamic acid (TXA) an effective method to achieve cessation of bleeding compared with anterior nasal packing?
Clinical Scenario: You are about to see a 67-year-old patient with an episode of anterior epistaxis refractory to home care, and wonder which therapy would be most effective.
Simple Search Strategy: PubMed: TXA AND Epistaxis with filter Randomized Controlled Trial; Google Scholar: TXA for Epistaxis randomization.
Search Outcome: Seven papers were relevant to emergency department (ED) patients (including one Cochrane Review and one Case Report) and were reviewed further.
Conclusion : For non-traumatic anterior epistaxis, topical TXA may be used as an effective therapy at achieving hemostasis with decreased rates of rebleed and higher patient comfort compared with ANP. Recommended dose is 500 mg in 5 mL on pledgets inserted into the affected nares for 10–30 min, or application via atomizer, which would also increase patient comfort. If there are relative or absolute contraindications to TXA, or cessation of bleeding with TXA is not achieved within 30 min, consider ANP or escalation of care.
Conclusion (proposition de traduction) : Dans le cas d'une épistaxis antérieure non traumatique, l'acide tranexamique topique peut être utilisé comme un traitement efficace pour obtenir une hémostase avec des taux réduits de re-saignement et un meilleur confort pour le patient, par rapport au tamponnement nasal antérieur. La dose recommandée est de 500 mg dans 5 ml sur des compresses insérées dans les narines concernées pendant 10 à 30 minutes, ou une application via un nébuliseur, ce qui augmenterait également le confort du patient. S'il existe des contre-indications relatives ou absolues à l'acide tranexamique, ou si l'arrêt du saignement avec l'acide tranexamique n'est pas obtenu dans les 30 minutes, il faut envisager un tamponnement nasal antérieur ou une intensification des soins.
The 35-mm rule to guide pneumothorax management: Increases appropriate observation and decreases unnecessary chest tubes.
Figueroa JF, Karam BS, Gomez J, Milia D, Morris RS, Dodgion C, Carver T, Murphy P, Elegbede A, Schroeder M, de Moya MA. | J Trauma Acute Care Surg. 2022 Jun 1;92(6):951-957
2021 AAST PODIUM PAPER
Introduction : Axial imaging has allowed for more precise measurement and, in-turn, more objective guidelines related to the management of traumatic pneumothoraces (PTXs). In 2017, our trauma center used a guideline to observe any PTX ≤35 mm in stable patients. We hypothesize that this guideline would decrease unnecessary chest tubes without affecting failure rates.
Méthode : This is a single-center retrospective review of all adult trauma patients who had a PTX diagnosed on computed tomography before (2015-2016) and after (2018-2019) guideline implementation. We excluded patients with chest tubes inserted before computed tomography, concurrent hemothoraces, mechanical ventilation, or mortality in the first 24 hours. Descriptive statistical analyses, χ2 test, and Mann-Whitney U test were performed as appropriate.
Résultats : A total of 266 patients met our inclusion criteria. Ninety-nine (37.2%) and 167 patients (62.7%) were admitted before and after 2017, respectively. Overall, there were no differences in demographics or severity of injuries between both groups. After guideline implementation, there was a significant increase in observation rates and compliance rate. Tube thoracostomies decreased from 28.3% to 18% (p = 0.04). There were no statistically significant changes in observation failure rates, hospital or intensive care unit length of stay, complications, or mortality.
Conclusion : The implementation of the 35 mm guideline is an effective tool to decrease unnecessary tube thoracostomy in hemodynamically normal patients without evidence of hemothorax.
Conclusion (proposition de traduction) : La mise en œuvre de la règle des 35 mm est un outil efficace pour diminuer les thoracostomies inutiles par drains chez les patients hémodynamiquement stables sans signe d'hémothorax.
Prospective validation of the Rib Injury Guidelines for traumatic rib fractures.
Nelson A, Reina R, Northcutt A, Obaid O, Castanon L, Ditillo M, Gries L, Bible L, Anand T, Joseph B. | J Trauma Acute Care Surg. 2022 Jun 1;92(6):967-973
2021 AAST QUICK SHOT
Introduction : The Rib Injury Guidelines (RIG) were developed to guide triage of traumatic rib fracture patients to home, regular floor, or intensive care unit (ICU) and standardize care. The RIG score is based on patient history, physical examination, and imaging findings. The aim of this study was to evaluate triage effectiveness and health care resources utilization following RIG implementation.
Méthode : This is a prospective analysis at a level I trauma center from October 2017 to January 2020. Adult (18 years or older) blunt trauma patients with a diagnosis of at least one rib fracture on computed tomography imaging were included. Patients before (PRE) and after (POST) implementation of RIG were compared. In the POST group, patients were divided into RIG 1, RIG 2, and RIG 3 based on their RIG score. Outcomes were readmission for RIG 1 patients, unplanned ICU admission for RIG 2 patients, and overall ICU admission. Secondary outcomes were hospital length of stay (LOS) and mortality.
Résultats : A total of 1,100 patients were identified (PRE, 754; POST, 346). Mean ± SD age was 56 ± 19 years, 788 (71.6%) were male, and median Injury Severity Score was 14 (range, 10-22). The most common mechanism of injury was motor vehicle collision (554 [50.3%]), 253 patients (22.9%) had ≥5 rib fractures, and 53 patients (4.8%) had a flail chest. In the POST group, 74 patients (21.1%) were RIG 1; 121 (35.2%), RIG 2; and 151 (43.7%), RIG 3. No patient in RIG 1 was readmitted following initial discharge, and two patients (1.6%) in RIG 2 had an unplanned ICU admission (both for alcohol withdrawal syndrome). Patients after implementation of RIG had shorter hospital LOS (3 [1-6] vs. 4 [1-7] days; p = 0.019) and no difference in mortality (5.8% vs. 7.7%; p = 0.252). On multivariate analysis, RIG implementation was associated with decreased ICU admission (adjusted odds ratio, 0.55 [0.36-0.82]; p = 0.004).
Conclusion : Rib Injury Guidelines are safe and effectively define triage of rib fracture patients with an overall reduction in ICU admissions, shorter hospital LOS, and no readmissions.
Conclusion (proposition de traduction) : Les directives relatives aux blessures thoraciques sont sûres et définissent efficacement le triage des patients souffrant de fractures de côtes, avec une réduction globale des admissions aux soins intensifs, une durée d'hospitalisation plus courte et aucune réadmission.
AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma.
Schroll R, Smith A and al.. | J Trauma Acute Care Surg. 2022 Jun 1;92(6):997-1004
2020 AAST POSTER
Introduction : Tourniquet use for extremity hemorrhage control has seen a recent increase in civilian usage. Previous retrospective studies demonstrated that tourniquets improve outcomes for major extremity trauma (MET). No prospective study has been conducted to date. The objective of this study was to evaluate outcomes in MET patients with prehospital tourniquet use. We hypothesized that prehospital tourniquet use in MET decreases the incidence of patients arriving to the trauma center in shock.
Méthode : Data were collected prospectively for adult patients with MET at 26 Level I and 3 Level II trauma centers from 2015 to 2020. Limbs with tourniquets applied in the prehospital setting were included in the tourniquet group and limbs without prehospital tourniquets were enrolled in the control group.
Résultats : A total of 1,392 injured limbs were enrolled with 1,130 tourniquets, including 962 prehospital tourniquets. The control group consisted of 262 limbs without prehospital tourniquets and 88 with tourniquets placed upon hospital arrival. Prehospital improvised tourniquets were placed in 42 patients. Tourniquets effectively controlled bleeding in 87.7% of limbs. Tourniquet and control groups were similarly matched for demographics, Injury Severity Score, and prehospital vital signs (p > 0.05). Despite higher limb injury severity, patients in the tourniquet group were less likely to arrive in shock compared with the control group (13.0% vs. 17.4%, p = 0.04). The incidence of limb complications was not significantly higher in the tourniquet group (p > 0.05).
Conclusion : This study is the first prospective analysis of prehospital tourniquet use for civilian extremity trauma. Prehospital tourniquet application was associated with decreased incidence of arrival in shock without increasing limb complications. We found widespread tourniquet use, high effectiveness, and a low number of improvised tourniquets. This study provides further evidence that tourniquets are being widely and safely adopted to improve outcomes in civilians with MET.
Conclusion (proposition de traduction) : Cette étude est la première analyse prospective de l'utilisation préhospitalière du garrot pour les traumatismes des extrémités chez les civils. L'application préhospitalière du garrot a été associée à une diminution de l'incidence de l'arrivée en état de choc sans augmenter les complications au niveau des membres. Nous avons constaté une utilisation généralisée du garrot, une grande efficacité et un faible nombre de garrots artisanaux. Cette étude fournit des preuves supplémentaires que les garrots sont largement adoptés et en toute sécurité pour améliorer les résultats chez les victimes de traumatismes majeurs des extrémités.
Appendectomy versus nonoperative management of simple appendicitis: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study using a hierarchical ordinal scale.
Yeh DD, Vasileiou G, Qian S, Zhang H, Abdul Jawad K, Dodgion C, Lawless R, Rattan R, Pust GD, Namias N; EAST Appendicitis Study Group. | J Trauma Acute Care Surg. 2022 Jun 1;92(6):1031-1038
Introduction : Controversy exists about the preferred initial treatment of appendicitis. We sought to compare the two treatments for initial management of simple appendicitis.
Méthode : In this post hoc analysis of the Multicenter Study for the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, subjects were divided into appendectomy or nonoperative management (NOM; antibiotics only or percutaneous drainage) cohorts. A novel topic-specific hierarchical ordinal scale was created with eight mutually exclusive categories: mortality, reoperation, other secondary interventions, readmission, emergency department visit, wound complication, surgical site infection, and no complication. Pairwise comparisons of American Association for the Surgery of Trauma Imaging Severity Grade 1 (simple appendicitis) patients were compared using win-lose-tie scoring and the sums of appendectomy/NOM groups were compared.
Résultats : A total 3,591 subjects were included: 3,262 appendectomy and 329 NOM, with significant differences in baseline characteristics between groups. Across 28 sites, the rate of NOM ranged from 0% to 48%, and the loss to follow-up rate was significantly higher for NOM compared with appendectomy (16.5% vs. 8.7%, p = 0.024). In the simple appendicitis hierarchical ordinal scale analysis, 2,319 subjects resulted in 8,714,304 pairwise comparisons; 75% of comparisons resulted in ties. The median (interquartile range) sums for the two groups are as follows: surgical, 400 (400-400), and NOM, 400 (-2,427 to 400) (p < 0.001). A larger proportion of appendectomy subjects (88.1%) had an outcome that was equivalent (or better) than at least half of the subjects compared with NOM subjects (NOM, 70.5%; OR [95% confidence interval], 0.3 [0.2-0.4]).
Conclusion : In contemporary American practice, appendectomy (compared with NOM) for simple appendicitis is associated with lower odds of developing clinically important unfavorable outcomes in the first year after illness.
Conclusion (proposition de traduction) : Dans la pratique américaine contemporaine, l'appendicectomie (par rapport à la prise en charge non opératoire ; antibiotiques seulement ou drainage percutané) pour l'appendicite simple est associée à une probabilité moindre de développer des résultats défavorables cliniquement importants au cours de la première année après la maladie.
Restriction of Intravenous Fluid in ICU Patients with Septic Shock.
Meyhoff TS, Hjortrup PB, Wetterslev J and al.; CLASSIC Trial Group. | N Engl J Med. 2022 Jun 30;386(26):2459-2470
Introduction : Intravenous fluids are recommended for the treatment of patients who are in septic shock, but higher fluid volumes have been associated with harm in patients who are in the intensive care unit (ICU).
Méthode : In this international, randomized trial, we assigned patients with septic shock in the ICU who had received at least 1 liter of intravenous fluid to receive restricted intravenous fluid or standard intravenous fluid therapy; patients were included if the onset of shock had been within 12 hours before screening. The primary outcome was death from any cause within 90 days after randomization.
Résultats : We enrolled 1554 patients; 770 were assigned to the restrictive-fluid group and 784 to the standard-fluid group. Primary outcome data were available for 1545 patients (99.4%). In the ICU, the restrictive-fluid group received a median of 1798 ml of intravenous fluid (interquartile range, 500 to 4366); the standard-fluid group received a median of 3811 ml (interquartile range, 1861 to 6762). At 90 days, death had occurred in 323 of 764 patients (42.3%) in the restrictive-fluid group, as compared with 329 of 781 patients (42.1%) in the standard-fluid group (adjusted absolute difference, 0.1 percentage points; 95% confidence interval [CI], -4.7 to 4.9; P = 0.96). In the ICU, serious adverse events occurred at least once in 221 of 751 patients (29.4%) in the restrictive-fluid group and in 238 of 772 patients (30.8%) in the standard-fluid group (adjusted absolute difference, -1.7 percentage points; 99% CI, -7.7 to 4.3). At 90 days after randomization, the numbers of days alive without life support and days alive and out of the hospital were similar in the two groups.
Conclusion : Among adult patients with septic shock in the ICU, intravenous fluid restriction did not result in fewer deaths at 90 days than standard intravenous fluid therapy.
Conclusion (proposition de traduction) : Chez les patients adultes en choc septique hospitalisés en soins intensifs, la restriction de l'apport liquidien intraveineux n'a pas entraîné moins de décès à 90 jours que le remplissage vasculaire standard.
Commentaire : Voir l'analyse de l'article sur le site de la SRLF : Remplir les patients en choc septique : éviter la goutte d’eau qui fait déborder le vase ? . Rédigé par les Dr Valentin de Villiers de la Noue Olfa Hamzaoui, CERC de la SRLF, le 31/03/2023.