Can right ventricular assessments improve triaging of low risk pulmonary embolism?.
Raper JD, Thomas AM, Lupez K, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, O'Connell NS, Weekes AJ. | Acad Emerg Med. 2022 Jul;29(7):835-850
Introduction : Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5-day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other.
Méthode : We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE.
Résultats : Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77-0.82) and 0.71 (0.68-0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5-day clinical deterioration by the multivariable logistic regression.
Conclusion : A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5-day clinical deterioration versus one without.
Conclusion (proposition de traduction) : Une stratégie de triage de l'embolie pulmonaire avec une imagerie du ventricule droit avait une performance pronostique supérieure pour classer le faible risque de détérioration clinique à 5 jours par rapport à une stratégie sans évaluation.
Chemical, Biological, Radiological, Nuclear (CBRN) Risks: the CBNR Chain of Survival and Its Mnemonic Device “I AM THOR”, a New Cognitive Tool to Approach Casualty Management to First Responders the First Few Hours.
Giaume L, Calamai F, Daniel Y, Demeny A, Derkenne C, Lachenaud L, Travers S, Dorandeu F. | Ann Fr Med Urgence. 2022 Juillet;12(4):224-33
Keywords: CBRN; First responders; Prehospital care; Disaster medicine; Cognitive tool
Editorial : Les risques terroristes nucléaires, radiologiques, biologiques et chimiques (NRBC) constituent une menace permanente. Les primo-intervenants seront probablement des personnels non spécialisés face à un événement de cette nature. À l’extérieur ou à l’accueil des hôpitaux, leur rôle sera pourtant décisif sur le plan tactique afin de mettre en œuvre les premières mesures et minimiser les effets sur la population. Acquérir et entretenir un niveau de formation suffisant pour un risque d’occurrence rare, pour agir efficacement en tenue de protection dans un contexte aussi stressant sont des défis pédagogiques et organisationnels pour nos services. En 2019, la brigade de sapeurs-pompiers de Paris conceptualise la « chaîne de survie NRBC » regroupant les cinq actions essentielles à mener par les primointervenants en cas d’événements NRBC. Ces tâches, indissociables, sont représentées sous la forme d’une chaîne constituée de cinq maillons : 1) Décontamination d’urgence pour limiter l’intoxication et la contamination ; 2) Recherche de symptômes pour identifier l’agent et alerter les secours ; 3) Administration précoce des traitements pour réduire la morbi mortalité ; 4) Décontamination approfondie pour protéger le système de santé ; 5) Évacuation vers l’hôpital. En 2020, l’acronyme « DUST DAHO » est ajouté pour optimiser la mémorisation et la restitution des cinq maillons de cette chaîne. Cet outil cognitif s’adresse à tous les acteurs, soignants ou non, à l’extérieur ou à l’accueil de l’hôpital, quel que soit l’agent NRBC en cause. Il pourrait également être un outil de communication précieux pour le grand public en cas de crise.
Conclusion (proposition de traduction) : Agir efficacement à la suite d’un événement NRBC est un enjeu complexe. Les primo-intervenants devront rapidement débuter les premières mesures de décontamination d’urgence, identifier l’agent incriminé, administrer les premiers traitements et antidotes, activer la chaîne de décontamination approfondie si nécessaire, pour limiter l’intoxication et la contamination en attendant l’arrivée des spécialistes NRBC. Le manque d’expérience, la faible proportion de personnel formé, le caractère inhabituel de ce type d’intervention et les difficultés induites par le port des EPI seront des facteurs supplémentaires qui viendront s’ajouter au stress majeur de ces primo-intervenants.
L’acronyme « DUST DAHO » associé à la chaîne de survie NRBC est une approche pédagogique simple et pragmatique résumant les premières actions à mener en cas d’événements NRBC pour limiter les effets de la sidération initiale risquant de paralyser les intervenants et leur permettre d’élaborer une manœuvre commune en attendant l’arrivée des spécialistes NRBC. Elle s’adresse à tous les acteurs, soignants ou non (forces de l’ordre, sauveteurs), qu’ils interviennent sur le terrain ou à l’accueil des établissements de santé, quelle que soit la nature de l’agent NRBC en cause. Elle peut être utilisée comme outil de communication pour le grand public en cas de crise pour délivrer les consignes de décontamination d’urgence et de décontamination approfondie si nécessaire.
Management of a Patient with Sickle Cell Disease in an Emergency Room.
Kassasseya C, Bressand S; Khellaf M. | Ann. Fr. Med. Urgence. 2022 Juillet;12(4):234-240
Keywords: Sickle cell disease; Genetic hemoglobin disease; Sickling; Vaso-occlusive crisis; Acute chest syndrome; Morphine
Editorial : La drépanocytose est aujourd’hui la première maladie génétique en France avec environ 30 000 patients adultes. Une mutation ponctuelle sur le chromosome 11 conduit à la production d’une hémoglobine pathologique qui polymérise sous l’effet de facteurs endo- ou exogènes induisant la falciformation des globules rouges à l’origine d’une vaso-occlusion artérielle dont une des conséquences est l’oblitération des vaisseaux à destinée osseuse. Les infarctus osseux sont particulièrement douloureux, conduisant les patients aux urgences où l’enjeu est de soulager rapidement les douleurs par l’utilisation de morphine principalement par analgésie autocontrôlée après titration morphinique. Le risque majeur au cours de ces crises vaso-occlusives (CVO) est l’apparition d’un syndrome thoracique aigu (STA) pouvant mettre en jeu le pronostic vital du patient. La spirométrie incitative est un moyen préventif du STA important à instituer dès les urgences. Une antibiothérapie sera mise en place en cas de fièvre chez ces patients aspléniques à risque d’infections à germes encapsulés notamment par le pneumocoque. L’échange transfusionnel est une des pierres angulaires du traitement des CVO ou du STA mais le risque d’accident hémolytique aigu post transfusionnel doit en limiter l’usage à des situations mettant en jeu le pronostic vital ou fonctionnel d’organe. Plusieurs scores clinicobiologiques permettent de décider de l’utilité d’un angioscanner thoracique au cours du STA à la recherche d’une embolie pulmonaire ou pour décider de la pertinence d’une sortie vers une hospitalisation à domicile (Programme DREPADOM). L’utilisation de la morphine en dehors de l’hôpital de façon prolongée doit être prudente en raison du risque d’addiction.
Conclusion (proposition de traduction) : Compte tenu de la progression rapide de la démographie des patients atteints de drépanocytose en France, il devient indispensable pour les urgentistes de connaitre les grandes lignes de la prise en charge des complications aiguës de cette pathologie, qui consiste essentiellement en l’administration d’un traitement antalgique morphinique adapté, d’une hydratation et du contrôle systématique de l’absence de complications pouvant mettre rapidement le pronostic vital du patient en jeu au premier rang desquelles figure le syndrome thoracique aigu. Les indications des échanges transfusionnels sont désormais limitées à des situations à risque de pronostic vital ou fonctionnel d’organe engagé et doivent être discutées avec les centres de références ou de compétences de proximité.
Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension.
Spaite DW, Hu C, Bobrow BJ, Barnhart B, Chikani V, Gaither JB, Denninghoff KR, Bradley GH, Rice AD, Howard JT, Keim SM. | Ann Emerg Med. 2022 Jul;80(1):46-59
DOI: https://doi.org/10.1016/j.annemergmed.2022.01.045 | Télécharger l'article au format
Emergency Medical Services
Introduction : Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension.
Méthode : This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort.
Résultats : Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort.
Conclusion : Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (<90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.
Conclusion (proposition de traduction) : La mortalité ajustée optimale était associée à une plage de pression artérielle systolique étonnamment élevée (130 à 180 mmHg). En dessous de ce niveau, il n'y avait pas de point ou de plage d'inflexion qui indiquerait un seuil physiologiquement significatif pour définir l'hypotension. Les résultats non mortels ont montré des schémas très similaires. Ces résultats soulignent à quel point le cerveau blessé est sensible à une perfusion insuffisante à des niveaux de pression artérielle systolique qui, jusqu'à présent, étaient considérés comme adéquats ou même normaux. Bien que la conception de l'étude ne nous permette pas de conclure que le seuil de traitement actuellement recommandé (<90 mmHg) devrait être augmenté, les résultats impliquent que la définition de l'hypotension dans le cadre de lésions cérébrales traumatiques est trop basse. Des essais randomisés évaluant des niveaux de traitement significativement plus élevés que 90 mmHg sont nécessaires.
Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability.
Dubée V, Hariri G, Joffre J, Hagry J, Raia L, Bonny V, Gabarre P, Ehrminger S, Bigé N, Baudel JL, Guidet B, Maury E, Dumas G, Ait-Oufella H. | Ann Intensive Care. 2022 Jul 18;12(1):68
DOI: https://doi.org/10.1186/s13613-022-01043-3 | Télécharger l'article au format
Keywords: Hemodynamic; Intubation; Mottling; Outcome; Tissue perfusion.
Introduction : Tracheal intubation and invasive mechanical ventilation initiation is a procedure at high risk for arterial hypotension in intensive care unit. However, little is known about the relationship between pre-existing peripheral microvascular alteration and post-intubation hemodynamic instability (PIHI).
Méthode : Prospective observational monocenter study conducted in an 18-bed medical ICU. Consecutive patients requiring tracheal intubation were eligible for the study. Global hemodynamic parameters (blood pressure, heart rate, cardiac function) and tissue perfusion parameters (arterial lactate, mottling score, capillary refill time [CRT], toe-to-room gradient temperature) were recorded before, 5 min and 2 h after tracheal intubation (TI). Post intubation hemodynamic instability (PIHI) was defined as any hemodynamic event requiring therapeutic intervention.
Résultats : During 1 year, 120 patients were included, mainly male (59%) with a median age of 68 [57-77]. The median SOFA score and SAPS II were 6 [4-9] and 47 [37-63], respectively. The main indications for tracheal intubation were hypoxemia (51%), hypercapnia (13%), and coma (29%). In addition, 48% of patients had sepsis and 16% septic shock. Fifty-one (42%) patients develop PIHI. Univariate analysis identified several baseline factors associated with PIHI, including norepinephrine prior to TI, sepsis, tachycardia, fever, higher SOFA and high SAPSII score, mottling score ≥ 3, high lactate level and prolonged knee CRT. By contrast, mean arterial pressure, baseline cardiac index, and ejection fraction were not different between PIHI and No-PIHI groups. After adjustment on potential confounders, the mottling score was associated with a higher risk for PIHI (adjusted OR: 1.84 [1.21-2.82] per 1 point increased; p = 0.005). Among both global haemodynamics and tissue perfusion parameters, baseline mottling score was the best predictor of PIHI (AUC: 0.72 (CI 95% [0.62-0.81]).
Conclusion : In non-selected critically ill patients requiring invasive mechanical ventilation, tissue hypoperfusion parameters, especially the mottling score, could be helpful to predict PIHI.
Conclusion (proposition de traduction) : Chez les patients non sélectionnés en état critique nécessitant une ventilation mécanique invasive, les paramètres d'hypoperfusion tissulaire, en particulier le score de marbrure, pourraient être utiles pour prédire l'instabilité hémodynamique post-intubation.
Effect of Interposed Abdominal Compression on Car-diopulmonary Resuscitation Outcomes; a RandomizedClinical Trial.
Ghanbari Khanghah A, Moghadamnia MT, Panahi L, Pouy S, Aghajani Nargesi M, Kazemnezhad Leyli E. | Arch Acad Emerg Med. 2022 Jul. 16;10(1):e57
DOI: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1678 | Télécharger l'article au format
Keywords: Heart Arrest; Cardiopulmonary Resuscitation; Treatment Outcome; Clinical trial
Introduction : Standard cardiopulmonary resuscitation (STD-CPR) is successful in only 10-15% of cases in emer-gency department (ED). This study aimed to determine the effect of interposed abdominal compression (IAC)during resuscitation on outcomes of ED cardiac arrests.
Méthode : In this randomized clinical trial study, non-trauma patients aged 18-85 years, patients with in-hospital cardiac arrest hospitalized in the ED were randomlyassigned into two either STD-CPR or IAC-CPR group on a 1:1 basis and using computer-generated random num-bers. Participants in the intervention group, received abdominal compression during the diastole phase of STD-CPR. The rate of return of spontaneous circulation (ROSC), heart rate (HR), respiratory rate (RR), arterial bloodgas (ABG) indicators, and survival rate were compared between the two groups.
Résultats : Ninety patients wereenrolled (45 in each group). There were no differences between the two groups regarding age (p = 0.76), sex (p= 0.39), employment status (p = 0.62) and Charlson comorbidity scale (p = 0.46). Abdominal compression hada positive effect on heart rate (p < 0.001), mean arterial pressure (p = 0.003), arterial blood oxygen pressure (p =0.001), and arterial blood carbon dioxide pressure (p = 0.001) as well as a negative effect on arterial blood oxy-gen saturation (p = 0.029) 30 minutes after resuscitation. Out of the 90 CPR cases, 8 (17.7%) cases in interventiongroup and 8 (17.7%) cases in control group were successful, among which all of the 8 patients in the interventiongroup and 5 of the patients in the control group had been discharged from hospital without any complications.
Conclusion : The results showed that abdominal compression during CPR can improve resuscitation outcomesin patients with cardiac arrest. Therefore, in order to use this technique, further research is recommended.
Conclusion (proposition de traduction) : Les résultats montrent que la compression abdominale pendant la RCP peut améliorer les résultats de la réanimation chez les patients en arrêt cardiaque. Par conséquent, afin d'utiliser cette technique, des recherches supplémentaires sont recommandées.
Capillary refill time for the management of acute circulatory failure: a survey among pediatric and adult intensivists.
Jacquet-Lagrèze M, Wiart C, Schweizer R, Didier L, Ruste M, Coutrot M, Legrand M, Baudin F, Javouhey E, Dépret F, Fellahi JL. | BMC Emerg Med. 2022 Jul 18;22(1):131
DOI: https://doi.org/10.1186/s12873-022-00681-x | Télécharger l'article au format
Keywords: Acute circulatory failure; Capillary refill time; Peripheral perfusion; Shock; Survey.
Introduction : Recent studies have shown the prognostic value of capillary refill time (CRT) and suggested that resuscitation management guided by CRT may reduce morbidity and mortality in patients with septic shock. However, little is known about the current use of CRT in routine clinical practice. This study aimed to assess the modalities of CRT use among French adult and pediatric intensivists.
Méthode : A cross-sectional survey exploring CRT practices in acute circulatory failure was performed. The targeted population was French adult and pediatric intensivists (SFAR and GFRUP networks). An individual invitation letter including a survey of 32 questions was emailed twice. Descriptive and analytical statistics were performed.
Résultats : Among the 6071 physicians who received the letter, 418 (7%) completed the survey. Among all respondents, 82% reported using CRT in routine clinical practice, mainly to diagnose acute circulatory failure, but 45% did not think CRT had any prognostic value. Perfusion goal-directed therapy based on CRT was viewed as likely to improve patient outcome by 37% of respondents. The measurement of CRT was not standardized as the use of a chronometer was rare (3%) and the average of multiple measurements rarely performed (46%). Compared to adult intensivists, pediatric intensivists used CRT more frequently (99% versus 76%) and were more confident in its diagnostic value and its ability to guide treatment.
Conclusion : CRT measurement is widely used by intensivists in patients with acute circulatory failure but most often in a non-standardized way. This may lead to a misunderstanding of CRT reliability and clinical usefulness.
Conclusion (proposition de traduction) : La mesure du temps de recoloration cutané est largement utilisée par les réanimateurs chez les patients souffrant d'insuffisance circulatoire aiguë, mais le plus souvent de manière non standardisée. Cela peut conduire à une mauvaise compréhension de la fiabilité du temps de recoloration cutané et de son utilité clinique.
Compromised cardiopulmonary resuscitation quality due to regurgitation during endotracheal intubation: a randomised crossover manikin simulation study.
Lin LW, DuCanto J, Hsu CY, Su YC, Huang CC, Hung SW. | BMC Emerg Med. 2022 Jul 9;22(1):124
DOI: https://doi.org/10.1186/s12873-022-00662-0 | Télécharger l'article au format
Keywords: Airway management; Cardiopulmonary resuscitation; Manikin; Regurgitation.
Introduction : Regurgitation is a complication common during cardiopulmonary resuscitation (CPR). This manikin study evaluated the effect of regurgitation during endotracheal intubation on CPR quality.
Méthode : An airway-CPR manikin was modified to regurgitate simulated gastric contents into the oropharynx during chest compression during CPR. In total, 54 emergency medical technician-paramedics were assigned to either an oropharyngeal regurgitation or clean airway scenario and then switched to the other scenario after finishing the first. The primary outcomes were CPR quality metrics, including chest compression fraction (CCF), chest compression depth, chest compression rate, and longest interruption time. The secondary outcomes were intubation success rate and intubation time.
Résultats : During the first CPR-intubation sequence, the oropharyngeal regurgitation scenario was associated with a significantly lower CCF (79.6% vs. 85.1%, P < 0.001), compression depth (5.2 vs. 5.4 cm, P < 0.001), and first-pass success rate (35.2% vs. 79.6%, P < 0.001) and greater longest interruption duration (4.0 vs. 3.0 s, P < 0.001) than the clean airway scenario. During the second and third sequences, no significant difference was observed in the CPR quality metrics between the two scenarios. In the oropharyngeal regurgitation scenario, successful intubation was independently and significantly associated with compression depth (hazard ratio = 0.47, 95% confidence interval, 0.24-0.91), whereas none of the CPR quality metrics were related to successful intubation in the clean airway scenario.
Conclusion : Regurgitation during endotracheal intubation significantly reduces CPR quality.
Conclusion (proposition de traduction) : L'inhalation pendant l'intubation endotrachéale réduit significativement la qualité de la RCP.
Evaluation of the effectiveness and costs of inhaled methoxyflurane versus usual analgesia for prehospital injury and trauma: non-randomised clinical study.
Smith MD, Rowan E, Spaight R, Siriwardena AN. | BMC Emerg Med. 2022 Jul 7;22(1):122
DOI: https://doi.org/10.1186/s12873-022-00664-y | Télécharger l'article au format
Keywords: Ambulance; Analgesia; Emergency medical services; Methoxyflurane; Pain; Prehospital.
Introduction : We aimed to investigate clinical benefits and economic costs of inhaled methoxyflurane when used by ambulance staff for prehospital emergency patients with trauma. Comparison is to usual analgesic practice (UAP) in the UK in which patient records were selected if treatment had been with Entonox® or intravenous morphine or intravenous paracetamol.
Méthode : Over a 12-month evaluation period, verbal numerical pain scores (VNPS) were gathered from adults with moderate to severe trauma pain attended by ambulance staff trained in administering and supplied with methoxyflurane. Control VNPS were obtained from ambulance database records of UAP in similar patients for the same period. Statistical modelling enabled comparisons of methoxyflurane to UAP, where we employed an Ordered Probit panel regression model for pain, linked by observational rules to VNPS.
Résultats : Overall, 96 trained paramedics and technicians from the East Midlands Ambulance Service NHS Trust (EMAS) prepared 510 doses of methoxyflurane for administration to a total of 483 patients. Comparison data extracted from the EMAS database of UAP episodes involved: 753 patients using Entonox®, 802 patients using intravenous morphine, and 278 patients using intravenous paracetamol. Modelling results included demonstration of faster pain relief with inhaled methoxyflurane (all p-values < 0.001). Methoxyflurane's time to achieve maximum pain relief was estimated to be significantly shorter: 26.4 min (95%CI 25.0-27.8) versus Entonox® 44.4 min (95%CI 39.5-49.3); 26.5 min (95%CI 25.0-27.9) versus intravenous morphine 41.8 min (95%CI 38.9-44.7); 26.5 min (95%CI 25.1-28.0) versus intravenous paracetamol 40.8 (95%CI 34.7-46.9). Scenario analyses showed that durations spent in severe pain were significantly less for methoxyflurane. Costing scenarios showed the added benefits of methoxyflurane were achieved at higher cost, eg versus Entonox® the additional cost per treated patient was estimated to be £12.30.
Conclusion : When administered to adults with moderate or severe pain due to trauma inhaled methoxyflurane reduced pain more rapidly and to a greater extent than Entonox® and parenteral analgesics. Inclusion of inhaled methoxyflurane to the suite of prehospital analgesics provides a clinically useful addition, but one that is costlier per treated patient.
Conclusion (proposition de traduction) : Lorsqu'il est administré à des adultes souffrant de douleurs modérées ou sévères dues à un traumatisme, le méthoxyflurane inhalé réduit la douleur plus rapidement et dans une plus large mesure que l'Entonox® et les analgésiques parentéraux. L'inclusion du méthoxyflurane inhalé dans la gamme des analgésiques préhospitaliers constitue un ajout cliniquement utile, mais plus coûteux par patient traité.
Association of emergency department boarding times on hospital length of stay for patients with psychiatric illness.
Lane DJ, Roberts L, Currie S, Grimminck R, Lang E. | Emerg Med J. 2022 Jul;39(7):494-500
Keywords: emergency department; emergency department operations; psychological conditions.
Introduction : Extended periods awaiting an inpatient bed in the emergency department (ED) may exacerbate the state of patients with acute psychiatric illness, increasing the time it takes to stabilise their acute problem in hospital. Therefore, we assessed the association between boarding time and hospital length of stay for psychiatric patients.
Méthode : ED clinical records were linked to inpatient administrative records for all patients with a primary psychiatric diagnosis admitted to a Calgary, Alberta hospital between April 2014 and March 2018. The primary exposure was boarding time (admission decision to inpatient bed transfer), and primary outcome was inpatient length of stay. Confounders for this relationship, including indicators of illness severity, were selected a priori then the association was assessed using hierarchical Bayesian Poisson regression, which accounts for repeat observations of the same patient and differences between hospital sites. Changes in length of stay were measured using a rate ratio (ie, expected change in length of stay for each 1 hour increase in boarding time).
Résultats : A total of 19 212 admissions (14 261 unique patients) were included in the analysis. The average boarding time was 14 hours (range: 0-186 hours). Patients who were boarded for greater than 14 hours more frequently required a high-observation bed (14% vs 3.5%), received an antipsychotic (44% vs 14%) or received sedation (55% vs 33%) while in the ED. The probability that boarding time increased hospital length of stay (rate ratio: >1) was 92%, with a median increase for a patient boarded for 24 hours of 0.01 days.
Conclusion : Boarding in the ED was associated with a high probability of increasing the hospital length of stay for psychiatric patients; however, the absolute increase is minimal. Although slight, this signal for longer length of stay may be a sign of increased morbidity for psychiatric patients held in the ED.
Conclusion (proposition de traduction) : La durée de séjour aux urgences est associée à une probabilité élevée d'augmentation de la durée d'hospitalisation des patients psychiatriques ; toutefois, l'augmentation absolue est minime. Bien que légère, cette indication d'une durée de séjour plus longue peut être le signe d'une morbidité accrue pour les patients psychiatriques retenus aux urgences.
Associations of initial haemodynamic profiles and neurological outcomes in children with traumatic brain injury: a secondary analysis.
Yao SHW, Chong SL, James V, Lee KP, Ong GY. | Emerg Med J. 2022 Jul;39(7):527-533
Keywords: emergency care systems; emergency departments; head; paediatric emergency med; paediatric resuscitation; paediatrics; trauma.
Introduction : Initial low systolic blood pressure (SBP) in paediatric traumatic brain injury (TBI) is associated with mortality. There is limited literature on how other haemodynamic parameters including heart rate (HR); diastolic blood pressure (DBP); mean arterial pressure (MAP); and shock index, paediatric age-adjusted (SIPA) affect not only mortality but also long-term neurological outcomes in paediatric TBI. We aimed to analyse the associations of these haemodynamic variables (HR, SBP, MAP, DBP and SIPA) with mortality and long-term neurological outcomes in isolated moderate-to-severe paediatric TBI.
Méthode : This was a secondary analysis of our primary study that analysed the association of TBI-associated coagulopathy with mortality and neurological outcome in isolated, moderate-to-severe paediatric head injury. A trauma registry-based, retrospective study of children <18 years old who presented to the emergency department with isolated, moderate-to-severe TBI from January 2010 to December 2016 was conducted. The association between initial haemodynamic variables and less favourable outcomes using Glasgow Outcome Scale-Extended Paediatric) at 6 months post injury was analysed using logistic regression.
Résultats : Among 152 children analysed, initial systolic and diastolic hypotension (<5th percentile) (OR) for SBP 11.40, 95% CI 3.60 to 36.05, p<0.001; OR for DBP 15.75, 95% CI 3.09 to 80.21, p<0.001) and Glasgow Coma Scale scores <8 (OR 14.50, 95% CI 3.65 to 57.55, p<0.001) were associated with 'moderate-to-severe neurological disabilities', 'vegetative state' and 'death'. After adjusting for confounders, only SBP was significant (adjusted OR 5.68, 95% CI 1.40 to 23.08, p=0.015).
Conclusion : Initial systolic hypotension was independently associated with mortality and moderate-to-severe neurological deficits at 6 months post injury. Further work is required to understand if early correction of hypotension will improve long-term outcomes.
Conclusion (proposition de traduction) : L'hypotension systolique initiale était indépendamment associée à la mortalité et à des déficits neurologiques modérés à sévères 6 mois après la blessure. Des travaux supplémentaires sont nécessaires pour comprendre si la correction précoce de l'hypotension améliore les résultats à long terme.
Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada.
Heidet M, Hubert H, Grunau BE, Cheskes S, Baert V, Fraticelli L, Freyssenge J, Lecarpentier E, Stitt A, Tallon JM, Tazarourte K, Truong C, Vaillancourt C, Vilhelm C, Wysocki K, Christenson J, El Khoury C; Gr-ReAC and CanROC investigators. | Emerg Med J. 2022 Jul;39(7):547-553
Keywords: access to care; cardiac arrest; cardiac care; care systems; chain of survival; prehospital care.
Editorial : France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.
Conclusion : The ReACanROC network is the first Europe-North America research network on OHCA. By allowing for the first time indepth comparisons between two different EMS systems through a single, large, homogenised dataset, it aims at better exploring the variability in practices and outcomes between the countries and territories, and their broader geographic and socioeconomic predictors. The results of the first, preliminary observational analyses drawn from the ReACanROC registry will serve as scientific background for further studies on systems effectiveness, and international randomised clinical trials for new practices and organisations.
Conclusion (proposition de traduction) : Le réseau ReACanROC est le premier réseau de recherche Europe-Amérique du Nord sur les arrêts cardiaques extrahospitaliers. En permettant pour la première fois des comparaisons approfondies entre deux systèmes de SMU différents grâce à un seul grand ensemble de données homogénéisées, il vise à mieux explorer la variabilité des pratiques et des résultats entre les pays et territoires, ainsi que leurs prédicteurs géographiques et socio-économiques plus larges. Les résultats des premières analyses observationnelles préliminaires tirées du registre ReACanROC serviront de base scientifique à d'autres études sur l'efficacité des systèmes et à des essais cliniques randomisés internationaux pour de nouvelles pratiques et organisations.
Elements of Teamwork in Resuscitation: An Integrative Review.
Hosseini M, Heydari A, Reihani H, Kareshki H. | Bull Emerg Trauma. 2022 Jul;10(3):95-102
DOI: https://doi.org/10.30476/beat.2021.91963.1291 | Télécharger l'article au format
Keywords: Elements; Resuscitation; Skills; Teamwork.
Introduction : To identify the elements of teamwork in resuscitation, an integrative review and synthesize current primary studies conducted.
Méthode : PubMed, Scopus, Web of Science, and Embase, as well as Google Scholar search engine were searched from November 2015 to March 2020 to review previously published peer-reviewed studies. Out of the 5495 articles, 16 were finally included in the study. Search strategy implemented with these keywords (in the title/abstract) were (team* AND CPR) or (team* AND resuscitation). Six descriptive criteria was performed by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline to analyze the articles and a modified version of Cooper's five-stage method.
Résultats : Sixteen studies were included in this research. Twenty elements related to teamwork in resuscitation were identified by using data synthesis, then classified into four categories includes team interaction elements, leadership skills, individual elements and environmental elements. Communication, leadership, situation awareness and scene organization had the highest frequency of reviewed articles 10, 5, 4, 4, respectively.
Conclusion : The interactions between resuscitation team members and the skills of the leader and team members along with environmental elements had attracted the most attention of researchers by focusing on teamwork in resuscitation. Due to the limited number of articles related to this subject, more research is needed to reveal all the key elements of teamwork in resuscitation.
Conclusion (proposition de traduction) : Les interactions entre les membres de l'équipe de réanimation et les compétences du leader et des membres de l'équipe ainsi que les éléments environnementaux ont retenu l'attention des chercheurs en se concentrant sur le travail d'équipe en réanimation. En raison du nombre limité d'articles relatifs à ce sujet, des recherches supplémentaires sont nécessaires pour révéler tous les éléments clés du travail d'équipe en réanimation.
Red flags to screen for vertebral fracture in patients presenting with low back pain.
Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Maher CG. | Cochrane Database Syst Rev. 2022 Juli 20;(7):CD014461
DOI: https://doi.org/10.1002/14651858.CD014461 | Télécharger l'article au format
Editorial : This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:
The objective of this review is to assess the diagnostic accuracy of red flags used to screen for vertebral fracture in patients presenting with low back pain. Where possible, we will report the results of red flags separately for different types of vertebral fracture as follows.
Conclusion : Despite the inclusion of several red flags in guidelines, the usefulness of red flags to screen for serious pathology, such as fracture, continues to be debated. Several red flags endorsed by previous guidelines have poor or untested diagnostic accuracy with little information on their utility for clinical practice, and are based on evidence from individual studies.
Conclusion (proposition de traduction) : Malgré l'inclusion de plusieurs signaux d'alarme dans les recommandations, l'utilité de ces signaux pour dépister des pathologies graves, telles que les fractures, continue d'être débattue. Plusieurs drapeaux rouges approuvés par les recommandations précédentes ont une précision diagnostique faible ou non testée, avec peu d'informations sur leur utilité pour la pratique clinique, et sont basés sur des preuves provenant d'études individuelles. Traduit avec www.DeepL.com/Translator (version gratuite)
Developing and validating a checklist for assessing the performance of air ambulance services.
Jafari H, Askari R, Montazeralfaraj R, Pahlavanpoor SR, AlsadatKalantarzadeh Z. | Front Emerg Med. 2022;6(3):e32
DOI: https://doi.org/10.18502/fem.v6i3.9394 | Télécharger l'article au format
Keywords: Air Ambulances; Emergency Medical Services; Health Care Process Assessment; Validation Studies as Topic
Introduction : The purpose of this study was to develop a checklist for assessing the performance of air ambulance services.
Méthode : This is a qualitative study. The first phase involved a review of existing documentation about air emergency standards to create a checklist of the most critical factors and components affecting the performance of air ambulance services. The second phase required experts to complete a performance evaluation checklist from the previous phase. The third phase utilized the Delphi technique to validate the performance evaluation checklist for air ambulance services. The experts in this study were 24 pundits with a vested interest in the subject.
Résultats : A total of 31 items exist in the area of helipad-related facilities, 17 items in the area of process requirements for medical centers with helicopter landing areas, 15 items in the category of human resources for air ambulances, 10 items in the category of human resources for receiving or delivering patients from air ambulances to medical centers, 27 items in the area of base equipment, 17 items in the area of helicopter equipment, and requirements, 14 items in the category of technical, communication, and safety equipment for use inside the helicopter, 1o items dealing with time standards, 11 items dealing with road and urban base requirements for air ambulance operations. Experts approved two items in the area of utilizing other rescue and law enforcement agencies to assist and cooperate with air emergency flights and two items in the area of comfort for conscious patients to alleviate stress during flight.
Conclusion : A performance evaluation checklist is an effective tool for evaluating the quantity and quality of emergency helicopter services provided and measuring their performance.
Conclusion (proposition de traduction) : Une liste de contrôle pour l'évaluation des performances est un outil efficace pour évaluer la quantité et la qualité des services proposés par les services d'urgence par hélicoptère et pour mesurer leurs performances.
A randomized non-inferiority pilot study on the use of methoxyflurane (Penthrox®) for pain control in the emergency department.
Wong KY, Ki Lau JS, Chung SiuAY, Kan PG. | Hong Kong J Emerg Med. 2022 July;29(4):203–211
DOI: https://doi.org/10.1177/10249079211040695 | Télécharger l'article au format
Keywords: Methoxyflurane; ketorolac; analgesics; wounds and injuries
Introduction : Patients commonly visit the emergency department for pain after musculoskeletal injury, but the problem of oligoanalgesia is prevalent. Methoxyflurane (Penthrox®) is an inhalational analgesic for moderate to severe trauma-associated pain in stable and conscious patients. It is a fast-acting, effective analgesic that can be readily administered via a non-invasive route, making it an attractive agent for managing acute pain in the emergency departments.
Objectives: The aim was to assess the analgesic efficacy of methoxyflurane in patients with acute traumatic pain by comparing it to ketorolac, a standard analgesic treatment for moderate pain in emergency departments in Hong Kong.
Méthode : This was a single-center, open-label, randomized controlled, parallel-group, non-inferiority pilot study that enrolled adult patients with moderate trauma-associated pain in an emergency department in Hong Kong. Patients were randomized 1:1 to the methoxyflurane group or the ketorolac group. The primary outcome was the change in pain intensity measured by visual analogue scale from baseline to 5, 15, 30, and 60min after drug administration.
Résultats : Twenty patients received methoxyflurane, and twenty patients received ketorolac. There were significant reductions in pain score over 60min in both groups. The pain reduction at 5min was significantly greater for the methoxyflurane group (−13.912mm; 95% confidence interval=−20.008 to −7.817) than for the ketorolac group (−4.888mm; 95% confidence interval=−10.983 to 1.208), with the treatment effect (−9.025mm; 95% confidence interval=−17.656 to −0.393; p=0.041) demonstrating superiority of methoxyflurane. The treatment effect at 15 and 30 min demonstrated non-inferiority of methoxyflurane versus ketorolac.
Conclusion : Methoxyflurane provided non-inferior analgesia in the first 30min with a faster onset of action when compared with ketorolac in moderate traumatic pain. It can be considered a non-invasive, rapid-acting, and effective first-line alternative to currently available analgesics for traumatic pain in emergency settings.
Conclusion (proposition de traduction) : Le méthoxyflurane a procuré une analgésie non inférieure dans les 30 premières minutes, avec un début d'action plus rapide, par rapport au kétorolac dans les cas de douleur traumatique modérée. Il peut être considéré comme une alternative de première ligne non invasive, à action rapide et efficace aux analgésiques actuellement disponibles pour la douleur traumatique dans les services d'urgence.
Sedative and analgesic effects
of propofol–ketamine versus propofol–fentanyl for emergency department procedures.
Tajoddini S, Motaghi m. | Hong Kong J Emerg Med. 2022 July;29(4):212–219
DOI: https://doi.org/10.1177/1024907919893466 | Télécharger l'article au format
Keywords: Analgesia; emergency department; fentofol; ketofol; painful procedures; sedation
Introduction : To manage and reduce painful procedures in the emergency wards, procedural sedation as well as analgesia can be used. Propofol combinations are the most common short-acting intravenous sedative drugs in the field of emergency medicine.
Objectives: This research aimed to compare the effectiveness, safety, and complications of intravenous infusion of ketofol with fentofol in painful emergency procedures.
Méthode : This study was a randomized, double-blind clinical trial. Sampling was simple and used random assignment; 196 participants were randomly assigned to two groups of 98 patients each. In each group, injection was done with fentanyl– propofol or ketamine–propofol. For data gathering, pre-procedure, and procedure, modified Aldrete’s scoring checklist was used. In order to determine the levels of sedation, we used the Ramsay Sedation Scale. Data analysis was performed via SPSS Version 20 using statistical tests such as mean ± standard division, t-test, chi-square test, and analysis of variance.
Résultats : Among the participants in this study, shoulder procedure was performed more than other procedures (56.6%). The mean of recovery time was significantly different in the two groups (ketofol: 5.65±0.35 vs fentofol: 9.33±0.78); the recovery time in group B (fentofol) was longer than that in group A (ketofol) (p = 0.001). Drug complications were statistically significant in the two groups, and complications by ketofol were less than those by fentofol (p=0.001). “Hypotension and bradycardia” were observed with fentofol and “tachycardia” was observed with ketofol. The performance of these two drugs was not the same when subject to various procedures.
Conclusion : Results of this study revealed that ketofol provided better analgesia and sedation, faster recovery time, lesser complications and adverse events, and reduced bradycardia and hypotension.
Conclusion (proposition de traduction) : Les résultats de cette étude ont révélé que le kétofol procurait une meilleure analgésie et sédation, un temps de récupération plus rapide, moins de complications et d'événements indésirables, et une réduction de la bradycardie et de l'hypotension.
Paracetamol, ketorolac, and morphine in post-trauma headache in emergency department: A double blind randomized clinical trial.
Azimi Far A, Abdoli A, Poorolajal j, Salimi R. | Hong Kong J Emerg Med. 2022 July; 29(4):220–226
DOI: https://doi.org/10.1177/1024907920920747 | Télécharger l'article au format
Keywords: Paracetamol; ketorolac; morphine; post-trauma headache
Introduction : Headache is one of the most common complaints of patients after head trauma. The aim of this study was the comparison of the analgesic effects of intravenous ketorolac, morphine, and paracetamol in patients with headache following head trauma.
Méthode : This clinical trial was performed on 105 referred patients to emergency unit with headache after head trauma. Patients were randomly divided into three groups of intravenous paracetamol (15mg/kg in 100mL normal saline), intravenous ketorolac (30 mg/kg in 100 mL normal saline), and intravenous morphine (0.1 mg/kg in 100 mL normal saline). Headache severity and side effects of drugs were assessed at baseline and 15, 30, and 60 min after intervention.
Résultats : Headache severity score at baseline was similar among groups. After 15min, headache severity score in paracetamol group was significantly lower than that in morphine and ketorolac groups (3.7 vs. 4.6 and 4.5, respectively). After 30min, the score in paracetamol and ketorolac groups was significantly lower than that in morphine group (1.9 and 2.4 vs. 3.2, respectively). After 60 min, headache severity score in three groups was similar (1.6 in morphine and ketorolac groups and 1.5 in paracetamol group). The incidence of side effects in morphine group was significantly more than that in paracetamol and ketorolac groups.
Conclusion : In emergency department, intravenous paracetamol and ketorolac obtain a faster and more effective onset compared with morphine for headache after head trauma.
Conclusion (proposition de traduction) : Dans le service des urgences, le paracétamol et le kétorolac intraveineux obtiennent un effet plus rapide et plus efficace que la morphine pour les maux de tête après un traumatisme crânien.
Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial.
Russell DW, Casey JD, Gibbs KW, Ghamande S, Dargin JM, Vonderhaar DJ, Joffe AM, Khan A, Prekker ME, Brewer JM, Dutta S, Landsperger JS, White HD, Robison SW, Wozniak JM, Stempek S, Barnes CR, Krol OF, Arroliga AC, Lat T, Gandotra S, Gulati S, Bentov I, Walters AM, Dischert KM, Nonas S, Driver BE, Wang L, Lindsell CJ, Self WH, Rice TW, Janz DR, Semler MW; PREPARE II Investigators and the Pragmatic Critical Care Research Group. | JAMA. 2022 Jul 19;328(3):270-279
Introduction : Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain.
Objective: To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death.
Méthode : This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021.
Interventions: Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527).
Main outcomes and measures: The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge.
Résultats : Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, -2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, -1.8% [95% CI, -7.9% to 4.3%]; P = .55).
Conclusion : Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse.
Conclusion (proposition de traduction) : Chez les adultes gravement malades subissant une intubation trachéale, l'administration d'un bolus de liquide intraveineux par rapport à l'absence de bolus de liquide n'a pas diminué de manière significative l'incidence du collapsus cardiovasculaire.
Skin and Soft Tissue Infection Treatment and Prevention Practices by Pediatric Emergency Medicine Providers.
Mistry RD, Hogan PG, Parrish KL, Thompson RM, Fritz SA. | Pediatr Emerg Care. 2022 Jul 1;38(7):e1348-e1354
Introduction : The aim of the study was to evaluate skin and soft tissue infection (SSTI) treatment and prevention practices among pediatric emergency medicine (PEM) clinicians in the context of current clinical practice guidelines and contemporary evidence.
Méthode : This was a cross-sectional survey of PEM clinicians belonging to the American Academy of Pediatrics Section on Emergency Medicine Survey listserv. Four varying hypothetical clinical scenarios of children with SSTI were posed to respondents; subsequent items assessed SSTI treatment and prevention practices. Provider demographics were collected.
Résultats : Of 160 survey respondents, more than half stated that they would prescribe oral antibiotics for each clinical scenario, particularly for more complex presentations (small uncomplicated abscess, 51.8%; large uncomplicated abscess, 71.5%; recurrent abscess, 83.5%; febrile abscess, 90.3%; P < 0.001). Most commonly selected antibiotics were clindamycin and trimethoprim-sulfamethoxazole. Across scenarios, more than 80% selected a duration of treatment 7 days or more. Of the 121 respondents who prescribe preventive measures, 85.1% recommend hygiene measures; 52.5% would prescribe decolonization with topical antibiotic ointment and 77.5% would recommend antiseptic body washes. Half of the respondents reported that their institution has standard guidance for SSTI management.
Conclusion : Although current evidence supports adjuvant antibiotics for all drained SSTI and decolonization for the index patient and household contacts, PEM clinicians do not consistently adhere to these recommendations. In light of these findings, development and implementation of institutional guidelines are necessary to aid PEM clinicians' point-of-care decision making and improving evidence-based practice.
Conclusion (proposition de traduction) : Bien que les données probantes actuelles soutiennent l'administration d'antibiotiques en traitement adjuvant pour toutes les infections de la peau et des tissus mous drainées et la décolonisation pour le patient de référence et les contacts familiaux, les cliniciens en médecine d'urgence pédiatrique n'adhèrent pas systématiquement à ces recommandations. À la lumière de ces résultats, le développement et la mise en œuvre de directives institutionnelles sont nécessaires pour aider les cliniciens de la médecine d'urgence pédiatrique à prendre des décisions sur le lieu de soins et à améliorer la pratique fondée sur des preuves.
Variation in Prehospital Protocols for Pediatric Respiratory Distress Management in the United States.
McCans K, Varma S, Ramgopal S, Martin-Gill C, Owusu-Ansah S. | Pediatr Emerg Care. 2022 Jul 1;38(7):e1355-e1361
Introduction : This study aimed to compare statewide emergency medical services protocols for the management of pediatric respiratory distress.
Méthode : We performed a descriptive study of emergency medical services protocols for the management of pediatric respiratory distress in the United States, excluding those without model or mandatory protocols. We compared medication recommendations for specific disease processes, including asthma, croup, epiglottitis, anaphylaxis, generalized respiratory distress, intubation, and drug assisted intubation.
Résultats : Thirty-four state protocols were included. All had protocols to address the management of pediatric respiratory distress. There was high agreement in albuterol use for bronchospasm and epinephrine use in anaphylaxis. Epinephrine was recommended in all anaphylaxis protocols, 27 croup protocols (79%), and 3 epiglottitis protocols (9%). Six states (18%) called for albuterol in patients with generalized respiratory distress. Steroid recommendations and indications had variance among states; 26 states (76%) allowed steroid use in patients with asthma, 19 states (56%) recommended steroid use in anaphylaxis, and 11 (32%) recommended steroid use in croup protocols. The route for steroid administration also varied among protocols. Five states (15%) allowed continuous positive airway pressure application in pediatric patients, whereas endotracheal intubation and rapid sequence intubations had varying requirements as well as recommendations for use. Twelve (35%) listed impending or current respiratory failure as an indication, whereas other states had specific markers, such as Glasgow Coma Scale or oxygen saturation, as indications.
Conclusion : All included states had specific recommendations for the management of pediatric respiratory distress. There was consistency in recommendations for albuterol use for wheezing and epinephrine use for anaphylaxis. However, there was wide variability in other uses for epinephrine, steroid administration, continuous positive airway pressure use, and specific treatments for croup and epiglottitis. The findings of this study provide a base for important future evidence-based protocol developments and changes in prehospital pediatric respiratory distress treatment.
Conclusion (proposition de traduction) : Tous les états inclus avaient des recommandations spécifiques pour la gestion de la détresse respiratoire pédiatrique. Les recommandations concernant l'utilisation d'albutérol en cas de respiration sifflante et d'adrénaline en cas d'anaphylaxie étaient uniformes. Cependant, il y avait une grande variabilité dans les autres utilisations de l'adrénaline, l'administration de corticoïdes, l'utilisation de la pression positive continue et les traitements spécifiques du croup et de l'épiglottite. Les résultats de cette étude constituent une base pour d'importants développements futurs de protocoles fondés sur des preuves et des changements dans le traitement préhospitalier de la détresse respiratoire chez l'enfant.
Risk Factors of Serious Bacterial Infection in Previously Healthy Children Older Than 90 Days Old With Fever and Neutropenia.
Mora-Capín A, Lorente-Romero J, Hernanz-Lobo A, Rivas-García A, Vázquez-López P, Carrascosa-García P, González-Hermosa A, Mena-Huarte J, Pérez-Saez MA, Nadal G, García-de-Diego I, Marañón-Pardillo R; Research Network of the Spanish Society of Pediatric Emergencies (RISeuP-SPERG). | Pediatr Emerg Care. 2022 Jul 1;38(7):e1378-e1383
Introduction : The main objective was to determine the clinical or analytical factors that independently predict risk of serious bacterial infection (RSBI) in immunocompetent patients older than 90 days given a diagnosis of fever and for whom neutropenia was an incidental finding. The secondary objective was to describe the prevalence of serious bacterial infections (SBIs).
Méthode : This is a 3-year-long, multicenter, prospective analytical and observational study carried out at 6 pediatric emergency departments. Data for epidemiological, clinical, and analytical variables were collected.
Résultats : One hundred forty patients with febrile neutropenia (60.7% mild, 39.3% moderate to severe) were recruited. Serious bacterial infection incidence was 15.0% (95% confidence interval [CI], 9-21): 1 Invasive Bacterial Infection (Staphylococcus epidermidis bacteremia), 10 urinary tract infections, 8 pneumonias, and 2 cellulitis. Median total neutrophil counts per microliter showed no statistically significant differences (P = 0.512; 1000 [750-1200] in SBI patients vs 1100 [800-1300] in non-SBI patients). Higher RSBI was observed in patients with neutrophils less than 20% relative to total leukocytes (SBI, 15, 26.3%) than in those with neutrophils of 20% or greater (SBI, 6, 7.2%) (odds ratio, 4.6; 95% CI, 1.7-12.7). In patients with greater than 5000 leukocytes/μL, a percentage of neutrophils less than 20% was related to a greater RSBI with a trend toward statistical significance (odds ratio, 6.1; 95% CI, 0.7-51.1; P = 0.066). The clinical variables did not show a significant association with RSBI.
Conclusion : None of the clinical or analytical variables assessed were associated with the RSBI. However, according to a post hoc analysis, in patients with greater than 5000 leukocytes/μL, a neutrophil percentage less than 20% could be an independent risk factor for SBI. A thorough physical examination and basic diagnostic tests (urinalysis and chest x-ray) may help to establish a diagnosis of SBI in the vast majority of cases.
Conclusion (proposition de traduction) : Aucune des variables cliniques ou analytiques évaluées n'a été associée au risque d'infection bactérienne grave. Cependant, selon une analyse post hoc, chez les patients présentant plus de 5 000 leucocytes/μL, un pourcentage de neutrophiles inférieur à 20 % pourrait être un facteur de risque indépendant d'infection bactérienne grave. Un examen physique approfondi et des examens diagnostiques de base (analyse d'urine et radiographie pulmonaire) peuvent permettre d'établir un diagnostic d'infection bactérienne grave dans la grande majorité des cas.
Lidocaine infusions for refractory chronic migraine: a retrospective analysis.
Schwenk ES, Walter A, Torjman MC, Mukhtar S, Patel HT, Nardone B, Sun G, Thota B, Lauritsen CG, Silberstein SD. | Reg Anesth Pain Med. 2022 Jul;47(7):408-413
DOI: https://doi.org/10.1136/rapm-2021-103180 | Télécharger l'article au format
Keywords: Acute Pain; Anesthesia, Local; CHRONIC PAIN; Pain Management.
Introduction : Patients with refractory chronic migraine have poor quality of life. Intravenous infusions are indicated to rapidly 'break the cycle' of pain. Lidocaine infusions may be effective but evidence is limited.
Méthode : The records of 832 hospital admissions involving continuous multiday lidocaine infusions for migraine were reviewed. All patients met criteria for refractory chronic migraine. During hospitalization, patients received additional migraine medications including ketorolac, magnesium, dihydroergotamine, methylprednisolone, and neuroleptics. The primary outcome was change in headache pain from baseline to hospital discharge. Secondary outcomes measured at the post-discharge office visit (25-65 days after treatment) included headache pain and the number of headache days, and percentage of sustained responders. Percentage of acute responders, plasma lidocaine levels, and adverse drug effects were also determined.
Résultats : In total, 609 patient admissions met criteria. The mean age was 46±14 years; 81.1% were female. Median pain rating decreased from baseline of 7.0 (5.0-8.0) to 1.0 (0.0-3.0) at end of hospitalization (p<0.001); 87.8% of patients were acute responders. Average pain (N=261) remained below baseline at office visit 1 (5.5 (4.0-7.0); p<0.001). Forty-three percent of patients were sustained responders at 1 month. Headache days (N=266) decreased from 26.8±3.9 at baseline to 22.5±8.3 at the post-discharge office visit (p<0.001). Nausea and vomiting were the most common adverse drug effects and all were mild.
Conclusion : Lidocaine infusions may be associated with short-term and medium-term pain relief in refractory chronic migraine. Prospective studies should confirm these results.
Conclusion (proposition de traduction) : Les perfusions de lidocaïne peuvent être associées à un soulagement de la douleur à court et à moyen terme dans la migraine chronique réfractaire. Des études prospectives devraient confirmer ces résultats.
Long term risk of recurrence among survivors of sudden cardiac arrest: A systematic review and meta-analysis.
Lam TJR, Yang J, Poh JE, Ong MEH, Liu N, Yeo JW, Gräsner JT, Masuda Y, Ho AFW. | Resuscitation. 2022 Jul;176:30-41
Keywords: Meta-analysis; Out-of hospital; Recurrence; Sudden cardiac arrest.
Introduction : With a growing number of survivors of sudden cardiac arrest globally, their natural disease progression is of interest. This systematic review and meta-analysis aimed to determine the risk of recurrence after sudden cardiac arrest and its associated risk factors.
Méthode : Medline, Embase, Cochrane Library and Scopus were searched from inception to October 2021. Studies involving survivors of an out-of-hospital sudden cardiac arrest event of any non-traumatic aetiology were included. Meta-analyses of proportions using the random-effects model estimated the primary outcome of first recurrent sudden cardiac arrest incidence as well as secondary outcomes including cumulative incidence of recurrence at 1-year and incidence of second recurrence among survivors of first recurrence. A recurrent episode was defined as a sudden cardiac arrest that occurs 28 or more days after the index event. Subgroup and meta-regression analyses were conducted for predetermined variables. The Newcastle-Ottawa Scale was used to assess risk of bias for most studies.
Résultats : 35 studies of moderate to high quality comprising a total of 7186 survivors were analysed. The pooled incidence of first recurrence was 15.24% (32 studies; 95%CI, 11.01-19.95; mean follow-up time, 41.3 ± 29.3 months) and second recurrence was 35.03% (3 studies; 95%CI, 19.65-51.93; mean follow-up time, 161.1 ± 54.3 months). At 1-year, incidence of recurrence was 10.62% (3 studies; 95%CI, 0.25-30.42). Subgroup analyses found no significant difference (p = 0.204) between incidence of first recurrence published from 1975-1992 and 1993-2021, and between studies with mean follow-up time of <24 months, 24-48 months, and >48 months. On meta-regression, initial shockable rhythm increased incidence of first recurrence (p = 0.01).
Conclusion : 15.24% of sudden cardiac arrest survivors experienced a recurrence, and of these, 35.03% experienced a second recurrence. Most recurrences occurred in the first year. Initial shockable rhythm increased this risk. Despite the limitations of inter-study heterogeneity, these findings can still guide intervention and follow-up of sudden cardiac arrest survivors.
Conclusion (proposition de traduction) : 15,24 % des survivants d'une mort subite ont eu une récidive, et parmi eux, 35,03 % ont eu une deuxième récidive. La plupart des récidives sont survenues au cours de la première année. Le rythme initial choquable a augmenté ce risque. Malgré les limites de l'hétérogénéité inter-études, ces résultats peuvent néanmoins guider l'intervention et le suivi des survivants d'une mort subite.
Prevalence of intracranial hemorrhage amongst patients presenting with out-of-hospital cardiac arrest: A systematic review and meta-analysis.
Lee KY, So WZ, Ho JSY, Guo L, Shi L, Zhu Y, Tiah L, Ho AFW. | Resuscitation. 2022 Jul;176:136-149
Keywords: Computed tomography; Heart arrest; Intracranial hemorrhage; Meta-analysis; Subarachnoid hemorrhage; Sudden cardiac arrest.
Introduction : An unknown proportion of out-of-hospital cardiac arrest (OHCA) is caused by intracranial hemorrhage (ICH). There is uncertainty over the role of early head computed tomography (CT) in non-traumatic OHCA due to uncertain diagnostic yield and ways to identify high-risk patients. This study aimed to identify the prevalence of ICH in non-traumatic OHCA and possible predictors.
Méthode : PubMed, EMBASE, and the Cochrane library were searched from inception to January 2022. Data extraction and quality assessment were independently reviewed by two authors. Meta-analyses estimated the prevalence of ICH amongst OHCA patients and pre-specified subgroups and geographical settings. Subgroup analysis were used to explore potential clinical predictors.
Résultats : 23 studies involving 54,349 patients were included. The pooled ICH prevalence was 4.28% (95%CI: 3.31-5.24). Asia had a significantly larger risk ratio (RR = 3.93, P value < 0.0001) than Europe. The ICH subgroup was significantly more likely to be female (OR: 2.16; 95%CI: 1.10-4.26), and less likely to experience shockable rhythms compared with non-shockable rhythms (OR: 0.22; 95% CI: 0.04-1.22), achieve ROSC prior to arrival (OR: 0.27; 95%CI: 0.10-0.77), and survive to discharge compared to those without ICH (OR: 0.26; 95%CI: 0.11-0.59).
Conclusion : One in twenty OHCA have ICH at the time of presentation. An early head CT scan should be strongly considered after return of spontaneous circulation (ROSC), especially in patients who are female, with non-shockable rhythm and did not attain ROSC prior to arrival. These finding should influence clinical protocols to favor routine scans especially in Asia where prevalence is higher.
Conclusion (proposition de traduction) : Un arrêt cardiaque extrahospitalier sur vingt présente une hémorragie intracrânienne au moment de la présentation. Un scanner crânien précoce devrait être fortement envisagé après le retour à une activité circulatoire spontanée (RACS), en particulier chez les patients de sexe féminin, dont le rythme n'est pas choquable et qui n'ont pas présenté de retour à une activité circulatoire spontanée avant leur arrivée. Ces résultats devraient influencer les protocoles cliniques pour favoriser les scanners de routine, en particulier en Asie où la prévalence est plus élevée.
In-hospital versus out-of-hospital cardiac arrest: Characteristics and outcomes in patients admitted to intensive care after return of spontaneous circulation.
Andersson A, Arctaedius I, Cronberg T, Levin H, Nielsen N, Friberg H, Lybeck A. | Resuscitation. 2022 Jul;176:1-8
DOI: https://doi.org/10.1016/j.resuscitation.2022.04.023 | Télécharger l'article au format
Keywords: Cardiac arrest; In-hospital cardiac arrest, Out-of-hospital cardiac arrest; Neurological outcome; Post Cardiac Arrest Care; Survival.
Introduction : Cardiac arrest is characterized depending on location as in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). Strategies for Post Cardiac Arrest Care were developed based on evidence from OHCA. The aim of this study was to compare characteristics and outcomes in patients admitted to intensive care after IHCA and OHCA.
Méthode : A retrospective multicenter observational study of adult survivors of cardiac arrest admitted to intensive care in southern Sweden between 2014-2018. Data was collected from registries and medical notes. The primary outcome was neurological outcome according to the Cerebral Performance Category (CPC) scale at 2-6 months.
Résultats : 799 patients were included, 245 IHCA and 554 OHCA. IHCA patients were older, less frequently male and less frequently without comorbidity. In IHCA the first recorded rhythm was more often non-shockable, all delay-times (ROSC, no-flow, low-flow, time to advanced life support) were shorter and a cardiac cause of the arrest was less common. Good long-term neurological outcome was more common after IHCA than OHCA. In multivariable analysis, witnessed arrest, age, shorter arrest duration (no-flow and low-flow times), low lactate, shockable rhythm, and a cardiac cause were all independent predictors of good long-term neurological outcome whereas location of arrest (IHCA vs OHCA) was not.
Conclusion : In patients admitted to intensive care after cardiac arrest, patients who suffered IHCA vs OHCA differed in demographics, co-morbidities, cardiac arrest characteristics and outcomes. In multivariable analyses, cardiac arrest characteristics were independent predictors of outcome, whereas location of arrest (IHCA vs OHCA) was not.
Conclusion (proposition de traduction) : Chez les patients admis en soins intensifs après un arrêt cardiaque, les patients ayant subi un arrêt cardiaque à l'hôpital et ceux ayant subi un arrêt cardiaque en dehors de l'hôpital diffèrent en termes de démographie, de comorbidités, de caractéristiques de l'arrêt cardiaque et de résultats. Dans les analyses multivariables, les caractéristiques de l'arrêt cardiaque étaient des prédicteurs indépendants de l'issue, alors que le lieu de l'arrêt (arrêt cardiaque hospitalier ou extrahospitalier) ne l'était pas.
Pre-hospital airway management and survival outcomes after paediatric out-of-hospital cardiac arrests.
Tham LP, Fook-Chong S, Binte Ahmad NS, Ho AF, Tanaka H, Shin SD, Ko PC, Wong KD, Jirapong S, Rao GVR, Cai W, Al Qahtani S, Ong MEH; Pan-Asian Resuscitation Outcomes Study Clinical Research Network. | Resuscitation. 2022 Jul;176:9-18
Keywords: Advanced airway; Advanced airway management; Bag-valve-mask ventilation; Emergency Medical Service; Endotracheal intubation; Out-of-hospital cardiac arrests; Paediatric; Prehospital; Prehospital airway management; Supraglottic airway; Survival outcomes.
Introduction : Paediatric out-of-hospital cardiac arrest (OHCA) results in high mortality and poor neurological outcomes. We conducted this study to describe and compare the effects of pre-hospital airway management on survival outcomes for paediatric OHCA in the Asia-pacific region.
Méthode : We performed a retrospective analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data from January 2009 to June 2018. PAROS is a prospective, observational, multi-centre cohort study from eleven countries. The primary outcomes were one-month survival and survival with favourable neurological status, defined as Cerebral Performance Category1 or 2. We performed multivariate analyses of the unmatched and propensity matched cohort.
Résultats : We included 3131 patients less than 18 years in the study. 2679 (85.6%) children received bag-valve-mask (BVM) ventilations, 81 (2.6%) endotracheal intubations (ETI) and 371 (11.8%) supraglottic airways (SGA). 792 patients underwent propensity score matching. In the matched cohort, advanced airway management (AAM: SGA and ETI) when compared with BVM group was associated with decreased one-month survival [AAM: 28/396 (7.1%) versus BVM: 55/396 (13.9%); adjusted odds ratio (aOR), 0.46 (95% CI, 0.29 - 0.75); p = 0.002] and survival with favourable neurological status [AAM: 8/396 (2.0%) versus BVM: 31/396 (7.8%); aOR, 0.22 (95% CI, 0.10 - 0.50); p < 0.001]. For SGA group, we observed less 1-month survival [SGA: 24/337 (7.1%) versus BVM: 52/337 (15.4%); aOR, 0.41 (95 %CI, 0.25-0.69), p = 0.001] and survival with favourable neurological status.
Conclusion : In children with OHCA in the Asia-Pacific region, pre-hospital AAM was associated with decreased one-month survival and less favourable neurological status.
Conclusion (proposition de traduction) : Chez les enfants victimes d'un arrêt cardiaque extrahospitalier dans la région Asie-Pacifique, la gestion préhospitalière avancée des voies aériennes était associée à une diminution de la survie à un mois et à un état neurologique moins favorable.
Functionality of registered automated external defibrillators.
Jespersen SS, Kjoelbye JS, Christensen HC, Andelius L, Gregers MCT, Torp-Pedersen C, Hansen CM, Folke F. | Resuscitation. 2022 Jul;176:58-63
DOI: https://doi.org/10.1016/j.resuscitation.2022.05.013 | Télécharger l'article au format
Keywords: Automated external defibrillator; Functionality; Out-of-hospital cardiac arrest.
Introduction : Little is known about automated external defibrillator (AED) functionality in real-life settings. We aimed to assess the functionality of all registered AEDs in a geographically selected area and calculate the proportion of historical out-of-hospital cardiac arrests (OHCAs) covered by non-functioning AEDs.
Méthode : In this cross-sectional study we inspected all registered and available AEDs on the island of Bornholm in Denmark. We collected information on battery status (determined by AED self-test) and electrode status, as well as AED availability. We identified all historical OHCAs registered with the Danish Cardiac Arrest Registry on Bornholm during 2016-2019 and calculated the proportion of OHCAs covered by an AED (regardless of functionality status) within ≤100, ≤750, and ≤1800 meters and the proportion of OHCAs covered by non-functioning AEDs.
Résultats : Of 211 registered AEDs, 181 (81.9%) were publicly accessible and functional. The remaining 40 (18.1%) were not functional, primarily due to expired electrodes (42.5%, n = 17), obstacles to AED retrieval (20.0%, n = 8) or failed self-tests (17.5%, n = 7). Of 197 historical OHCAs, non-functional AEDs resulted in an OHCA coverage loss of 5.6%, 4.1% and 1.0 % for ≤100 m, ≤750 m and ≤1800 m, respectively.
Conclusion : Almost one-fifth of all registered and publicly available AEDs were not functional, primarily due to expired electrodes, failed self-tests or obstacles to retrieving AEDs. One in twenty historical OHCA was covered by a non-functional AED. Although general AED functionality was high, this finding underlines the importance of regular AED maintenance.
Conclusion (proposition de traduction) : Près d'un cinquième de tous les défibrillateurs automatiques externes (DAE) enregistrés et accessibles au public n'étaient pas fonctionnels, principalement en raison de la date d'expiration des électrodes, de l'échec des autotests ou d'obstacles à la récupération des DAE. Un arrêt cardiaque extrahospitalier historique sur vingt a été couvert par un DAE non fonctionnel. Bien que la fonctionnalité générale des DAE soit élevée, ce résultat souligne l'importance d'un entretien régulier des DAE.
Simulation-based randomized trial of medical emergency cognitive aids.
Sellmann T, Alchab S, Wetzchewald D, Meyer J, Rassaf T, Thal SC, Burisch C, Marsch S, Breuckmann F. | Scand J Trauma Resusc Emerg Med. 2022 Jul 11;30(1):45.
DOI: https://doi.org/10.1186/s13049-022-01028-y | Télécharger l'article au format
Keywords: CPR; Cognitive aid; Medical education; Patient care; Patient safety; Simulation.
Introduction : Medical emergencies are complex and stressful, especially for the young and inexperienced. Cognitive aids (CA) have been shown to facilitate management of simulated medical emergencies by experienced teams. In this randomized trial we evaluated guideline adherence and treatment efficacy in simulated medical emergencies managed by residents with and without CA.
Méthode : Physicians attending educational courses executed simulated medical emergencies. Teams were randomly assigned to manage emergencies with or without CA. Primary outcome was risk reduction of essential working steps. Secondary outcomes included prior experience in emergency medicine and CA, perceptions of usefulness, clinical relevance, acceptability, and accuracy in CA selection. Participants were grouped as "medical" (internal medicine and neurology) and "perioperative" (anesthesia and surgery) regarding their specialty. The study was designed as a prospective randomized single-blind study that was approved by the ethical committee of the University Duisburg-Essen (19-8966-BO).
Résultats : Eighty teams participated in 240 simulated medical emergencies. Cognitive aid usage led to 9% absolute and 15% relative risk reduction. Per protocol analysis showed 17% absolute and 28% relative risk reduction. Wrong CA were used in 4%. Cognitive aids were judged as helpful by 94% of the participants. Teams performed significantly better when emergency CA were available (p < 0.05 for successful completion of critical work steps). Stress reduction using CA was more likely in "medical" than in "perioperative" subspecialties (3.7 ± 1.2 vs. 2.9 ± 1.2, p < 0.05).
Conclusion : In a high-fidelity simulation study, CA usage was associated with significant reduction of incorrect working steps in medical emergencies management and was characterized by high acceptance. These findings suggest that CA for medical emergencies may have the potential to improve emergency care.
Conclusion (proposition de traduction) : Dans une étude de simulation haute-fidélité, l'utilisation d'aides cognitives a été associée à une réduction significative des étapes de travail incorrectes dans la gestion des urgences médicales et a été caractérisée par une acceptation élevée. Ces résultats suggèrent que les aides cognitives pour les urgences médicales pourraient avoir le potentiel d'améliorer les soins d'urgence.
Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM).
Price J, Lachowycz K, Steel A, Moncur L, Major R, Barnard EBG. | Scand J Trauma Resusc Emerg Med. 2022 Jul 8;30(1):44
DOI: https://doi.org/10.1186/s13049-022-01032-2 | Télécharger l'article au format
Keywords: HEMS; Intubation; PHEA; Pre hospital care; RSI.
Introduction : Pre hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic-termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM.
Méthode : A retrospective observational study of consecutive trauma patients ≥ 16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015-2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher's exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95% CI)), p value. The study design complied with the STROBE (Strengthening The Reporting of Observational studies in Epidemiology) reporting guidelines.
Résultats : In the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥ 16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28-63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs-90.2% and 87.4% respectively, OR 1.3 (95% CI 0.7-2.5), p = 0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt.
Conclusion : In an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.
Conclusion (proposition de traduction) : Dans un contexte de "modèle d'opérateur interchangeable", nous avons démontré un succès d'intubation de 100 % chez des patients adultes traumatisés bénéficiant d'une anesthésie d'urgence préhospitalière. Il n'y avait pas de différence significative dans la réussite de l'intubation au premier essai entre les médecins et les paramédicaux de soins intensifs.
2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association.
Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC 3rd, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS; American Heart Association/American Stroke Association. | Stroke. 2022 Jul;53(7):e282-e361
DOI: https://doi.org/10.1161/str.0000000000000407 | Télécharger l'article au format
Clinical Statement and Guideline
Editorial : Since 1990, the American Heart Association (AHA)/American Stroke Association (ASA) has translated scientific evidence into clinical practice guidelines with recommendations to improve cerebrovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cerebrovascular care. The AHA/ASA sponsors the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts.
Conclusion : TOP 10 TAKE-HOME MESSAGES FOR THE MANAGEMENT OF PATIENTS WITH SPONTANEOUS INTRACEREBRAL HEMORRHAGE GUIDELINE
1. The organization of health care systems is increasingly recognized as a key component of optimal stroke care. This guideline recommends development of regional systems that provide initial intracerebral hemorrhage (ICH) care and the capacity, when appropriate, for rapid transfer to facilities with neurocritical care and neurosurgical capabilities.
Conclusion (proposition de traduction) : 10 PRINCIPAUX MESSAGES À RETENIR SUR LA RECOMMANDATION SUR LA PRISE EN CHARGE DES PATIENTS SOUFFRANT D'HÉMORRAGIE INTRACÉRÉBRALE SPONTANÉE
1. :L'organisation des systèmes de soins de santé est de plus en plus reconnue comme un élément clé de la prise en charge optimale de l'AVC. Cette recommandation suggère le développement de systèmes régionaux qui fournissent des soins initiaux pour l'hémorragie intracérébrale (HIC) et la capacité, le cas échéant, d'un transfert rapide vers des établissements ayant des capacités de soins neurocritiques et neurochirurgicaux.
Impact of video laryngoscope shape on first-attempt success during non-supine emergency department intubations.
Nikolla DA, Carlson JN, Jimenez Stuart PM, Asar I, April MD, Kaji AH, Brown CA 3rd. | Am J Emerg Med. 2022 Jul;57:47-53
DOI: https://doi.org/10.1016/j.ajem.2022.04.024 | Télécharger l'article au format
Keywords: Endotracheal intubation; Ramped position; Video laryngoscopy.
Introduction : Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL).
Méthode : We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects.
Résultats : Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events.
Conclusion : Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.
Conclusion (proposition de traduction) : Les vidéolaryngoscopes hyperangulés et à géométrie standard ont eu un succès similaire lors de la première tentative d'intubation en ramped position et en position relevée aux urgences.
The role of a noninvasive index 'Spo2/ Fio2' in predicting mortality among patients with COVID-19 pneumonia.
Satici MO, Islam MM, Satici C, Uygun CN, Ademoglu E, Altunok İ, Aksel G, Eroglu SE. | Am J Emerg Med. 2022 Jul;57:54-59
DOI: https://doi.org/10.1016/j.ajem.2022.04.036 | Télécharger l'article au format
Keywords: 30 day mortality; COVID-19 pneumonia; Pneumonia risk scores; SpO(2)/FiO(2).
Introduction : Noninvasive risk assessment is crucial in patients with COVID-19 in emergency department. Since limited data is known about the role of noninvasive parameters, we aimed to evaluate the role of a noninvasive parameter 'SpO2/FiO2' in independently predicting 30-day mortality in patients with COVID-19 and its prognostic utility in combination with a noninvasive score 'CRB-65'.
Méthode : A retrospective study was performed in a tertiary training and research hospital, which included 272 patients with COVID-19 pneumonia diagnosed with polymerase chain reaction in emergency department. Data on characteristics, vital signs, and laboratory parameters were recorded from electronic medical records. The primary outcome of the study was 30-day mortality, and we assessed the discriminative ability of SpO2/FiO2 in predicting mortality in patients with COVID-19 pneumonia and its prognostic utility in combination with conventional pneumonia risk assessment scores.
Résultats : Multivariate analysis revealed that only SpO2/FiO2 level was found to be an independent parameter associated with 30-day mortality (OR:0.98, 95% CI: 0.98-0.99, p = 0.003). PSI and CURB-65 were found to be better scores than CRB-65 in predicting 30-day mortality (AUC: 0.79 vs 0.72, p = 0.04; AUC: 0.76 vs 0.72, p = 0.01 respectively). Both SpO2/FiO2 combined with CRB-65 and SpO2/FiO2 combined with CURB-65 have good discriminative ability and seemed to be more favorable than PSI in predicting 30-days mortality (AUC: 0.83 vs 0.75; AUC: 0.84 vs 0.75), however no significant difference was found (p = 0.21 and p = 0.06, respectively).
Conclusion : SpO2/FiO2 is a promising index in predicting mortality. Addition of SpO2/FiO2 to CRB-65 improved the role of CRB-65 alone, however it performed similar to PSI. The combined noninvasive model of SpO2/FiO2 and CRB-65 may help physicians quickly stratify COVID-19 patients on admission, which is expected to be particularly important in hospitals still stressed by pandemic volumes.
Conclusion (proposition de traduction) : La SpO2/FiO2 est un indice prometteur pour prédire la mortalité. L'ajout de SpO2/FiO2 au CRB-65 a amélioré le rôle du CRB-65 seul, mais ses performances sont similaires à celles du Pneumonia Severity Score (PSI). Le modèle non invasif combiné de la SpO2/FiO2 et du CRB-65 peut aider les médecins à stratifier rapidement les patients COVID-19 à l'admission, ce qui devrait être particulièrement important dans les hôpitaux encore stressés par les volumes pandémiques.
Outcome of cardiopulmonary resuscitation with different ventilation modes in adults: A meta-analysis.
Tang Y, Sun M, Zhu A. | Am J Emerg Med. 2022 Jul;57:60-69
DOI: https://doi.org/10.1016/j.ajem.2022.04.027 | Télécharger l'article au format
Keywords: Adult; Cardiopulmonary resuscitation; Meta-analysis; Outcome; Ventilation modes.
Introduction : The optimal airway management strategy for cardiac arrest remains unclear. This study aimed to compare the effects of different initial airway interventions on improving clinical outcomes based on the 2010 cardiopulmonary resuscitation (CPR) guidelines and later.
Méthode : We searched PubMed, EMBASE, and the Cochrane Library for CPR articles tailored to each database from October 19, 2010, to July 31, 2021, to compare endotracheal intubation (ETI), supraglottic airway (SGA), or bag-valve-mask ventilation (BMV). The initial results and long-term results were investigated by meta-analysis.
Résultats : Twenty-five articles (n = 196,486) were included. The ROSC rate in the ETI group (ES = 0.49, 95% CI: 0.38-0.59) was significantly higher than that in the SGA group (ES = 0.27, 95% CI: 0.20-0.34) and BMV group (ES = 0.24, 95% CI: 0.17-0.31). The rate of ROSC upon admission to the hospital in the ETI group (ES = 0.27, 95% CI: 0.13-0.42) was significantly higher than that in the SGA group (ES = 0.18, 95% CI: 0.13-0.23) and BMV group (ES = 0.16, 95% CI: 0.10-0.22). Compared with the BMV group (ES = 0.09, 95% CI: 0.04-0.14) and the SGA group (ES = 0.08, 95% CI: 0.05-0.10), the ETI group (ES = 0.14, 95% CI: 0.10-0.17) had a higher discharge rate, but all of the groups had the same neurological outcome (ETI group [ES = 0.06, 95% CI: 0.04-0.08], BMV group [ES = 0.05, 95% CI: 0.03-0.08] and SGA group [ES = 0.04, 95% CI: 0.03-0.05]).
Conclusion : Opening the airway is significantly associated with improved clinical outcomes, and the findings suggest that effective ETI based on mask ventilation should be implemented as early as possible once the patient has experienced cardiac arrest.
Conclusion (proposition de traduction) : L'ouverture des voies aériennes est significativement associée à l'amélioration des résultats cliniques. Les résultats suggèrent qu'une intubation endotrachéale efficace basée sur une ventilation au masque devrait être mise en œuvre le plus tôt possible une fois que le patient a subi un arrêt cardiaque.
High risk and low prevalence diseases: Adult epiglottitis.
Bridwell RE, Koyfman A, Long B. | Am J Emerg Med. 2022 Jul;57:14-20
DOI: https://doi.org/10.1016/j.ajem.2022.04.018 | Télécharger l'article au format
Keywords: Airway; Dysphagia; Epiglottitis; Odynophagia; Otolaryngology; Supraglottitis.
Introduction : Adult epiglottitis is a serious condition that carries with it a high rate of morbidity and even mortality due to airway occlusion.
Méthode : This review highlights the pearls and pitfalls of epiglottitis in adult patients, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence.
Résultats : Epiglottitis is a life-threatening emergency that occurs more commonly in adults in the current medical era with vaccinations. Children present more commonly with acute respiratory distress and fever, while adults present most commonly with severe dysphagia in a subacute manner. Other symptoms may include drooling, muffled voice, and dyspnea. Streptococcus and Staphylococcus bacteria are the most common etiologies, but others include viral, fungal, caustic, thermal injuries, and autoimmune. Lateral neck radiographs assist in diagnosis, but they may be falsely negative. Visualization of the epiglottis is the key to diagnosis. Airway assessment and management are paramount, which has transitioned from direct laryngoscopy to flexible intubating endoscopy and video laryngoscopy with assistance from anesthesia and/or otolaryngology if available. Along with airway assessment, antibiotics should be administered. Corticosteroids and nebulized epinephrine are controversial but should be considered. Patients should be admitted to the intensive care setting for close airway observation or ventilatory management if intubated.
Conclusion : An understanding of epiglottitis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Conclusion (proposition de traduction) : Une bonne compréhension de l'épiglottite peut aider les urgentistes à diagnostiquer et à gérer cette maladie potentiellement mortelle.
High risk and low prevalence diseases: Tubo-ovarian abscess.
Bridwell RE, Koyfman A, Long B. | Am J Emerg Med. 2022 Jul;57:70-75
DOI: https://doi.org/10.1016/j.ajem.2022.04.026 | Télécharger l'article au format
Keywords: Gynecology; Infectious diseases; Pelvic inflammatory disease; Tubo-ovarian abscess.
Introduction : Tubo-ovarian abscess (TOA) is a rare but serious condition that carries with it a high rate of morbidity and even mortality.
Méthode : This review highlights the pearls and pitfalls of TOA, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence.
Résultats : TOA is associated with pelvic inflammatory disease (PID) as well as intrauterine devices, uterine procedures, multiple sexual partners, diabetes mellitus, and immunocompromised states. While usually arising from a gynecologic infection, TOA can be associated with a gastrointestinal source. History and physical examination are limited, demonstrating predominantly lower abdominal pain, but a minority of patients will present with vaginal symptoms. Half of patients will exhibit systemic illness to include fever, nausea, and vomiting. Laboratory evaluation may reveal elevations in white blood cell count and other inflammatory markers. Transvaginal ultrasound and computed tomography (CT) may be utilized for diagnosis, though CT has higher sensitivity and can differentiate this disease from similarly presenting gastrointestinal pathology. Initial medical management includes antibiotics. Surgical intervention is indicated in those who fail initial medical therapy, which is more likely in those with bilateral abscesses, large abscesses, and older patients.
Conclusion : An understanding of TOA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Conclusion (proposition de traduction) : Une bonne compréhension de l'abcès tubo-ovarien peut aider les cliniciens des urgences à diagnostiquer et à gérer cette maladie potentiellement mortelle.
Clinical update on COVID-19 for the emergency clinician: Cardiac arrest in the out-of-hospital and in-hospital settings.
Brady WJ, Chavez S, Gottlieb M, Liang SY, Carius B, Koyfman A, Long B. | Am J Emerg Med. 2022 Jul;57:114-123
DOI: https://doi.org/10.1016/j.ajem.2022.04.031 | Télécharger l'article au format
Keywords: COVID-19; COVID-19 infection; Cardiac arrest; Coronavirus-2019; Resuscitation.
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. Its impact on the health and welfare of the human population is significant; its impact on the delivery of healthcare is also considerable.
Méthode : This article is another paper in a series addressing COVID-19-related updates to emergency clinicians on the management of COVID-19 patients with cardiac arrest.
Résultats : COVID-19 has resulted in significant morbidity and mortality worldwide. From a global perspective, as of February 23, 2022, 435 million infections have been noted with 5.9 million deaths (1.4%). Current data suggest an increase in the occurrence of cardiac arrest, both in the outpatient and inpatient settings, with corresponding reductions in most survival metrics. The frequency of out-of-hospital lay provider initial care has decreased while non-shockable initial cardiac arrest rhythms have increased. While many interventions, including chest compressions, are aerosol-generating procedures, the risk of contagion to healthcare personnel is low, assuming appropriate personal protective equipment is used; vaccination with boosting provides further protection against contagion for the healthcare personnel involved in cardiac arrest resuscitation. The burden of the COVID-19 pandemic on the delivery of cardiac arrest care is considerable and, despite multiple efforts, has adversely impacted the chain of survival.
Conclusion : This review provides a focused update of cardiac arrest in the setting of COVID-19 for emergency clinicians.
Conclusion (proposition de traduction) : Cette revue fournit une mise à jour ciblée de l'arrêt cardiaque dans le cadre de COVID-19 pour les cliniciens d'urgence.
Analgesic Efficacy of Oral Aspirin/Ketamine Combination for Management of Acute Musculoskeletal Pain in the Emergency Department - A Proof of Concept Pilot Study.
Davis A, Fassassi C, Dove D, Drapkin J, Likourezos A, Gohel A, Favale P, Hossain R, Butt M, Gerges L, Motov S. | J Emerg Med. 2022 Jun;62(6):750-759
Keywords: VTS-Aspirin; analgesia; emergency department; ketamine; musculoskeletal pain.
Introduction : Musculoskeletal pain (MSK) affects one out of three adults and is the most common source of significant long-term pain, physical disability, and under-treatment in the emergency department (ED).
Objective: We aimed to assess the analgesic efficacy of a combination of oral VTS-Aspirin® (Vitalis Analgesics, New York, NY) and ketamine in managing acute MSK pain in adult ED patients.
Méthode : This was a prospective, proof-of-concept, single-arm, pilot study evaluating the analgesic efficacy of a single dose of oral combination of VTS-Aspirin and ketamine in adult ED patients with acute moderate-to-severe MSK pain. The primary outcome included the difference in pain scores on an 11-point numeric pain rating scale at 60 min. Secondary outcomes included the need for rescue analgesia, the occurrence of adverse events at 60 min, and a change in pain scores at 120 min.
Résultats : We enrolled 25 subjects in the study. The mean baseline pain score was 8.6 and the mean pain score at 60 min decreased to 4.8. The oral ketamine dose ranged from 24 mg to 50 mg, with a mean dose of 37.8 mg. No clinically concerning changes in vital signs were noted. No serious adverse events occurred in any of the subjects. Majority of adverse effects were transient and weak in intensity.
Conclusion : We demonstrated that administration of an oral combination of VTS-Aspirin and ketamine to adult ED patients with acute MSK pain resulted in clinically significant pain relief in 80% of enrolled subjects.
Conclusion (proposition de traduction) : Nous avons démontré que l'administration d'une combinaison orale de VTS-Aspirine (Vitalis Analgesics, New York, NY) et de kétamine à des patients adultes des urgences souffrant de douleurs musculo-squelettiques aiguës a entraîné un soulagement cliniquement significatif de la douleur chez 80 % des sujets inscrits.
Do not forget the platelets: The independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients.
Dorken Gallastegi A, Naar L, Gaitanidis A, Gebran A, Nederpelt CJ, Parks JJ, Hwabejire JO, Fawley J, Mendoza AE, Saillant NN, Fagenholz PJ, Velmahos GC, Kaafarani HMA. | J Trauma Acute Care Surg. 2022 Jul 1;93(1):21-29
022 EAST PODIUM PAPER
Introduction : Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion.
Méthode : Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality.
Résultats : A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT >2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP >2 (1,160 [12.6%]) (p < 0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24]).
Conclusion : Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement.
Conclusion (proposition de traduction) : Les patients traumatisés recevant une transfusion massive ont significativement plus souvent un ratio de transfusion de plaquettes déséquilibré que de plasma frais congelé déséquilibré. L'impact du ratio de transfusion de plaquettes non équilibrées sur la mortalité à 24 heures est indépendant et potentiellement plus prononcé que celui du ration de transfusion de plasma frais congelé déséquilibré, ce qui justifie de sérieux efforts d'amélioration au niveau du système.
Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage.
Deeb AP, Hoteit L, Li S, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL, Brown JB. | J Trauma Acute Care Surg. 2022 Jul 1;93(1):52-58
2022 EAST PODIUM PAPER
Introduction : Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage.
Méthode : We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders.
Résultats : A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02).
Conclusion : For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients.
Conclusion (proposition de traduction) : Chez les patients blessés présentant un risque hémorragique, la transfusion préhospitalière de concentré de globules rouges + acide tranexamique est associée à une réduction de la mortalité à 30 jours. L'utilisation de la transfusion de concentré de globules rouges seule était associée à une réduction de la mortalité précoce. La synergie potentielle n'est apparue qu'au niveau de la mortalité à plus long terme et des travaux supplémentaires pour étudier les mécanismes de ce bénéfice thérapeutique sont nécessaires pour optimiser la réanimation préhospitalière des patients traumatisés.
Tranexamic acid is not inferior to placebo with respect to adverse events in suspected traumatic brain injury patients not in shock with a normal head computed tomography scan: A retrospective study of a randomized trial.
Harmer JW, Dewey EN, Meier EN, Rowell SE, Schreiber MA. | J Trauma Acute Care Surg. 2022 Jul 1;93(1):98-105Harmer JW,
2022 EAST QUICK SHOT
Introduction : A 2-g bolus of tranexamic acid (TXA) has been shown to reduce 28-day mortality in a randomized controlled trial. This study investigates whether out-of-hospital TXA use is associated with adverse events or unfavorable outcomes in suspected traumatic brain injury (TBI) when intracranial hemorrhage (ICH) is absent on initial computed tomography.
Méthode : This study used data from a 2015 to 2017, multicenter, randomized trial studying the effect of the following TXA doses on moderate to severe TBI: 2-g bolus, 1-g bolus plus 1-g infusion over 8 hours, and a placebo bolus with placebo infusion. Of the 966 participants enrolled, 395 with an initial computed tomography negative for ICH were included in this analysis. Fifteen adverse events (28-day incidence) were studied: myocardial infarction, deep vein thrombosis, seizure, pulmonary embolism, acute respiratory distress syndrome, cardiac failure, liver failure, renal failure, cerebrovascular accident, cardiac arrest, cerebral vasospasm, "any thromboembolism," hypernatremia, acute kidney injury, and infection. Other unfavorable outcomes analyzed include mortality at 28 days and 6 months, Glasgow Outcome Scale-Extended score of ≤4 at discharge and 6 months, intensive care unit-free days, ventilator-free days, hospital-free days, and combined unfavorable outcomes. In both study drug groups, the incidence of dichotomous outcomes and quantity of ordinal outcomes were compared with placebo.
Résultats : No statistically significant increase in adverse events or unfavorable outcomes was found between either TXA dosing regimen and placebo. Demographics and injury scores were not statistically different other than two methods of injury, which were overrepresented in the 1-g TXA bolus plus 1-g TXA infusion.
Conclusion : Administration of either a 2-g TXA bolus or a 1-g TXA bolus plus 1-g TXA 8-hour infusion in suspected TBIs without ICH is not associated with increased adverse events or unfavorable outcomes. Because the out-of-hospital 2-g bolus is associated with a mortality benefit, it should be administered in suspected TBI.
Conclusion (proposition de traduction) : L'administration d'un bolus d'acide tranexamique de 2 g ou d'un bolus d'acide tranexamique de 1 g plus une perfusion de 8 heures d'acide tranexamique de 1 g chez des patients suspectés d'avoir subi un traumatisme crânien en l'absence d'hémorragie intracrânienne au scanner initial, sans hémorragie intracrânienne, n'est pas associée à une augmentation des événements indésirables ou à des résultats négatifs. Comme le bolus de 2 g administré hors de l'hôpital est associé à un avantage en termes de mortalité, il devrait être administré en cas de suspicion de lésion cérébrale traumatique en l'absence d'hémorragie intracrânienne à la tomodensitométrie initiale.
Kahn SR, de Wit K. | N Engl J Med. 2022 Jul 7;387(1):45-57
Editorial : Pulmonary embolism occurs when embolic venous thrombi are caught within the branching lung vasculature. These thrombi often develop within the leg or pelvic veins, and approximately half of all deep-vein thrombi embolize to the lungs. The annual incidence of pulmonary embolism worldwide is approximately 1 in 1000 persons. Although almost 20% of patients who are treated for pulmonary embolism dies within 90 days, pulmonary embolism is not commonly the cause of death because it frequently coexists with other serious conditions, such as cancer, sepsis, or illness leading to hospitalization, or with other events, such as surgeries. The true mortality associated with undiagnosed pulmonary embolism is estimated to be less than 5%, but recovery from pulmonary embolism is associated with complications such as bleeding due to anticoagulant treatment, recurrent venous thromboembolism, chronic thromboembolic pulmonary hypertension, and long-term psychological distress. Approximately half the patients who receive a diagnosis of pulmonary embolism have functional and exercise limitations 1 year later (known as post–pulmonary-embolism syndrome), and the health-related quality of life for patients with a history of pulmonary embolism is diminished as compared with that of matched controls. Therefore, the timely diagnosis and expert management of pulmonary embolism are important.
Conclusion : The patient with breathlessness described in the vignette was estimated to have greater than a 15% likelihood of pulmonary embolism. In the context of the patient’s low Wells score for pulmonary embolism, d-dimer testing was warranted to guide the need for imaging; CT is indicated, given the d-dimer level of more than 1000 ng per milliliter. Under the presumption that the patient’s CT scan confirms pulmonary embolism and shows normal right-ventricle dimensions, he would be classified as having low-risk pulmonary embolism, given his normal troponin level. Treatment with a direct oral anticoagulant should be started promptly, and the patient should be given information about the pulmonary embolism diagnosis. In the absence of contraindications to treatment on an outpatient basis (no Hestia criteria present), the patient can be discharged directly from the emergency department with prompt clinic follow-up. We would recommend that he undergo cancer screening appropriate for his age and personal risk. After the patient receives 3 to 6 months of therapy with a direct oral anticoagulant administered at a treatment-level dose, in the absence of an increased bleeding risk and considering his preferences, we would recommend switching to a low-dose direct oral anticoagulant on a longterm basis for secondary prevention.
Conclusion (proposition de traduction) : On a estimé que le patient souffrant d'essoufflement décrit dans la vignette avait une probabilité d'embolie pulmonaire supérieure à 15 %. Dans le contexte du faible score de Wells pour l'embolie pulmonaire du patient, le test des d-dimères était justifié pour guider le besoin d'imagerie ; la tomodensitométrie est indiquée, étant donné le niveau de d-dimères de plus de 1000 ng par millilitre. En supposant que le scanner du patient confirme l'embolie pulmonaire et montre des dimensions normales du ventricule droit, il serait classé comme ayant un faible risque d'embolie pulmonaire, étant donné son taux normal de troponine. Un traitement par anticoagulant oral direct doit être instauré rapidement et le patient doit être informé du diagnostic d'embolie pulmonaire. En l'absence de contre-indications au traitement en ambulatoire (pas de critères Hestia présents), le patient peut sortir directement du service des urgences avec un suivi clinique rapide. Nous lui recommandons de se soumettre à un dépistage du cancer adapté à son âge et à son risque personnel. Après que le patient ait reçu un traitement de 3 à 6 mois avec un anticoagulant oral direct administré à une dose équivalente à celle du traitement, en l'absence d'une augmentation du risque de saignement et compte tenu de ses préférences, nous recommandons de passer à un anticoagulant oral direct à faible dose à long terme pour la prévention secondaire.