Bibliographie de Médecine d'Urgence

Mois d'août 2022


Academic Emergency Medicine

Ultrasound for the diagnosis of shoulder dislocation and reduction: A systematic review and meta-analysis.
Gottlieb M, Patel D, Marks A, Peksa GD. | Acad Emerg Med. 2022 Aug;29(8):999-1007
DOI: https://doi.org/10.1111/acem.14454
Keywords: musculoskeletal; shoulder dislocation; shoulder reduction; trauma; ultrasound.

SYSTEMATIC REVIEW (WITH OR WITHOUT META-ANALYSES)

Introduction : Shoulder dislocations are a common injury prompting presentation to the emergency department. Point-of-care ultrasound (POCUS) is a diagnostic tool for shoulder dislocations, which has the potential to reduce time to diagnosis and reduction, radiation exposure, and health care costs. This systematic review sought to evaluate the diagnostic accuracy of POCUS for diagnosing shoulder dislocations.

Méthode : We searched PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles for all prospective and randomized controlled trials evaluating the diagnostic accuracy of POCUS for identifying shoulder dislocations. We dual-extracted data into a predefined worksheet and performed quality analysis using the QUADAS-2 tool. We performed a meta-analysis with subgroup analyses by technique and transducer type. As a secondary outcome, we assessed the diagnostic accuracy of identifying associated fractures.

Résultats : Ten studies met our inclusion criteria, comprising 1,836 assessments with 636 dislocations (34.6%). Overall, POCUS was 100% (95% confidence interval [CI], 85.6%-100%) sensitive and 100% (95% CI, 79.4%-100%) specific for the diagnosis of shoulder dislocation with a LR+ of 11,254.8 (95% CI, 3.9-3.3e7) and a LR- of <0.1 (95% CI, < 0.1-0.2). When compared with the anterior/lateral technique, the posterior technique had greater sensitivity but no difference in specificity. There was no difference between transducer types. POCUS was also 96.8% (95% CI, 92.6%-98.7%) sensitive and 99.7% (95% CI, 92.5%-100%) specific for the diagnosis of associated fractures.

Conclusion : POCUS is a sensitive and specific tool for the rapid identification of shoulder dislocations and reductions, as well as for the detection of associated fractures. POCUS should be considered as an alternate diagnostic tool for the diagnosis and management of shoulder dislocations.

Conclusion (proposition de traduction) : L'échographie au point d'intervention est un outil sensible et spécifique pour l'identification rapide des luxations et des réductions de l'épaule, ainsi que pour la détection des fractures associées. L'échographie au point d'intervention devrait être considérée comme un outil de diagnostic alternatif pour le diagnostic et la gestion des luxations de l'épaule.

AEM Education and Training

Development of an expert consensus checklist for emergency ultrasound.
Bailitz J, O'Brien J, McCauley M, Murray D, Jung C, Peksa G, Gottlieb M. | AEM Educ Train. 2022 Aug 3;6(4):e10783
DOI: https://doi.org/10.1002/aet2.10783  | Télécharger l'article au format  
Keywords: Aucun

INNOVATIONS REPORT

Introduction : Within today's competency-based medical education, traditional set number proficiency benchmarks have been called into question. Checklists may help guide individualized training and standardized outcomes. However, multicenter expert consensus checklists based on established guidelines with supporting validity evidence have not been published for specific emergency ultrasound (EUS) applications. We describe a robust national EUS expert consensus methodology for developing a checklist for the extended focused assessment with sonography in trauma (eFAST examination).

Méthode : Utilizing the ACEP imaging compendium as a primary reference, 10 national EUS experts iteratively refined and agreed upon a final checklist. To obtain initial reliability and validity evidence, two different EUS experts blinded to resident experience then assessed 24 residents performing an eFAST in a simulated environment. Inter-rater reliability of the checklist was assessed using Cohen's kappa coefficient. Validity was assessed by comparing mean performance with the Student's t-test and discriminant ability of individual checklist items using item-total correlation.

Résultats : The 10 EUS experts agreed on the final checklist items after two rounds of iterations. When evaluating 24 emergency medicine (EM) PGY-1 to -4 residents, the kappa correlation between two blinded EUS faculty raters was moderate at 0.670. Kappa and agreement were near-perfect or perfect in right and left chest image optimization, right upper quadrant (RUQ) probe placement, RUQ anatomy identification, and pelvic first-view anatomy identification. The difference in checklist performance between junior and senior EM residents was significant at -8.1% (p = 0.004). Identification of pelvic structures and placement of the probe for pelvic views were found to have an excellent item-total correlation with values of >0.4.

Conclusion : We have described a robust national EUS expert consensus methodology for developing an eFAST checklist based on the ACEP imaging guidelines. Based on this encouraging initial reliability and validity evidence, further research and checklist development is warranted for additional EUS applications.

Conclusion (proposition de traduction) : Nous avons décrit une solide méthodologie de consensus national d'experts en échographie d'urgence pour développer une checklist eFAST basée sur les directives d'imagerie de l'American College of Emergency Physicians. Sur la base de ces premières preuves encourageantes de fiabilité et de validité, des recherches supplémentaires et le développement de listes de contrôle sont justifiés pour d'autres applications d'échographie d'urgence.

Annals of Emergency Medicine

Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock.
Eisenberg MA, Riggs R, Paul R, Balamuth F, Richardson T, DeSouza HG, Abbadesa MK, DeMartini TKM, Frizzola M, Lane R, Lloyd J, Melendez E, Patankar N, Rutman L, Sebring A, Timmons Z, Scott HF. | Ann Emerg Med. 2022 Sep;80(3):213-224
DOI: https://doi.org/10.1016/j.annemergmed.2022.04.008  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock.

Méthode : This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure.

Résultats : Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.)

Conclusion : In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

Conclusion (proposition de traduction) : Chez les enfants présentant un choc septique hypotendu et recevant un premier bolus de liquide dans l'heure suivant leur arrivée aux urgences, l'administration d'un bolus de liquide intraveineux supérieur ou égal à 30 ml/kg dans l'heure suivant l'arrivée aux urgences n'était pas associée à la mortalité par rapport à l'administration d'un bolus inférieur à 30 ml/kg.

Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial.
Hosseinialhashemi M, Jahangiri R, Faramarzi A, Asmarian N, Sajedianfard S, Kherad M, Soltaniesmaeili A, Babaei A. | Ann Emerg Med. 2022 Sep;80(3):182-188
DOI: https://doi.org/10.1016/j.annemergmed.2022.04.010  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : To determine the effectiveness of intranasal topical application of tranexamic acid in reducing the need for anterior nasal packing and determine the number of episodes of rebleeding in adult patients presenting with spontaneous atraumatic anterior epistaxis.

Méthode : This study was a double-blind randomized trial conducted from September to November 2021 in the ears, nose, and throat (ENT) emergency department (ED), Khalili Hospital, Shiraz, Iran. Cotton pledgets soaked in either phenylephrine and lidocaine (control group) or tranexamic acid with phenylephrine and lidocaine (intervention group) were inserted into the patients' nostrils for 15 minutes. The primary outcome was the need for anterior nasal packing. The secondary outcomes were staying in the ED for more than 2 hours, needing electrical cauterization, and rebleeding within 24 hours and 1 to 7 days of the first referral to the ED.

Résultats : A total of 240 patients (120 in each group) were enrolled in this study. Tranexamic acid was associated with a lower rate of need for anterior nasal packing (50.0% versus 64.2%; odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33 to 0.94). There were no significant differences between the 2 groups in terms of the need for electrical cauterization and the rate of rebleeding within 1 to 7 days. Tranexamic acid was associated with a lower rate of stay in the ED for more than 2 hours (9.2% versus 20.8%; OR, 0.38; 95% CI, 0.18 to 0.82) and rebleeding in 24 hours (15.0% versus 30%; OR, 0.41; 95% CI, 0.22 to 0.78) compared with the rates in the control group.

Conclusion : Intranasal topical application of tranexamic acid is associated with a lower rate of need for anterior nasal packing and a shortened stay in the ED; it may be considered a part of the treatment for atraumatic anterior epistaxis.

Conclusion (proposition de traduction) : Une administration intranasale topique d'acide tranexamique est associée à un taux plus faible de besoin en tamponnement nasal antérieur et à un séjour plus court aux urgences ; elle peut être considérée comme faisant partie du traitement de l'épistaxis antérieure non traumatique.

Emerg Med Clin North Am. 2022 Aug;40(3):603-613

Noninvasive Mechanical Ventilation.
Gill HS, Marcolini EG. | Emerg Med Clin North Am. 2022 Aug;40(3):603-613
DOI: https://doi.org/10.1016/j.emc.2022.05.010
Keywords: Bilevel positive airway pressure; Continuous positive airway pressure; High flow nasal canula; Hypoxemia; Noninvasive ventilation.

Review article

Editorial : This article explains the physiologic basis and fundamentals behind the technology of continuous positive airway pressure, bilevel positive airway pressure, and high flow nasal canula. Additionally, it explores some of the core literature behind their clinical applications. It will also compare HFNC with other noninvasive modalities for respiratory failure alongside clinical titration and weaning algorithms in the emergency department setting.

Conclusion : In summary, the noninvasive ventilatory modalities of CPAP, BiPAP, and HFNC are all beneficial in forestalling endotracheal intubation in the patient with respiratory distress. Understanding the physiologic basis and evidence-based applications for each will help optimize care with minimal invasiveness.

Conclusion (proposition de traduction) : En résumé, les modalités ventilatoires non invasives de CPAP, BiPAP et HNF sont toutes bénéfiques pour prévenir l'intubation endotrachéale chez le patient en détresse respiratoire. Comprendre la base physiologique et les applications fondées sur des preuves pour chacun aidera à optimiser les soins avec un minimum d'invasivité.

Emergencias

Recommendations for the management of hyperkalemia in the emergency department.
Álvarez-Rodríguez E, Olaizola Mendibil A, San Martín Díez MLÁ, Burzako Sánchez A, Esteban-Fernández A, Sánchez Álvarez E. | Emergencias. 2022 Aug;34(4):287-297
DOI: NC  | Télécharger l'article au format  
Keywords: Elevated potassium concentration; Emergency department; Heart failure

Consensus statement

Editorial : Hyperkalemia, a common electrolyte disorder, is seen often in emergency departments. Patient outcomes are impacted by proper management, which requires consideration of both clinical and laboratory findings in relation to kidney function, hydration, the acid-base balance, and heart involvement. Delicate decisions about the timing of potassium level correction must be tailored in each case. For these reasons the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Nephrology (SEN) joined forces to come to a consensus on defining the problem and recommending treatments that improve hospital emergency department management of hyperkalemia.

Conclusion : Intravenous calcium, insulin and glucose, and salbutamol continue to be used to treat acute hyperkalemia. Either loop or thiazide diuretics can help patients if volume is not depleted, and dialysis may be necessary if there is kidney failure. Ion-exchange resins are falling into disuse because of adverse effects and poor tolerance, whereas novel gastrointestinal cation-exchange resins are gaining ground and may even be of some use in managing acute cases. It is essential to adjust treatment rather than discontinue medications that, even if they favor the development of hyperkalemia, will improve a patient's long-term prognosis. Valid alternative treatment approaches must therefore be sought for each patient group, and close follow-up is imperative.

Conclusion (proposition de traduction) : Le calcium, l'insuline et le glucose intraveineux, ainsi que le salbutamol continuent d'être utilisés pour traiter l'hyperkaliémie aiguë. Les diurétiques de l'anse ou thiazidiques peuvent aider les patients si le débit n'est pas insuffisant, et la dialyse peut être nécessaire en cas d'insuffisance rénale. Les résines échangeuses d'ions tombent en désuétude en raison de leurs effets indésirables et de leur mauvaise tolérance, alors que les nouvelles résines échangeuses de cations gastro-intestinales gagnent du terrain et pourraient même être utiles pour gérer les cas aigus. Il est essentiel d'ajuster le traitement plutôt que d'arrêter les médicaments qui, même s'ils favorisent le développement de l'hyperkaliémie, amélioreront le pronostic à long terme du patient. Des approches thérapeutiques alternatives valables doivent donc être recherchées pour chaque groupe de patients, et un suivi étroit est impératif.

Emergency Medicine Australasia

Review article: Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation in the emergency department: A systematic review.
Tessarolo E, Alkhouri H, Lelos N, Sarrami P, McCarthy S. | Emerg Med Australas. 2022 Aug;34(4):484-491
DOI: https://doi.org/10.1111/1742-6723.13993  | Télécharger l'article au format  
Keywords: airway management; airway maneuvers; cricoid pressure; emergency department; sellick manoeuvre.

Review Article

Editorial : The use of cricoid pressure (CP) to prevent aspiration during rapid sequence induction (RSI) has become controversial, although CP is considered central to the practice of RSI. There is insufficient research to support its efficacy in reducing aspiration, and emerging concerns it reduces the first-pass success (FPS) of intubation. This systematic review aims to assess the safety and efficacy of CP during RSI in EDs by investigating its effect on FPS and the incidence of complications, including gastric regurgitation and aspiration. A systematic review of four databases was performed for all primary research investigating CP during RSI in EDs. The primary outcome was FPS; secondary outcomes included complications such as gastric regurgitation, aspiration, hypoxia, hypotension and oesophageal intubation. After screening 4208 citations, three studies were included: one randomised controlled trial (n = 54) investigating the incidence of aspiration during the application of CP and two registry studies (n = 3710) comparing the rate of FPS of RSI with and without CP. The results of these individual studies are not sufficient to draw concrete conclusions but do suggest that aspiration occurs regardless of the application of CP, and that FPS is not reduced by the application of CP. There is insufficient evidence to conclude whether applying CP during RSI in EDs affects the rate of FPS or the incidence of complications such as aspiration. Further research in the ED, including introducing CP usage into other existing airway registries, is needed.

Conclusion : Emergency RSI is a high-risk procedure where FPS without adverse events is essential for optimising intubation outcomes in critically ill patients. There is currently inadequate evidence to conclude whether CP during RSI in the ED affects FPS at intubation or reduces complications such as gastric regurgitation and aspiration. Further primary research into the outcomes of CP in EDs and investigation into the minimum effective force of CP are needed to guide clinical decision making in this area.

Conclusion (proposition de traduction) : L'induction à séquence rapide en urgence est une procédure à haut risque où la réussite du premier essai sans événements indésirables est essentielle pour optimiser les résultats de l'intubation chez les patients en état critique. Les preuves sont actuellement insuffisantes pour conclure que la pression cricoïde pendant l'induction en séquence rapide aux urgences influence la réussite du premier essai d'intubation ou réduit les complications telles que la régurgitation gastrique et l'aspiration. Des recherches plus poussées sur les résultats de la pression cricoïde dans les services d'urgence et sur la force minimale efficace de la pression cricoïde sont nécessaires pour guider la prise de décision clinique dans ce domaine.

Review article: Clinical manifestations and outcomes of chronic nitrous oxide misuse: A systematic review.
Marsden P, Sharma AA, Rotella JA. | Emerg Med Australas. 2022 Aug;34(4):492-503
DOI: https://doi.org/10.1111/1742-6723.13997
Keywords: drug misuse; nitrous oxide; subacute combined degeneration; vitamin B 12.

Review Article

Editorial : Recreational nitrous oxide (N2 O) use is widespread, and complications associated with its use are increasingly common. We sought to identify risk factors, clinical features and outcomes in individuals presenting with effects of chronic N2 O abuse to develop an approach to clinical assessment and management. A systemic literature review was completed with searches conducted across EMBASE, MEDLINE, PSYCINFO and Cochrane databases. Our search strategy identified 612 studies, 105 met inclusion criteria, and 10 were added via hand search. Subjects from 24 case series and 91 case reports were typically in their 20s, using over 100 bulbs daily for several months. Neurological presentations, including sensory change, gait disturbance or weakness, were characteristic. Serum Vitamin B12 was normal or raised in 133 out of 243 case series subjects and 37 out of 84 reports. Serum homocysteine and methylmalonic acid were usually raised. Macrocytosis and anaemia were not commonly seen. MRI findings were abnormal with dorsal column change where specified, typically involving the cervical spine. Nerve conduction studies mostly reported a sensorimotor polyneuropathy. B12 replacement was the treatment of choice and partial recovery was most reported. This review highlights the dose-dependent nature of chronic N2 O toxicity and recognises functional B12 deficiency as the cause. As B12 is often normal, homocysteine and methylmalonic acid are important biomarkers of disease. An approach to diagnosis is offered but requires validation in prospective studies. Research exploring B12 and methionine therapy is required to refine management.

Conclusion : Overall, this review supports the dose-dependent nature of sequelae related to chronic N2O toxicity, of which neurological presentations are most common. Although presentations are comparable to those seen in severe B12 deficiency through malnutrition, most subjects were B12 replete, suggesting a functional B12 deficiency as a cause for toxicity. Homocysteine and MMA were consistently elevated highlighting their utility as diagnostic biomarkers. MRI was useful in confirming the diagnosis and demonstrated disease predominantly in the cervical spine. There was insufficient data to assess the efficacy of therapeutic agents reported and recovery. A suggested approach to diagnosis is offered but requires validation in prospective studies. Further research exploring the efficacy of B12 and methionine therapy is required to refine management.

Conclusion (proposition de traduction) : Dans l'ensemble, cette revue soutient la nature dose-dépendante des séquelles liées à la toxicité chronique du N2O, dont les présentations neurologiques sont les plus fréquentes. Bien que les présentations soient comparables à celles observées dans le cas d'une grave carence en B12 due à la malnutrition, la plupart des sujets étaient riches en B12, ce qui suggère une carence fonctionnelle en B12 comme cause de la toxicité. L'homocystéine et l'acide méthylmalonique étaient constamment élevés, ce qui souligne leur utilité comme biomarqueurs diagnostiques. L'IRM a été utile pour confirmer le diagnostic et a montré que la maladie se situait principalement dans la colonne cervicale. Les données étaient insuffisantes pour évaluer l'efficacité des agents thérapeutiques rapportés et la récupération. Une approche suggérée pour le diagnostic est proposée mais nécessite une validation dans des études prospectives. D'autres recherches explorant l'efficacité des traitements à la B12 et à la méthionine sont nécessaires pour affiner la prise en charge.

Emergency Medicine Clinics of North America

Intubating Special Populations.
Somwaru B, Grossman D. | Emerg Med Clin North Am. 2022 Aug;40(3):443-458
DOI: https://doi.org/10.1016/j.emc.2022.05.001  | Télécharger l'article au format  
Keywords: Airway contamination; Anaphylaxis; Angioedema; Burns; Difficult airway; Neck trauma.

Review article

Editorial : Emergency clinicians are tasked with managing a variety of patients with acute deformities. One of the most acute situations management of the patient who presents with an airway emergency. Patients present with various pathologies may result in anatomically challenging intubation scenarios. Deferral of intubation is often not an option in the emergency department. In some cases, challenging anatomic issues can be predicted before beginning laryngoscopy, but in many situations, prediction models fall short. It is critically important for emergency clinicians to anticipate anatomic issues in all airways and to have premeditated strategies for managing them.

Conclusion : The term “anatomically difficult airway” is one that encompasses a vast amount of deformities that the emergency physician may face when intubating a critically ill patient. The specific management of patients with difficult airway features can be guided by the features of the specific deformities, although many recommendations remain based on expert opinions and weak data, often obtained outside the emergency department. Physicians managing these airways should give careful consideration to various airway modalities and choose a technique based on pathology, resources, and experience.

Conclusion (proposition de traduction) : L'expression "voies aériennes anatomiquement difficiles" englobe un grand nombre de malformations auxquelles l'urgentiste peut être confronté lorsqu'il intube un patient gravement malade. La prise en charge spécifique des patients présentant des caractéristiques de voies aériennes difficiles peut être guidée par les caractéristiques des malformations spécifiques, bien que de nombreuses recommandations restent basées sur des opinions d'experts et des preuves faibles, souvent obtenues en dehors du service des urgences. Les médecins qui prennent en charge ces voies aériennes doivent examiner attentivement les différentes modalités de prise en charge et choisir une technique en fonction de la pathologie, des ressources et de son expérience.

Acute Respiratory Distress Syndrom.
Gragossian A, Siuba MT. | Emerg Med Clin North Am. 2022 Aug;40(3):459-472
DOI: https://doi.org/10.1016/j.emc.2022.05.002  | Télécharger l'article au format  
Keywords: ARDS; High-flow nasal cannula; Mechanical ventilation; Noninvasive ventilation; Respiratory failure; Respiratory support.

Review article

Editorial : Acute respiratory distress syndrome (ARDS) occurs in up to 10% of patients with respiratory failure admitted through the emergency department. Use of noninvasive respiratory support has proliferated in recent years; clinicians must understand the relative merits and risks of these technologies and know how to recognize signs of failure. The cornerstone of ARDS care of the mechanically ventilated patient is low-tidal volume ventilation based on ideal body weight. Adjunctive therapies, such as prone positioning and neuromuscular blockade, may have a role in the emergency department management of ARDS depending on patient and department characteristics.

Conclusion : ARDS occurs commonly in patients with respiratory failure in the emergency department. Lung protective ventilation strategies as well as early prone position ventilation have the largest impact on mortality. Protocolized care for ARDS, in the emergency department or ICU, is associated with increased adherence to lung protective ventilation and improved outcomes. Other interventions, such as NMB and VV-ECMO, can be considered in a sequential fashion if airway pressure and gas exchange targets cannot be achieved. In challenging or refractory cases, early expert consultation is advised.

Conclusion (proposition de traduction) : Le SDRA se rencontre fréquemment chez les patients souffrant d'insuffisance respiratoire dans les services d'urgence. Les stratégies de ventilation de protection pulmonaire ainsi que la ventilation précoce en position ventrale ont le plus grand impact sur la mortalité. La prise en charge protocolaire du SDRA, aux urgences ou aux soins intensifs, est associée à une meilleure adhésion à la ventilation de protection pulmonaire et à de meilleurs résultats. D'autres interventions, comme la curarisation et l'ECMO veino-veineuse, peuvent être envisagées de manière séquentielle si les objectifs de pression des voies aériennes et d'échange gazeux ne peuvent être atteints. Dans les cas difficiles ou réfractaires, il est conseillé de consulter rapidement un expert.

Infectious Pulmonary Diseases.
Rafeq R, Igneri LA. | Emerg Med Clin North Am. 2022 Aug;40(3):503-518
DOI: https://doi.org/10.1016/j.emc.2022.05.005  | Télécharger l'article au format  
Keywords: Allergies; Antimicrobial stewardship; Community-acquired pneumonia; Cross-sensitivity; Hospital-acquired pneumonia; MRSA nasal screening; Procalcitonin; Ventilator-associated pneumonia.

Review article

Editorial : Pneumonia is a lower respiratory tract infection caused by the inability to clear pathogens from the lower airway and alveoli. Cytokines and local inflammatory markers are released, causing further damage to the lungs through the accumulation of white blood cells and fluid congestion, leading to pus in the parenchyma. The Infectious Diseases Society of America defines pneumonia as the presence of new lung infiltrate with other clinical evidence supporting infection, including new fever, purulent sputum, leukocytosis, and decline in oxygenation. Importantly, lower respiratory infections remain the most deadly communicable disease. Pneumonia is subdivided into three categories: (1) community acquired, (2) hospital acquired, and (3) ventilator associated. Therapy for each differs based on the severity of the disease and the presence of risk factors for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa.

Conclusion : CLINICS CARE POINTS
• Classification of pneumonia as either community-acquired or hospital-acquired will guide selection of empirical antimicrobial therapy.
• 5 to 7 days of treatment is generally sufficient to treat community-acquired pneumonia; however, procalcitonin may be a useful biomarker to support cessation of therapy sooner.
• Patients with hospital-acquired and ventilator-associated pneumonia should be risk-stratified for multidrug-resistant pathogens, with the cornerstone of therapy being a combination of anti-pseudomonal and anti-methicillin-resistant Staphylococcus aureus therapy.
• Immunocompromised patients should be managed on a case-by-case basis to ensure appropriate broad-spectrum antibiotics have been initiated to target certain pathogens.
• Collaboration with antimicrobial stewardship programs ensures optimization in overall antibiotic use while minimizing the risk of adverse effects from excessive antibiotic treatment (eg, Clostridioides difficile infection, development of antimicrobial resistance, and so forth)

Conclusion (proposition de traduction) : POINTS DE SOINS EN CLINIQUE
• La classification de la pneumopathie comme étant d'origine communautaire ou hospitalière guidera le choix du traitement antibiotique empirique.
• 5 à 7 jours de traitement sont généralement suffisants pour traiter une pneumopathie communautaire ; cependant, la procalcitonine peut être un biomarqueur utile pour confirmer l'arrêt du traitement plus précocement.
• Les patients présentant une pneumopathie acquise à l'hôpital et associée à la ventilation avec un respirateur devraient être stratifiés en fonction du risque de pathogènes multirésistants, la pierre angulaire du traitement étant une combinaison d'antibiotique anti-pseudomonale et anti-Staphylococcus aureus résistant à la méthicilline.
• Les patients immunodéprimés doivent être pris en charge au cas par cas pour s'assurer que des antibiotiques à large spectre appropriés ont été initiés pour cibler certains agents pathogènes.
• La collaboration avec les programmes de bonne pratique des antibiotiques permet d'optimiser l'utilisation globale des antibiotiques tout en minimisant le risque d'effets indésirables d'un traitement antibiotique excessif (par exemple, infection à Clostridioides difficile, développement de la résistance aux antibiotiques, etc.).

Right Ventricular Failure and Pulmonary Hypertension.
Crager SE, Humphreys C. | Emerg Med Clin North Am. 2022 Aug;40(3):519-537.
DOI: https://doi.org/10.1016/j.emc.2022.05.006
Keywords: Cardiogenic shock; Massive pulmonary embolism; Pulmonary hypertension; Right ventricular failure.

Review article

Editorial : Right ventricular dysfunction is an important component of the pathophysiology of several disorders commonly encountered in the emergency department (ED). Interventions often performed routinely early in the ED course such as fluid administration and endotracheal intubation have the potential to cause precipitous clinical deterioration in patients with right ventricular failure and pulmonary hypertension. It is important for emergency physicians to understand the pathophysiology of acute decompensated right ventricular failure in order to avoid common pitfalls in diagnosis and management that can result in significant morbidity and mortality.

Conclusion : Although RVD plays a central role in high-risk, but relatively rare, conditions such as massive PE and chronic PAH, it is also an important —if frequently unrecognized— component of several disorders routinely encountered in the ED setting such as sepsis, ARDS, and CHF. Comorbid conditions frequently present in the ED population, such as morbid obesity, COPD, and methamphetamine abuse, are not infrequently associated with undiagnosed underlying PH, and these patients may be particularly susceptible to the development of ADRVF when presenting with acute disorders that are independently associated with RVD. ADRFV may be easily mistaken for entities such as abdominal sepsis or septic shock, and a high index of suspicion in the appropriate clinical setting is required to avoid common pitfalls in the recognition of evolving ADRVF.
It is important for emergency physicians to understand the pathophysiology of ADRVF in order to avoid common management pitfalls that can result in significant morbidity and mortality, including aggressive IV fluid administration, failure to support blood pressure by prompt initiation of appropriate vasopressors, and unnecessary ETI.
Early diagnosis and appropriate management of PH and RVD by EPs has the potential to profoundly affect a patient’s clinical course and can mean the difference between a routine admission of a hemodynamically stable patient and that same patient going into cardiac arrest in the ED.

Conclusion (proposition de traduction) : Bien que la dysfonction ventriculaire droite joue un rôle central dans les affections à haut risque, mais relativement rares, telles que l'EP massive et l'hypertension artérielle pulmonaire chronique, elle est également une composante importante, bien que souvent méconnue, de plusieurs troubles couramment rencontrés dans les services d'urgence, tels que la septicémie, le syndrome de détresse respiratoire de l'adulte et l'insuffisance cardiaque congestive. Les affections comorbides fréquemment présentes dans la population des services d'urgence, telles que l'obésité morbide, la maladie pulmonaire obstructive chronique et l'abus de méthamphétamine, ne sont pas rarement associées à une hypertension pulmonaire sous-jacente non diagnostiquée, et ces patients peuvent être particulièrement susceptibles de développer une insuffisance ventriculaire droite aiguë décompensée lorsque présentant des troubles aigus qui sont indépendamment associés à un dysfonctionnement ventriculaire léger. L'insuffisance ventriculaire droite aiguë décompensée peut facilement être confondue avec des entités telles que le sepsis abdominal ou le choc septique, et un indice de suspicion élevé dans le cadre clinique approprié est nécessaire pour éviter les pièges courants dans la reconnaissance de l'évolution de l'insuffisance ventriculaire droite aiguë décompensée.
Il est important que les médecins urgentistes comprennent la physiopathologie de l'insuffisance ventriculaire droite aiguë décompensée afin d'éviter les pièges de prise en charge courants qui peuvent entraîner une morbidité et une mortalité importantes, y compris l'administration agressive de liquide IV, l'incapacité à maintenir la pression artérielle par l'introduction rapide de vasopresseurs appropriés, et une intubation endotrachéale inutile.
Un diagnostic précoce et une prise en charge appropriée de l'hypertension pulmonaire et de la dysfonction ventriculaire légère par les services d'urgence peuvent affecter profondément l'évolution clinique d'un patient et peuvent faire la différence entre l'admission de routine d'un patient hémodynamiquement stable et l'arrêt cardiaque de ce même patient à l'urgence. .

Evaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department.
Long B, Rezaie SR. | Emerg Med Clin North Am. 2022 Aug;40(3):539-563
DOI: https://doi.org/10.1016/j.emc.2022.05.007
Keywords: Acute exacerbation; Asthma; COPD; Obstructive lung disease; Pulmonary.

Review article

Editorial : Obstructive lung disease includes asthma and chronic obstructive pulmonary disease (COPD). Exacerbation of asthma or COPD can result in significant morbidity and mortality, and emergency department (ED) care is often required. ED evaluation should assess risk factors for severe exacerbation and the patient's hemodynamic and respiratory status. Assessments including chest radiograph, point-of-care ultrasound, capnography, and electrocardiogram can assist. First-line treatments for acute exacerbation include bronchodilators and corticosteroids. Noninvasive ventilation, magnesium, ketamine, and epinephrine should be considered in those with severe exacerbation. Mechanical ventilation is challenging and should use an obstructive lung strategy with permissive hypercapnia.

Conclusion : Detailed asthma or COPD care plans are integral to patient care and improved outcomes. These plans typically include explicit discharge instruction, medications, and instructions on how to use them, self-assessment, action plan for managing recurrent obstruction, and follow-up appointment. These care plans are associated with medication compliance and improved patient outcomes. Admitted patients on discharge should follow-up within 1 week. Pulmonary rehabilitation for those with COPD can prevent recurrent exacerbation.

Conclusion (proposition de traduction) : Des protocoles de soins détaillés pour l'asthme ou la BPCO font partie intégrante des soins aux patients et de l'amélioration des résultats. Ces protocoles comprennent généralement des instructions de sortie explicites, des médicaments et des instructions sur la façon de les utiliser, une auto-évaluation, un plan d'action pour gérer l'obstruction récurrente et un rendez-vous de suivi (ndlr : plan d'action personnalisé). Ces protocoles de soins sont associés à l'observance des médicaments et à l'amélioration des résultats pour les patients. Les patients admis à la sortie doivent être suivis dans un délai d'une semaine. La réadaptation pulmonaire pour les personnes atteintes de BPCO peut prévenir les exacerbations récurrentes.

Diagnosis and Management of Pulmonary Embolism.
Trott T, Bowman J. | Emerg Med Clin North Am. 2022 Aug;40(3):565-581
DOI: https://doi.org/10.1016/j.emc.2022.05.008
Keywords: Cardiac arrest; Pulmonary embolism; Thrombolysis.

Review article

Editorial : Pulmonary embolism is a challenging pathology commonly faced by emergency physicians, and diagnosis and management remain a crucial skill set. Inherent to the challenge is the breadth of presentation, ranging from asymptomatic pulmonary emboli to sudden cardiac death. Diagnosis and exclusion have evolved over time and now use a combination of clinical decision calculators and updates to the classic d-dimer cutoffs. Management of pulmonary emboli revolves around appropriate anticoagulation, which for most of the patients will comprise newer oral agents. However, there remains a substantial degree of practice variation and ambiguity when it comes to higher risk patients with submassive or massive pulmonary emboli.

Conclusion : Diagnosis and management of pulmonary emboli are a crucial skill for any emergency physician. The wide range of clinical presentations and multiple modalities of testing and risk stratification exemplify the challenges in this population. Management of intermediate risk and high risk or massive pulmonary emboli still remains a target of research and debate. Identifying the resources and protocols at any particular institution is prudent given these practice variations.

Conclusion (proposition de traduction) : Le diagnostic et la prise en charge des embolies pulmonaires sont une compétence cruciale pour tout médecin urgentiste. Le large éventail de présentations cliniques et les multiples modalités de test et de stratification des risques illustrent les défis dans cette population. La prise en charge des embolies pulmonaires à risque intermédiaire et à haut risque ou massives reste encore un objet de recherche et de débat. L'identification des ressources et des protocoles dans un établissement particulier doit être prudente compte tenu de ces variations de pratique.

The Physiologically Difficult Intubation.
Butler K, Winters M. | Emerg Med Clin North Am. 2022 Aug;40(3):615-627
DOI: https://doi.org/10.1016/j.emc.2022.05.011
Keywords: Intubation checklist; Peri-intubation cardiac arrest; Peri-intubation cardiovascular collapse; Preintubation hypotension; Preintubation hypoxemia; Shock index.

Review article

Editorial : Emergency physicians intubate critically ill patients almost daily. Intubation of the critically ill emergency department (ED) patient is a high-risk, high-stress situation, as many have physiologic derangements such as hypotension, hypoxemia, acidosis, and right ventricular dysfunction that markedly increase the risk of peri-intubation cardiovascular collapse and cardiac arrest. This chapter discusses critical pearls and pitfalls to intubate the critically ill ED patient with physiologic derangements. These pearls and pitfalls include appropriate preoxygenation; circulatory resuscitation; proper patient position and room setup; selection of medications for rapid sequence intubation; and intubation of patients with severe acidosis, traumatic brain injury, and pulmonary hypertension.

Conclusion : Emergency physicians intubate critically ill patients almost daily. Intubation of the critically ill ED patient is a high-risk, high-stress situation, as many have physiologic derangements such as hypotension, hypoxemia, acidosis, and RV dysfunction that markedly increase the risk of peri-intubation cardiovascular collapse and cardiac arrest. In order to prevent disastrous peri-intubation outcomes, it is imperative for the EP to use the tips discussed in this article to improve the physiology of these patients before intubation. These tips include appropriate preoxygenation, correction of hypotension, patient position, setup of the room, proper selection and doses of RSI medications, and consideration of awake intubation in select patients.

Conclusion (proposition de traduction) : Les urgentistes intubent presque quotidiennement des patients gravement malades. L'intubation d'un patient aux urgences gravement malade est une situation à haut risque et à stress élevé, car beaucoup présentent des troubles physiologiques tels que l'hypotension, l'hypoxémie, l'acidose et un dysfonctionnement du ventricule droit qui augmentent considérablement le risque de collapsus cardiovasculaire et d'arrêt cardiaque péri-intubation. Afin d'éviter des résultats péri-intubation désastreux, il est impératif que le médecin urgentiste utilise les conseils discutés dans cet article pour améliorer la physiologie de ces patients avant l'intubation. Ces conseils incluent une préoxygénation appropriée, la correction de l'hypotension, la position du patient, la configuration de la chambre, la sélection et les doses appropriées de médicaments d'intubation à séquence rapide, et la prise en compte de l'intubation éveillée chez certains patients.

Emergency Medicine International

Influence of the Level of Emergency Medical Facility on the Short-Term Treatment Results of Cardiac Arrest: Out-of-Hospital Cardiac Arrest and Interhospital Transfer.
Chung JY, Choi Y, Jeong J, Lee SW, Han KS, Kim SJ, Kim WY, Kang H, Hong ES. | Emerg Med Int. 2022 Aug 27;2022:2662956
DOI: https://doi.org/10.1155/2022/2662956  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Introduction : This study aimed to elucidate whether direct transport of out-of-hospital cardiac arrest (OHCA) patients to higher-level emergency medical centres (EMCs) would result in better survival compared to resuscitation in smaller local emergency departments (EDs) and subsequent transfer.

Méthode : This study was a retrospective population-based analysis of cases registered in the national database of 2019. This study investigated the immediate results of cardiopulmonary resuscitation for OHCA compared between EMCs and EDs and the results of therapeutic temperature management (TTM) compared between the patients directly transported from the field and those transferred from other hospitals. In-hospital mortality was compared using multivariate logistic regression.

Résultats : From the population dataset, 11,493 OHCA patients were extracted. (8,912 in the EMC group vs. 2,581 in the ED group). Multivariate logistic regression revealed that the odds for ED mortality were lower with treatment in EDs than with treatment in EMCs. (odds ratio 0.712 (95% confidence interval (CI): 0.638-0.796)). From the study dataset, 1,798 patients who received TTM were extracted. (1,164 in the direct visit group vs. 634 in the transferred group). Multivariate regression analysis showed that the odds ratio for overall mortality was 1.411 (95% CI: 0.809-2.446) in the transferred group. (p = 0.220).

Conclusion : The immediate outcome of OHCA patients who were transported to EDs was not inferior to that of EMCs. Therefore, it would be acceptable to transport OHCA patients to the nearest emergency facilities rather than to the specialized centres in distant areas.

Conclusion (proposition de traduction) : Les résultats immédiats des patients victimes d'un arrêt cardiaque extrahospitalier qui ont été transportés aux urgences n'étaient pas inférieurs à ceux des centres médicaux d'urgence. Par conséquent, il serait acceptable de transporter les patients victimes d'un arrêt cardiaque extrahospitalier vers les services d'urgence les plus proches plutôt que vers les centres spécialisés des régions éloignées.

Injury

Health care utilization and outcomes in older adults after Traumatic Brain Injury: A CENTER-TBI study.
van der Vlegel M, Mikolić A, Lee Hee Q, Kaplan ZLR, Retel Helmrich IRA, van Veen E, Andelic N, Steinbuechel NV, Plass AM, Zeldovich M, Wilson L, Maas AIR, Haagsma JA, Polinder S; CENTER-TBI Participants and Investigators. | Injury. 2022 Aug;53(8):2774-2782
DOI: https://doi.org/10.1016/j.injury.2022.05.009
Keywords: Health care utilization; Health-related quality of life; Mental health; Older adults; Outcomes; Traumatic Brain Injury.

General Trauma Section

Introduction : The incidence of Traumatic Brain Injury (TBI) is increasingly common in older adults aged ≥65 years, forming a growing public health problem. However, older adults are underrepresented in TBI research. Therefore, we aimed to provide an overview of health-care utilization, and of six-month outcomes after TBI and their determinants in older adults who sustained a TBI.

Méthode : We used data from the prospective multi-center Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. In-hospital and post-hospital health care utilization and outcomes were described for patients aged ≥65 years. Ordinal and linear regression analyses were performed to identify determinants of the Glasgow Outcome Scale Extended (GOSE), health-related quality of life (HRQoL), and mental health symptoms six-months post-injury.

Résultats : Of 1254 older patients, 45% were admitted to an ICU with a mean length of stay of 9 days. Nearly 30% of the patients received inpatient rehabilitation. In total, 554/1254 older patients completed the six-month follow-up questionnaires. The mortality rate was 9% after mild and 60% after moderate/severe TBI, and full recovery based on GOSE was reported for 44% of patients after mild and 6% after moderate/severe TBI. Higher age and increased injury severity were primarily associated with functional impairment, while pre-injury systemic disease, psychiatric conditions and lower educational level were associated with functional impairment, lower generic and disease-specific HRQoL and mental health symptoms.

Conclusion : The rate of impairment and disability following TBI in older adults is substantial, and poorer outcomes across domains are associated with worse preinjury health. Nonetheless, a considerable number of patients fully or partially returns to their preinjury functioning. There should not be pessimism about outcomes in older adults who survive.

Conclusion (proposition de traduction) : Le taux de handicap et d'invalidité après un traumatisme crânien chez les personnes âgées est considérable, et les résultats plus défavorables dans tous les domaines sont associés à un mauvais état de santé avant le traumatisme. Néanmoins, un nombre considérable de patients retrouvent totalement ou partiellement le niveau de vie qui était le leur avant la blessure. Il ne faut pas être pessimiste quant aux suites données aux adultes plus âgés qui survivent.


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