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.

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.

Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study.
Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, Lascarrou JB, Szułdrzyński K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Pesenti A, Valsecchi MG, Fumagalli R, Foti G, Bellani G, Laffey JG. | Am J Respir Crit Care Med. 2022 Aug 15;206(4):449-458
DOI: https://doi.org/10.1164/rccm.202111-2575oc  | Télécharger l'article au format  
Keywords: airway management; cardiovascular collapse; intubation.

Original article

Introduction : Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill.
Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest).

Méthode : INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019.

Résultats : A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/FiO2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse.

Conclusion : Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.

Conclusion (proposition de traduction) : Un collapsus ou une instabilité cardiovasculaire péri-intubation a été associé à un risque accru de mortalité à la fois en USI et à 28 jours. L'utilisation du propofol pour l'induction a été identifiée comme une intervention modifiable significativement associée à l'instabilité au collapsus cardiovasculaire.

Pediatric Emergencies in Helicopter Emergency Medical Services: A National Population-Based Cohort Study From Denmark.
Nielsen VML, Bruun NH, Søvsø MB, Kløjgård TA, Lossius HM, Bender L, Mikkelsen S, Tarpgaard M, Petersen JAK, Christensen EF. | Ann Emerg Med. 2022 Aug;80(2):143-153
DOI: https://doi.org/10.1016/j.annemergmed.2022.03.024  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics

Introduction : To examine the diagnostic pattern, level of severity of illness or injuries, and mortality among children for whom a physician-staffed helicopter emergency medical service (HEMS) was dispatched.

Méthode : Population-based cohort study including patients aged less than 16 years treated by the Danish national HEMS from October 1, 2014, to September 30, 2018. Diagnoses were retrieved from inhospital medical records, and the severity of illness or injuries was assessed by a severity score on scene, administration of advanced out-of-hospital care, need for intensive care in a hospital, and mortality.

Résultats : In total, 651 HEMS missions included pediatric patients aged less than 1 year (9.2%), 1 to 2 years (29.0%), 3 to 7 years (28.3%), and 8 to 15 years (33.5%). A third of the patients had critical emergencies (29.6%), and for 20.1% of the patients, 1 or more out-of-hospital interventions were performed: intubation, mechanical chest compressions, intraosseous vascular access, blood transfusion, chest tube insertion, and/or ultrasound examination. Among the 525 patients with hospital follow-up, the most frequent hospital diagnoses were injuries (32.2%), burns (11.2%), and respiratory diseases (7.8%). Within 24 hours of the mission, 18.1% of patients required intensive care. Twenty-nine patients (5.1%, 95% confidence interval [CI] 3.6 to 7.3) died either on or within 1 day of the mission, and the cumulative 30-day mortality was 35 of 565 (6.2%, 95% CI 4.5 to 8.5) (N=565 first-time missions).

Conclusion : On Danish physician-staffed HEMS missions, 1 in 5 pediatric patients required advanced out-of-hospital care. Among hospitalized patients, nearly one-fifth of the patients required immediate intensive care and 6.2% died within 30 days of the mission.

Conclusion (proposition de traduction) : Lors des missions des services médicaux d'urgence en hélicoptères danois assurés par des médecins, un patient pédiatrique sur cinq a nécessité des soins extrahospitaliers spécialisés. Parmi les patients hospitalisés, près d'un cinquième a nécessité des soins intensifs immédiats et 6,2 % sont décédés dans les 30 jours suivant la mission.

Kinetics of capillary refill time after fluid challenge.
Raia L, Gabarre P, Bonny V, Urbina T, Missri L, Boelle PY, Baudel JL, Guidet B, Maury E, Joffre J, Ait-Oufella H. | Ann Intensive Care. 2022 Aug 13;12(1):74
DOI: https://doi.org/10.1186/s13613-022-01049-x  | Télécharger l'article au format  
Keywords: Capillary time refill; Fluid challenge; Intensive care medicine; Kinetics; Sepsis.

RESEARCH

Introduction : Capillary refill time (CRT) is a valuable tool for triage and to guide resuscitation. However, little is known about CRT kinetics after fluid infusion.

Méthode : We conducted a prospective observational study in a tertiary teaching hospital. First, we analyzed the intra-observer variability of CRT. Next, we monitored fingertip CRT in sepsis patients during volume expansion within the first 24 h of ICU admission. Fingertip CRT was measured every 2 min during 30 min following crystalloid infusion (500 mL over 15 min).

Résultats : First, the accuracy of repetitive fingertip CRT measurements was evaluated on 40 critically ill patients. Reproducibility was excellent, with an intra-class correlation coefficient of 99.5% (CI 95% [99.3, 99.8]). A CRT variation larger than 0.2 s was considered as significant. Next, variations of CRT during volume expansion were evaluated on 29 septic patients; median SOFA score was 7 [5-9], median SAPS II was 57 [45-72], and ICU mortality rate was 24%. Twenty-three patients were responders as defined by a CRT decrease > 0.2 s at 30 min after volume expansion, and 6 were non-responders. Among responders, we observed that fingertip CRT quickly improved with a significant decrease at 6-8 min after start of crystalloid infusion, the maximal improvement being observed after 10-12 min (-0.7 [-0.3;-0.9] s) and maintained at 30 min. CRT variations significantly correlated with baseline CRT measurements (R = 0.39, P = 0.05).

Conclusion : CRT quickly improved during volume expansion with a significant decrease 6-8 min after start of fluid infusion and a maximal drop at 10-12 min.

Conclusion (proposition de traduction) : Le temps de remplissage capillaire s'est rapidement amélioré au cours de l'expansion volumique, avec une diminution significative 6-8 min après le début de la perfusion de liquide et une chute maximale à 10-12 min.

Effects of mean arterial pressure target on mottling and arterial lactate normalization in patients with septic shock: a post hoc analysis of the SEPSISPAM randomized trial.
Fage N, Demiselle J, Seegers V, Merdji H, Grelon F, Mégarbane B, Anguel N, Mira JP, Dequin PF, Gergaud S, Weiss N, Legay F, Le Tulzo Y, Conrad M, Coudroy R, Gonzalez F, Guitton C, Tamion F, Tonnelier JM, Bedos JP, Van Der Linden T, Vieillard-Baron A, Mariotte E, Pradel G, Lesieur O, Ricard JD, Hervé F, Du Cheyron D, Guerin C, Mercat A, Teboul JL, Radermacher P, Asfar P. | Ann Intensive Care. 2022 Aug 19;12(1):78
DOI: https://doi.org/10.1186/s13613-022-01053-1  | Télécharger l'article au format  
Keywords: Arterial lactate; Lactate clearance; Mean arterial pressure; Microcirculation; Mottling; Septic shock.

RESEARCH

Introduction : In patients with septic shock, the impact of the mean arterial pressure (MAP) target on the course of mottling remains uncertain. In this post hoc analysis of the SEPSISPAM trial, we investigated whether a low-MAP (65 to 70 mmHg) or a high-MAP target (80 to 85 mmHg) would affect the course of mottling and arterial lactate in patients with septic shock.

Méthode : The presence of mottling was assessed every 2 h from 2 h after inclusion to catecholamine weaning. We compared mottling and lactate time course between the two MAP target groups. We evaluated the patient's outcome according to the presence or absence of mottling.

Résultats : We included 747 patients, 374 were assigned to the low-MAP group and 373 to the high-MAP group. There was no difference in mottling and lactate evolution during the first 24 h between the two MAP groups. After adjustment for MAP and confounding factors, the presence of mottling ≥ 6 h during the first 24 h was associated with a significantly higher risk of death at day 28 and 90. Patients without mottling or with mottling < 6 h and lactate ≥ 2 mmol/L have a higher probability of survival than those with mottling ≥ 6 h and lactate < 2 mmol/L.

Conclusion : Compared with low MAP target, higher MAP target did not alter mottling and lactate course. Mottling lasting for more than 6 h was associated with higher mortality. Compared to arterial lactate, mottling duration appears to be a better marker of mortality.

Conclusion (proposition de traduction) : Par rapport à une cible de PAM basse, une cible de PAM plus élevée n'a pas modifié l'évolution des marbrures et du lactate. Les marbrures qui ont duré plus de 6 heures ont été associées à une mortalité plus élevée. Comparée au lactate artériel, la durée de présences des marbrures semble être un meilleur marqueur de mortalité.

From Q/Non-Q Myocardial Infarction to STEMI/NSTEMI:Why It’s Time to Consider Another Simplified Dichotomy;a Narrative Literature Review.
Avdikos G, Michas G, Smith SW. | Arch Acad Emerg Med [Internet]. 2022; 10(1): e78
DOI: https://doi.org/10.22037/aaem.v10i1.1783  | Télécharger l'article au format  
Keywords: Acute coronary syndrome; coronary occlusion; myocardial infarction; myocardial reperfusion; non-ST elevatedmyocardial infarction

REV I EWART I C L E

Editorial : Acute coronary syndromes (ACSs) are classified as ST-segment elevation myocardial infarction (STEMI) andnon-ST-segment elevation myocardial infarction (NSTEMI) based on the presence of guideline-recommendedST-segment elevation (STE) criteria on the electrocardiogram (ECG). STEMI is associated with acute total coro-nary occlusion (ATO) and transmural myocardial necrosis and is managed with emergent reperfusion therapy,and NSTEMI is supposedly synonymous with subendocardial myocardial infarction without ATO. However,coronary angiograms reveal that a significant proportion of patients with NSTEMI have ATO. Here, we reviewarticles that studied the frequency and cardiovascular outcomes of ATO in NSTEMI patients compared withthose without ATO. We discuss ECG patterns of patients with suspected acute myocardial infarction that do notfulfill STEMI criteria but are associated with ATO. Under-recognition of these atypical patterns results in delaysto reperfusion therapy. We also advocate revision of the current STEMI/NSTEMI paradigm because consider-ation of STE, by itself, out of context of other clinical and ECG features, leads to the ECG diagnosis of STEMIwhen the ECG actually represents a mimic [“Pseudo-STEMI”], and suggest renaming the ACSs classification asthe Occlusion Myocardial Infarction (OMI)/Non-Occlusion Myocardial Infarction (NOMI) paradigm.

Conclusion : Recent studies suggest that 25%-30% of NSTEMI patientshave ATO with increased adverse cardiovascular outcomescompared with those with patent coronary arteries. Earlyrecognition of this high-risk group of ACS patients is based onthe identification of ECG patterns that are related to ATO anddo not satisfy current STEMI criteria. Knowledge and con-tinuous training in interpretation of these ECG presentationscould improve management and outcomes of ACS patients.Considering STE as a hallmark of acute MI with ATO can be attimes misleading and STEMI/NSTEMI classification should be revised to include more high-risk ECG patterns that signifyATO. We agree with renaming the paradigm as the OcclusionMI/Non-Occlusion MI paradigm.

Conclusion (proposition de traduction) : Des études récentes suggèrent que 25 à 30 % des patients présentant un infarctus du myocarde sans sus-décalage du segment ST souffrent d'une occlusion coronaire totale aiguë, ce qui entraîne une augmentation des conséquences cardiovasculaires négatives par rapport aux patients dont les artères coronaires sont intactes. La reconnaissance précoce de ce groupe à haut risque de patients souffrant d'un syndrome coronarien aigu repose sur l'identification de tracés ECG liés à une occlusion coronarienne totale aiguë et ne répondant pas aux critères actuels du STEMI. La compétence et la formation continue à l'interprétation de ces présentations ECG pourraient améliorer la prise en charge et les résultats des patients présentant un syndrome coronarien aigu. Considérer le sus-décalage du segment ST comme une caractéristique de l'infarctus aigu du myocarde avec occlusion coronaire totale aiguë peut parfois induire en erreur et la classification STEMI/NSTEMI devrait être révisée pour inclure davantage de tracés ECG à haut risque qui signifient une occlusion coronaire totale aiguë. Nous pensons qu'il faut renommer le paradigme en tant que paradigme de l'infarctus du myocarde avec ou sans occlusion.

.
Kareemi H, Eagles D, Rosenberg H. | CJEM. 2022 Aug;24(5):480-481
DOI: https://doi.org/10.1007/s43678-022-00351-8  | Télécharger l'article au format  
Keywords: Aucun

NEED TO KNOW: CJEM JOURNAL CLUB

Introduction : The evidence regarding indications and timing of coronary angiography in patients with out-of-hospital cardiac arrest remains limited.

Résultats : The two groups were overall well balanced, with more wit- nessed arrest in the immediate angiography group (91.1% vs. 87.9%) and more shockable first rhythm and bystander CPR in the delayed angiography group (58.7% vs. 52.3%; 60.3% vs. 57.5%, respectively).
Among 530 patients included in the intention to treat analysis, the primary outcome occurred in 143/265 (54.05%) of the immediate angiography group and 122/265 of the delayed angiography group, with no difference in time- to-event analyses (hazard ratio 1.28, 95% CI 1.00–1.63; p = 0.06). There was also no difference between groups in the per-protocol or safety analyses, nor in the subgroup analyses including shockable vs. non-shockable first moni- tored rhythm, confirmed myocardial infarction as trigger for OHCA, or time from arrest to ROSC greater than or less than 15 min. The composite secondary outcome occurred more frequently in the immediate angiography group than in the delayed angiography group (relative risk 1.16; 95% CI 1.00–1.34).

Conclusion : The TOMAHAWK trial demonstrates that immediate angiography does not improve 30-day survival, with a sig- nal towards harm, compared to delayed angiography for patients with return of spontaneous circulation after OHCA. It expands the results of the COACT trial to patients with initial non-shockable rhythms. Although particular patient groups were excluded, the authors provide clear definitions and rationale for pursuing early angiography in patients who develop signs of myocardial injury, including hemodynamic or electrical instability. An essential role of the emergency clinician is to recognize these signs to better select patients that may benefit from early angiography.

Conclusion (proposition de traduction) : L'essai TOMAHAWK démontre que l'angiographie immédiate n'améliore pas la survie à 30 jours, avec un signal de préjudice, par rapport à l'angiographie différée pour les patients avec retour de la circulation spontanée après un arrêt cardiaque extrahospitalier. Elle étend les résultats de l'essai COACT aux patients présentant un rythme initial non choquable. Bien que des groupes de patients particuliers aient été exclus, les auteurs fournissent des définitions claires et des arguments en faveur de la réalisation d'une angiographie précoce chez les patients qui présentent des signes de lésions myocardiques, notamment une instabilité hémodynamique ou électrique. Un rôle essentiel du clinicien d'urgence est de reconnaître ces signes pour mieux sélectionner les patients qui peuvent bénéficier d'une angiographie précoce.

The impact of post-intubation hypotension on length of stay and mortality in adult and geriatric patients: a cohort study.
Émond M, Lachance-Perreault D, Boucher V, Carmichael PH, Turgeon J, Brousseau AA, Akoum A, Tourigny JN, Le Sage N. | CJEM. 2022 Aug;24(5):509-514
DOI: https://doi.org/10.1007/s43678-022-00305-0  | Télécharger l'article au format  
Keywords: Emergency medicine; Hypotension; Intubation.

Brief Original Research

Introduction : o evaluate the association between standard post-intubation hypotension (< 90 mmHg) and in-hospital mortality. Secondary objectives were to evaluate the association of post-intubation hypotension and length of stay and to assess the impact of increasing post-intubation hypotension threshold to 110 mmHg on hospital length of stay and 48 h-mortality in patients aged ≥ 65 years.

Méthode : Design and setting: A cohort of patients admitted in a level-1 trauma centre emergency department (ED) between November 2011 and July 2016.
Inclusion criteria: aged ≥ 16 with available pre-intubation vital signs, intubation performed in ≤ 3 attempts with no surgical access needed.
Measures: Prospective electronic data collection was used for clinical data.
Main outcome: 48-h in-hospital mortality.
Secondary outcome: hospital length of stay.
Analyses: Univariate and multivariate analyses.

Résultats : A total of 586 patients were included. The mean age was 56.3 ± 18.8 years and 37% were aged ≥ 65 years. Within 60 min of intubation, 224 (38%) patients had at least one systolic blood pressure measure < 90 mmHg and 164(28%) had at least two measures. The < 110 mmHg threshold showed a total of 377 patients (64%) had at least one systolic blood pressure measure < 110 mmHg and 286 (49%) had at least two measures. We found no significant difference in the risk of mortality overall and in stratified-age groups and no association with increased hospital length of stay using both post-intubation hypotension thresholds.

Conclusion : Post-intubation hypotension was recorded in one out of three patients in the ED but we found no association between post-intubation hypotension and 48-h in-hospital mortality overall in adults or geriatric patients.

Conclusion (proposition de traduction) : Une hypotension post-intubation a été enregistrée chez un patient sur trois aux urgences, mais nous n'avons trouvé aucune association entre l'hypotension post-intubation et la mortalité hospitalière à 48 heures chez les adultes ou les patients gériatriques.

Commentaire : Voir l'éditorial :
Green RS, Erdogan M. Are outcomes worse in patients who develop post-intubation hypotension? CJEM  . 2022 Aug;24(5):465-466.

Does immediate coronary angiography improve survival following out-of-hospital cardiac arrest?.
Kareemi H, Eagles D, Rosenberg H. | CJEM. 2022 Aug;24(5):480-481
DOI: https://doi.org/10.1007/s43678-022-00351-8  | Télécharger l'article au format  
Keywords: Aucun

NEED TO KNOW: CJEM JOURNAL CLUB

Introduction : The evidence regarding indications and timing of coronary angiography in patients with out-of-hospital cardiac arrest remains limited.

Méthode : To compare 30-day all-cause mortality between resuscitated patients with out-of-hospital cardiac arrest (OHCA) treated with immediate angiography and possible revascularization versus delayed (at least 24 h) angiography.

Résultats : The two groups were overall well balanced, with more witnessed arrest in the immediate angiography group (91.1% vs. 87.9%) and more shockable first rhythm and bystander CPR in the delayed angiography group (58.7% vs. 52.3%; 60.3% vs. 57.5%, respectively). Among 530 patients included in the intention to treat analysis, the primary outcome occurred in 143/265 (54.05%) of the immediate angiography group and 122/265 of the delayed angiography group, with no difference in time-to-event analyses (hazard ratio 1.28, 95% CI 1.00–1.63; p = 0.06). There was also no difference between groups in the per-protocol or safety analyses, nor in the subgroup analyses including shockable vs. non-shockable first monitored rhythm, confirmed myocardial infarction as trigger for OHCA, or time from arrest to ROSC greater than or less than 15 min. The composite secondary outcome occurred more frequently in the immediate angiography group than in the delayed angiography group (relative risk 1.16; 95% CI 1.00–1.34).

Conclusion : The TOMAHAWK trial demonstrates that immediate angiography does not improve 30-day survival, with a signal towards harm, compared to delayed angiography for patients with return of spontaneous circulation after OHCA. It expands the results of the COACT trial to patients with initial non-shockable rhythms. Although particular patient groups were excluded, the authors provide clear definitions and rationale for pursuing early angiography in patients who develop signs of myocardial injury, including hemodynamic or electrical instability. An essential role of the emergency clinician is to recognize these signs to better select patients that may benefit from early angiography.

Conclusion (proposition de traduction) : L'essai TOMAHAWK démontre que l'angiographie immédiate n'améliore pas la survie à 30 jours, avec un signal de préjudice, par rapport à l'angiographie tardive pour les patients avec retour de la circulation spontanée après un arrêt cardiaque extrahospitalier. Elle étend les résultats de l'essai COACT (Coronary angiography after cardiac arrest without ST segment elevation) aux patients présentant un rythme initial non choquable. Bien que des groupes de patients particuliers aient été exclus, les auteurs fournissent des définitions claires et des arguments en faveur de la poursuite de l'angiographie précoce chez les patients qui présentent des signes de lésions myocardiques, notamment une instabilité hémodynamique ou électrique. Un rôle essentiel du clinicien d'urgence est de reconnaître ces signes pour mieux sélectionner les patients qui peuvent bénéficier d'une angiographie précoce.

Trajectory of patients consulting the emergency department for high blood pressure values.
Vadeboncoeur A, Marcil MJ, Cyr S, Gupta M, Cournoyer A, Minichiello A, Larose D, Sirois-Leclerc J, Tardif JC, Morin J, Masson V, Cossette M, Brouillette J. | CJEM. 2022 Aug;24(5):515-519
DOI: https://doi.org/10.1007/s43678-022-00307-y  | Télécharger l'article au format  
Keywords: Blood pressure; Emergency; Hypertension; Patient-reported experience measures.

Brief Original Research

Introduction : Les visites aux services d'urgence pour hypertension artérielle (TA) sont de plus en plus fréquentes. Nous avons cherché à cartographier le parcours de ces patients, depuis les sources d'orientation jusqu'au type de soins reçus aux urgences, en passant par les mesures prévues en cas de problèmes futurs de tension artérielle élevée, et à mieux comprendre les raisons pour lesquelles ils consultent les urgences pour des valeurs de tension artérielle élevées.

Méthode : Entre 2018 et 2020, les patients qui se sont présentés aux urgences de l'Institut de cardiologie de Montréal pour une TA élevée ont été recrutés dans le cadre d'une étude observationnelle prospective comprenant une entrevue téléphonique structurée post-hoc et un examen des dossiers médicaux. Cinq sources de référence possibles ont été prédéterminées. Nous avons fourni des proportions et des intervalles de confiance à 95 %.

Résultats : Au total, 100 patients ont été recrutés (femmes : 59 %, âge moyen : 69 ± 12). Une majorité (93%, IC à 95% 88-98%) possédait un tensiomètre à domicile, parmi lesquels 46% (IC à 95% 36-56%) se souvenaient avoir reçu des conseils pour son utilisation. Les principales sources d'orientation vers les urgences en cas de tension artérielle élevée étaient l'auto-référence (53 %, IC 95 % 43-63 %), le conseil d'un tiers non-professionnel de la santé (19 %, IC à 95 % 11-27 %) ou d'une infirmière (13 %, IC à 95 % 6-20 %). Principalement, les patients ont déclaré être préoccupés par des symptômes concomitants ou des conséquences médicales aiguës (44 %, IC à 95 %, 34-54 %), avoir suivi la recommandation d’un tiers (33 %, IC à 95 %, 24-42 %) ou avoir des préoccupations au sujet de leurs médicaments (6 %, IC à 95 %, 1-11 %). Deux semaines après leur visite au service d'urgence, la consultation du service d'urgence est restée le principal choix en cas de préoccupations futures concernant l'hypertension artérielle pour 27 % des participants. À la question spécifique de savoir s'ils retourneraient aux urgences pour une TA élevée, 73% (IC à 95% 64-83%) ont répondu oui.

Conclusion : Most patients who consulted the ED for elevated blood pressure values were self-referred. More can be done to promote blood pressure education, effective use of personal blood pressure devices, and recommendations for patients and health professionals when confronted with high blood pressure results.

Conclusion (proposition de traduction) : La plupart des patients qui ont consulté les urgences pour des valeurs élevées de la tension artérielle se sont adressés d'eux-mêmes. Il y a place à l'amélioration pour promouvoir l’éducation sur la TA, l’utilisation efficace des appareils de pression artérielle personnels et les recommandations aux patients et aux professionnels de la santé lorsqu’ils sont confrontés à des résultats élevés en matière de TA.

Targeted Temperature Management After In-Hospital Cardiac Arrest: An Ancillary Analysis of Targeted Temperature Management for Cardiac Arrest With Nonshockable Rhythm Trial Data.
Blanc A, Colin G, Cariou A, Merdji H, Grillet G, Girardie P, Coupez E, Dequin PF, Boulain T, Frat JP, Asfar P, Pichon N, Landais M, Plantefeve G, Quenot JP, Chakarian JC, Sirodot M, Legriel S, Massart N, Thevenin D, Desachy A, Delahaye A, Botoc V, Vimeux S, Martino F, Reignier J, Taccone FS, Lascarrou JB. | Chest. 2022 Aug;162(2):356-366
DOI: https://doi.org/10.1016/j.chest.2022.02.056
Keywords: in-hospital cardiac arrest; moderate therapeutic hypothermia; neurological outcome; nonshockable rhythm.

Original Research - CRITICAL CARE

Introduction : Targeted temperature management (TTM) currently is the only treatment with demonstrated efficacy in attenuating the harmful effects on the brain of ischemia-reperfusion injury after cardiac arrest. However, whether TTM is beneficial in the subset of patients with in-hospital cardiac arrest (IHCA) remains unclear.
Research question: Is TTM at 33 °C associated with better neurological outcomes after IHCA in a nonshockable rhythm compared with targeted normothermia (TN; 37 °C)?

Méthode : We performed a post hoc analysis of data from the published Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm randomized controlled trial in 584 patients. We included the 159 patients with IHCA; 73 were randomized to 33 °C treatment and 86 were randomized to 37 °C treatment. The primary outcome was survival with a good neurologic outcome (cerebral performance category [CPC] score of 1 or 2) on day 90. Mixed multivariate adjusted logistic regression analysis was performed to determine whether survival with CPC score of 1 or 2 on day 90 was associated with type of temperature management after adjustment on baseline characteristics not balanced by randomization.

Résultats : Compared with TN for 48 h, hypothermia at 33 °C for 24 h was associated with a higher percentage of patients who were alive with good neurologic outcomes on day 90 (16.4% vs 5.8%; P = .03). Day 90 mortality was not significantly different between the two groups (68.5% vs 76.7%; P = .24). By mixed multivariate analysis adjusted by Cardiac Arrest Hospital Prognosis score and circulatory shock status, hypothermia was associated significantly with good day 90 neurologic outcomes (OR, 2.40 [95% CI, 1.17-13.03]; P = .03).

Conclusion : Hypothermia at 33 °C was associated with better day 90 neurologic outcomes after IHCA in a nonshockable rhythm compared with TN. However, the limited sample size resulted in wide CIs. Further studies of patients after cardiac arrest resulting from any cause, including IHCA, are needed.

Conclusion (proposition de traduction) : L'hypothermie à 33° C était associée à de meilleurs résultats neurologiques au 90^e jour après un arrêt cardiaque à l'hôpital avec un rythme non choquable, par rapport à une normothermie ciblée. Cependant, la taille limitée de l'échantillon a entraîné des intervalles de confiance larges. D'autres études sur les patients après un arrêt cardiaque, quelle qu'en soit la cause, y compris un arrêt cardiaque à l'hôpital, sont nécessaires.

High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain.
Sandoval Y, Apple FS, Mahler SA, Body R, Collinson PO, Jaffe AS; International Federation of Clinical Chemistry and Laboratory Medicine Committee on the Clinical Application of Cardiac Biomarkers. | Circulation. 2022 Aug 16;146(7):569-581
DOI: https://doi.org/10.1161/circulationaha.122.059678  | Télécharger l'article au format  
Keywords: chest pain; myocardial infarction; troponin

PRIMER

Editorial : The 2021 American Heart Association/American College of Cardiology/American Society of Echocardiography/American College of Chest Physicians/Society for Academic Emergency Medicine/Society of Cardiovascular Computed Tomography/Society for Cardiovascular Magnetic Resonance guidelines for the evaluation and diagnosis of acute chest pain make important recommendations that include the recognition of high-sensitivity cardiac troponin (hs-cTn) as the preferred biomarker, endorsement of 99th percentile upper reference limits to define myocardial injury, and the use of clinical decision pathways, as well as acknowledgment of the uniqueness of women and other patient subsets. Details on how to integrate hs-cTn into clinical practice are less extensively addressed. Clinicians should be aware of some of the analytical aspects related to hs-cTn assays regarding the limit of detection and the limit of quantitation and how they are used clinically, especially for the single sample strategy to rule out acute myocardial infarction. Likewise, it is important for clinicians to understand issues related to the derivation of the 99th percentile upper reference limit; the value of sex-specific 99th percentile upper reference limits; how to use changing concentrations (deltas) to facilitate diagnosis and risk stratification of patients with suspected acute coronary syndrome, including the differentiation of acute from chronic myocardial injury; and how to best integrate the use of hs-cTn with clinical decision pathways. With the use of hs-cTn, conditions such as type 2 myocardial infarction become more common, whereas others such as unstable angina become less frequent but still occur. Sections relating to these issues are included.

Conclusion : We have provided evidence-based perspectives to assist with the evaluation of patients with suspected ACS and the proper use of hs-cTn assays to integrate them into the recent ACC/AHA guidelines. It is encouraging and a good start to see hs-cTn incorporated into new guidelines. Their use should be coordinated globally across all medical disciplines. Opportunities exist to address many key elements that we have articulated in upcoming policy documents from the major societies.

Conclusion (proposition de traduction) : Nous avons fourni des perspectives fondées sur des données probantes pour aider à l'évaluation des patients suspects de SCA et à l'utilisation correcte des dosages de la hs-cTn afin de les intégrer dans les récentes lignes directrices de l'ACC/AHA. Il est encourageant et c'est un bon début de voir la hs-cTn intégrée dans les nouvelles directives. Leur utilisation devrait être coordonnée au niveau mondial dans toutes les disciplines médicales. Il existe des possibilités d'aborder de nombreux éléments clés que nous avons articulés dans les documents de politique à venir des principales sociétés.

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.

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.

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.

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.

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.

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.

Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department.
Abid ES, Miller KA, Monuteaux MC, Nagler J. | Emerg Med J. 2022 Aug;39(8):601-607
DOI: https://doi.org/10.1136/emermed-2021-211570
Keywords: airway; paediatric emergency medicine; paediatrics.

Original research

Introduction : Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting.
Objective: We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations.

Méthode : We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors.

Résultats : During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy.

Conclusion : Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.

Conclusion (proposition de traduction) : L'augmentation du nombre de tentatives d'intubation endotrachéale est associée à un risque plus élevé d'événements indésirables. Les efforts visant à optimiser la réussite de la première tentative chez les enfants en cours d'intubation peuvent atténuer ce risque et améliorer les résultats cliniques.

Utility of magnesium sulfate in the treatment of rapid atrial fibrillation in the emergency department: a systematic review and meta-analysis.
Hoffer M, Tran QK, Hodgson R, Atwater M, Pourmand A. | Eur J Emerg Med. 2022 Aug 1;29(4):253-261
DOI: https://doi.org/10.1097/mej.0000000000000941
Keywords: Aucun

Review

Editorial : Atrial fibrillation with rapid ventricular response (Afib/RVR) is a frequent reason for emergency department (ED) visits and can be treated with a variety of pharmacological agents. Magnesium sulfate has been used to prevent and treat postoperative Afib/RVR. We performed a systematic review and meta-analysis to assess the effectiveness of magnesium for treatment of Afib/RVR in the ED. PubMed and Scopus databases were searched up to June 2021 to identify any relevant randomized trials or observational studies. We used Cochrane's Risk-of-Bias tools to assess study qualities and random-effects meta-analysis for the difference of heart rate (HR) before and after treatment. Our search identified 395 studies; after reviewing 11 full texts, we included five randomized trials in our analysis. There were 815 patients with Afib/RVR; 487 patients (60%) received magnesium treatment, whereas 328 (40%) patients received control treatment. Magnesium treatment was associated with significant reduction in HR [standardized mean difference (SMD), 0.34; 95% CI, 0.21-0.47; P < 0.001; I2 = 4%), but not associated with higher rates of sinus conversion (OR, 1.46; 95% CI, 0.726-2.94; P = 0.29), nor higher rates of hypotension and bradycardia (OR, 2.2; 95% CI, 0.62-8.09; P = 0.22). Meta-regressions demonstrated that higher maintenance dose (corr. coeff, 0.17; P = 0.01) was positively correlated with HR reductions, respectively. We observed that magnesium infusion can be an effective rate control treatment for patients who presented to the ED with Afib/RVR. Further studies with more standardized forms of control and magnesium dosages are necessary to assess the benefit/risk ratio of magnesium treatment, besides to confirm our observations.

Conclusion : Magnesium sulfate has been used successfully in the treatment of rapid atrial fibrillation in the ED setting, both as an independent agent and as an adjunct to other medication for rate control. Further randomized control studies in the ED setting using magnesium as a single agent comparing to other medications are necessary to confirm our observations.

Conclusion (proposition de traduction) : Le sulfate de magnésium a été utilisé avec succès dans le traitement de la fibrillation atriale rapide dans le contexte des urgences, à la fois comme agent indépendant et comme adjuvant à d'autres médicaments pour contrôler la fréquence. D'autres études de contrôle randomisées dans le contexte des urgences, utilisant le magnésium comme agent unique en comparaison avec d'autres médicaments, sont nécessaires pour confirmer nos observations. Traduit avec www.DeepL.com/Translator (version gratuite)

Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis.
Vang M, Østberg M, Steinmetz J, Rasmussen LS. | Eur J Trauma Emerg Surg. 2022 Aug;48(4):2559-2566
DOI: https://doi.org/10.1007/s00068-022-01932-z
Keywords: Emergency department; Massive blood transfusion; Mortality; Shock index; Trauma.

Review Article

Introduction : The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1.

Méthode : This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa.

Résultats : We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low.

Conclusion : This systematic review found a fourfold increased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

Conclusion (proposition de traduction) : Cette revue systématique a trouvé un risque quatre fois plus élevé de mortalité à l'hôpital chez les patients adultes victimes de traumatismes avec un IS initial ≥ 1 dans le service d'urgence ou le centre de traumatologie.

Prehospital FAST reduces time to admission and operative treatment: a prospective, randomized, multicenter trial.
Lucas B, Hempel D, Otto R, Brenner F, Stier M, Marzi I, Breitkreutz R, Walcher F. | Eur J Trauma Emerg Surg. 2022 Aug;48(4):2701-2708
DOI: https://doi.org/10.1007/s00068-021-01806-w  | Télécharger l'article au format  
Keywords: Abdominal injury; FAST; Prehospital ultrasound; Time-to-surgery; Trauma room.

Original Article

Introduction : The focused assessment with sonography in trauma (FAST) exam is an established trauma care diagnostic procedure. Ultrasound performed during prehospital care can improve early treatment and management of the patients. In this prospective randomized clinical trial, we wanted to assess whether a pre-hospital FAST (p-FAST) influences pre-hospital strategy and the time to operative treatment.

Méthode : We studied 296 trauma victims in a prehospital setting. Inclusion criteria were potential abdominal injuries identified either by clinical examination or suggested by the mechanism of injury. Physician-staffed helicopters and emergency ambulances were equipped with portable ultrasound devices. According to a scheme related to calendar weeks, a clinical exam only (CEX) or a clinical exam together with a p-FAST (CEX-p-FAST) was conducted. Outcome variables were prehospital diagnosis and strategy, the time to admission to the trauma room and to operation theater. The study was approved by the university ethical committee (REB#: 46/06).

Résultats : CEX-p-FAST showed a high sensitivity (94.7%) and specificity (97.6%) in detection of free fluid compared to CEX-only (80.0%, 84.4%). The median time to admission was reduced significantly by 13 min and to operative treatment by 15 min after CEX-p-FAST. We observed a cross-over rate of 30.8% of p-FAST (n = 36) to CEX-p-FAST during the CEX-only weeks.

Conclusion : According to the experience of the principal investigators, CEX-p-FAST was superior to CEX-only. Despite the time needed for p-FAST, the relevant admission time was significantly shorter. Thus, p-FAST is recommended in addition to CEX if possible for decision-making in prehospital trauma care.

Conclusion (proposition de traduction) : Selon l'expérience des investigateurs principaux, l'examen clinique associé à une évaluation préhospitalière ciblée par échographie en traumatologie était supérieur à l'examen clinique seul. Malgré le temps nécessaire à l'évaluation pré-hospitalière ciblée avec échographie en traumatologie, le temps d'admission pertinent était significativement plus court. Par conséquent, l'évaluation préhospitalière ciblée avec échographie en traumatologie est recommandée en plus de l'examen clinique si possible pour la prise de décision dans les soins préhospitaliers de traumatologie.

Association between the time to definitive care and trauma patient outcomes: every minute in the golden hour matters.
Hsieh SL, Hsiao CH, Chiang WC, Shin SD, Jamaluddin SF, Son DN, Hong KJ, Jen-Tang S, Tsai W, Chien DK, Chang WH, Chen TH; PATOS Clinical Research Network. | Eur J Trauma Emerg Surg. 2022 Aug;48(4):2709-2716
DOI: https://doi.org/10.1007/s00068-021-01816-8  | Télécharger l'article au format  
Keywords: Golden hour; PATOS; Pan-Asia trauma outcomes study; Time to definitive care; Trauma.

Original Article

Introduction : This study examined the association between lapsed time and trauma patients, suggesting that a shorter time to definitive care leads to a better outcome.

Méthode : We used the Pan-Asian Trauma Outcome Study registry to analyze a retrospective cohort of 963 trauma patients who received surgical intervention or transarterial embolization within 2 h of injury in Asian countries between January 2016 and December 2020. Exposure measurement was recorded every 30 min from injury to definitive care. The 30 day mortality rate and functional outcome were studied using the Modified Rankin Scale ratings of 0-3 vs 4-6 for favorable vs poor functional outcomes, respectively. Subgroup analyses of different injury severities and patterns were performed.

Résultats : The mean time from injury to definitive care was 1.28 ± 0.69 h, with cases categorized into the following subgroups: < 30, 30-60, 60-90, and 90-120 min. For all patients, a longer interval was positively associated with the 30 day mortality rate (p = 0.053) and poor functional outcome (p < 0.05). Subgroup analyses showed the same association in the major trauma (n = 321, p < 0.05) and torso injury groups (n = 388, p < 0.01) with the 30 day mortality rate and in the major trauma (p < 0.01), traumatic brain injury (n = 741, p < 0.05), and torso injury (p < 0.05) groups with the poor functional outcome.

Conclusion : Even within 2 h, a shorter time to definitive care is positively associated with patient survival and functional outcome, especially in the subgroups of major trauma and torso injury.

Conclusion (proposition de traduction) : Même dans les 2 heures, un délai plus court avant l'arrivée des soins définitifs est associé positivement à la survie et au résultat fonctionnel du patient, en particulier dans les sous-groupes des traumatismes majeurs et des lésions du thorax.

Elevated serum lactate levels and age are associated with an increased risk for severe injury in trauma team activation due to trauma mechanism.
Hagebusch P, Faul P, Klug A, Gramlich Y, Hoffmann R, Schweigkofler U. | Eur J Trauma Emerg Surg. 2022 Aug;48(4):2717-2723
DOI: https://doi.org/10.1007/s00068-021-01811-z  | Télécharger l'article au format  
Keywords: Age; Injury severity; Lactate; Risk factors; Trauma team activation; Trauma triage.

Original Article

Introduction : The identification of risk factors for severe injury is crucial in trauma triage and trauma team activation (TTA) depends on a sufficient triage. The aim of this study was to determine whether or not elevated serum lactate levels and age are risk factors for severe injury in TTA due to trauma mechanism.

Méthode : We conducted a retrospective cohort study in a single level one trauma center between September 2019 and May 2021 and analysed every TTA due to trauma mechanism. Primary endpoint of interest was the association of serum lactate as well as age with injury severity assessed by the injury severity score (ISS).

Résultats : During the study period, we included 250 patients. Mean age was 43.3 years (Min.: 11, Max.: 90, SD: 18.7) and the initial lactate level was 1.7 mmol/L (SD: 0.95) with a mean ISS of 8.4 (SD: 8.99). The adjusted odds ratio (OR) for age > 65 being associated with an ISS > 16 is 9.7 (p < 0.001; 95% CI 4.01-25.58) and for lactate > 2.2 mmol/L being associated with an ISS > 16 is 6.29 (p < 0.001; 95% CI 2.93-13.48). A lactate level of > 4 mmol/L results in a 36-fold higher risk of severe injury with an ISS > 16 (OR 36.06; 95% CI 4-324.29).

Conclusion : This study identifies age (> 65) and lactate (> 2.2 mmol/L) as independent risk factors for severe injury in a TTA due to trauma mechanism. Existing triage protocols might benefit from congruous amendments.

Conclusion (proposition de traduction) : Cette étude identifie l'âge (> 65 ans) et le taux de lactate (> 2,2 mmol/L) comme des facteurs de risque indépendants de blessure grave lors d'une activation d'une équipe de traumatologie due à un mécanisme de traumatisme. Les protocoles de triage existants pourraient bénéficier de modifications congruentes.

Incidence and prognosis of myocardial injury in patients with severe trauma.
Stroda A, Thelen S, M'Pembele R, Adelowo A, Jaekel C, Schiffner E, Bieler D, Bernhard M, Huhn R, Lurati Buse G, Roth S. | Eur J Trauma Emerg Surg. 2022 Aug;48(4):3073-3079
DOI: https://doi.org/10.1007/s00068-021-01846-2  | Télécharger l'article au format  
Keywords: Cardiac biomarkers; Mortality; Multiple trauma; Resuscitation room; Troponin.

Original Article

Introduction : Severe trauma can lead to end organ damages of varying severity, including myocardial injury. In the non-cardiac surgery setting, there is extensive evidence that perioperative myocardial injury is associated with increased morbidity and mortality. The impact of myocardial injury on outcome after severe trauma has not been investigated adequately yet. We hypothesized that myocardial injury is associated with increased in-hospital mortality in patients with severe trauma.

Méthode : This retrospective cohort study included patients ≥ 18 years with severe trauma [defined as injury severity score (ISS) ≥ 16] that were admitted to the resuscitation room of the Emergency Department of the University Hospital Duesseldorf, Germany, between 2016 and 2019. The main endpoint was in-hospital mortality. Main exposure was myocardial injury at arrival [defined as high-sensitive troponin T (hsTnT) > 14 ng/l]. For statistical analysis, receiver operating characteristic curve (ROC) and multivariate binary logistic regression were performed.

Résultats : Out of 368 patients, 353 were included into statistical analysis (72.5% male, age: 55 ± 21, ISS: 28 ± 12). Overall in-hospital mortality was 26.1%. Myocardial injury at presentation was detected in 149 (42.2%) patients. In-hospital mortality of patients with and without myocardial injury at presentation was 45% versus 12.3%, respectively. The area under the curve (AUC) for hsTnT and mortality was 0.76 [95% confidence interval (CI) 0.71-0.82]. The adjusted odds ratio of myocardial injury for in-hospital mortality was 2.27 ([95%CI 1.16-4.45]; p = 0.017).

Conclusion : Myocardial injury after severe trauma is common and independently associated with in-hospital mortality. Thus, hsTnT might serve as a new prognostic marker in this cohort.

Conclusion (proposition de traduction) : Les lésions myocardiques après un traumatisme grave sont fréquentes et associées de manière indépendante à la mortalité hospitalière. La troponine T ultrasensible pourrait donc servir de nouveau marqueur pronostique dans cette cohorte.

Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center.
El-Menyar A, Ahmed K, Hakim S, Kanbar A, Mathradikkal S, Siddiqui T, Jogol H, Younis B, Taha I, Mahmood I, Ajaj A, Atique S, Alaieb A, Bahey AA, Asim M, Alinier G, Castle NR, Mekkodathil A, Rizoli S, Al-Thani H. | Eur J Trauma Emerg Surg. 2022 Aug;48(4):3089-3099
DOI: https://doi.org/10.1007/s00068-021-01848-0  | Télécharger l'article au format  
Keywords: Bleeding; Prehospital; Randomized controlled trial; Tranexamic acid; Trauma.

ORIGINAL ARTICLE

Introduction : Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients.

Méthode : A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF).

Résultats : A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062-16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157-1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance.

Conclusion : The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies.

Conclusion (proposition de traduction) : La deuxième dose d'acide tranexamique n'a pas modifié le taux de mortalité, le besoin de transfusion sanguine, les complications thromboemboliques, la défaillance d'organe et la durée de séjour à l'hôpital par rapport à une dose préhospitalière unique ; son administration systématique devrait donc être revue dans le cadre d'études plus vastes et multicentriques.

Prehospital traumatic cardiac arrest: a systematic review and meta-analysis.
Vianen NJ, Van Lieshout EMM, Maissan IM, Bramer WM, Hartog DD, Verhofstad MHJ, Van Vledder MG. | Eur J Trauma Emerg Surg. 2022 Aug;48(4):3357-3372
DOI: https://doi.org/10.1007/s00068-022-01941-y  | Télécharger l'article au format  
Keywords: Mortality; Neurological outcome; Organization of EMS system; Prognostic factors; Registry type; Traumatic cardiac arrest (TCA).

ORIGINAL ARTICL

Introduction : Circulatory arrest after trauma is a life-threatening situation that mandates urgent action. The aims of this sys- tematic review and meta-analysis on prehospital traumatic cardiac arrest (TCA) were to provide an updated pooled mortality rate for prehospital TCA, to investigate the impact of the time of patient inclusion and the type of prehospital trauma system on TCA mortality rates and neurological outcome, and to investigate which pre- and intra-arrest factors are prognostic for prehospital TCA mortality.

Méthode : This review was conducted in accordance with the PRISMA and CHARMS guidelines. Databases were searched for primary studies published about prehospital TCA patients (1995–2020). Studies were divided into various EMS-system categories. Data were analyzed using MedCalc, Review Manager, Microsoft Excel, and Shinyapps Meta Power Calculator software.

Résultats : Thirty-six studies involving 51.722 patients were included. Overall mortality for TCA was 96.2% and a favorable neurological outcome was seen in 43.5% of the survivors. Mortality rates were 97.2% in studies including prehospital deaths and 92.3% in studies excluding prehospital deaths. Favorable neurological outcome rates were 35.8% in studies including prehospital deaths and 49.5% in studies excluding prehospital deaths. Mortality rates were 97.6% if no physician was avail- able at the prehospital scene and 93.9% if a physician was available. Favorable neurological outcome rates were 57.0% if a physician was available on scene and 38.0% if no physician was available. Only non-shockable rhythm was associated with a higher mortality (RR 1.12, p = 0.06).

Conclusion : Approximately 1 in 20 patients with prehospital TCA will survive; about 40% of survivors have favorable neu- rological outcome.

Conclusion (proposition de traduction) : Environ 1 patient sur 20 ayant subi un arrêt cardiaque traumatique préhospitalier survivra ; environ 40 % des survivants ont une issue neurologique favorable.

Commentaire : Erratum  

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.

Imaging the acute respiratory distress syndrome: past, present and future.
Bitker L, Talmor D, Richard JC. | Intensive Care Med. 2022 Aug;48(8):995-1008
DOI: https://doi.org/10.1007/s00134-022-06809-8  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; Computed tomography; Electrical impedance tomography; Lung ultrasounds; Positron emission tomography; Ventilator-induced lung injuries.

NARRATIVE REVIEW

Editorial : In patients with the acute respiratory distress syndrome (ARDS), lung imaging is a fundamental tool in the study of the morphological and mechanistic features of the lungs. Chest computed tomography studies led to major advances in the understanding of ARDS physiology. They allowed the in vivo study of the syndrome's lung features in relation with its impact on respiratory physiology and physiology, but also explored the lungs' response to mechanical ventilation, be it alveolar recruitment or ventilator-induced lung injuries. Coupled with positron emission tomography, morphological findings were put in relation with ventilation, perfusion or acute lung inflammation. Lung imaging has always been central in the care of patients with ARDS, with modern point-of-care tools such as electrical impedance tomography or lung ultrasounds guiding clinical reasoning beyond macro-respiratory mechanics. Finally, artificial intelligence and machine learning now assist imaging post-processing software, which allows real-time analysis of quantitative parameters that describe the syndrome's complexity. This narrative review aims to draw a didactic and comprehensive picture of how modern imaging techniques improved our understanding of the syndrome, and have the potential to help the clinician guide ventilatory treatment and refine patient prognostication.

Conclusion : The history of ARDS is closely related to that of lung imaging. Chest CT studies have led to major advances in our understanding of ARDS physiology by allowing the in vivo study of the mechanical forces that apply to the injured lungs under mechanical ventilation. Coupled with PET, morphological findings are now put in relation to functional parameters such as lung inflammation.
Point-of-care tools such as EIT or LUS, although limited in their spatial resolution, have confirmed their potential role in the assistance they bring to clinicians to improve their clinical reasoning beyond macro-respiratory mechanics, and possibly improve their ability to choose and select the best ventilation strategy. Yet, a long path remains ahead, to pursue the development of real-time, high-resolution, functional, and mechanistic imaging technologies, as an intermediate step before image-derived parameters may improve ARDS patients’ outcome.

Conclusion (proposition de traduction) : L'histoire du syndrome de détresse respiratoire aiguë est étroitement liée à celle de l'imagerie pulmonaire. Les études de tomodensitométrie thoracique ont permis des avancées majeures dans notre compréhension de la physiologie du syndrome de détresse respiratoire aiguë en permettant l'étude in vivo des forces mécaniques qui s'appliquent aux poumons lésés sous ventilation mécanique. Couplés à la tomographie par émission de positons, les résultats morphologiques sont désormais mis en relation avec des paramètres fonctionnels tels que l'inflammation pulmonaire.
Les outils de point-of-care tels que la tomographie par impédance électrique ou les ultrasons pulmonaires, bien que limités dans leur résolution spatiale, ont confirmé leur rôle potentiel dans l'aide qu'ils apportent aux cliniciens pour améliorer leur raisonnement clinique au-delà de la mécanique macro-respiratoire, et éventuellement améliorer leur capacité à choisir et sélectionner la meilleure stratégie de ventilation. Cependant, un long chemin reste à parcourir pour poursuivre le développement de technologies d'imagerie fonctionnelle et mécaniste en temps réel et à haute résolution, comme étape intermédiaire avant que les paramètres dérivés de l'imagerie puissent améliorer le résultat des patients atteints du syndrome de détresse respiratoire aiguë.

Understanding base excess (BE): merits and pitfalls.
Langer T, Brusatori S, Gattinoni L. | Intensive Care Med. 2022 Aug;48(8):1080-1083
DOI: https://doi.org/10.1007/s00134-022-06748-4  | Télécharger l'article au format  
Keywords: Aucun

UNDERSTANDING THE DISEASE

Editorial : Base excess (BE) was introduced by Siggaard-Andersen in 1960 as an answer to the forty-year-long quest for a reliable, stand-alone marker of metabolic acidosis/alkalosis, independent from co-existing respiratory derangements, and able to quantify the severity of the disorder.

Conclusion : SBE is a useful parameter to assist in the diagnosis of metabolic acid–base disorders and to assess the meta- bolic displacement quantitatively. It is a calculated value, that relies on several measured variables (pH, PCO2, hemoglobin concentration) and assumes normal plasma proteins. Importantly, SBE by itself does not provide information about the underlying condition and could be perfectly normal in the case of multiple conditions acting in opposite directions. Therefore, while an abnormal SBE is a reliable marker of an active metabolic issue, a normal SBE is not enough to exclude it. For this reason, SBE cannot be considered a stand-alone parameter. Indeed, it is fundamental to integrate its values with other information to identify complex acid–base disorders.

Conclusion (proposition de traduction) : L'excès de base standard est un paramètre utile pour aider au diagnostic des troubles acido-basiques métaboliques et pour évaluer quantitativement le déplacement métabolique. Il s'agit d'une valeur calculée, qui repose sur plusieurs variables mesurées (pH, PCO2, concentration d'hémoglobine) et suppose des protéines plasmatiques normales. Il est important de noter que l'excès de base standard en lui-même ne fournit pas d'informations sur l'affection sous-jacente et peut être parfaitement normal dans le cas d'affections multiples agissant dans des directions opposées. Par conséquent, si un excès de base standard anormal est un marqueur fiable d'un problème métabolique actif, un excès de base standard normal ne suffit pas à l'exclure. Pour cette raison, l'excès de base standard ne peut être considéré comme un paramètre autonome. En effet, il est fondamental d'intégrer ses valeurs à d'autres informations pour identifier les troubles acido-basiques complexes.

Is there still an indication for episiotomy? Results from a French national database analysis.
Levaillant M, Loury C, Venara A, Hamel-Broza JF, Legendre G. | Int J Gynaecol Obstet. 2022 Aug 9
DOI: https://doi.org/10.1002/ijgo.14385
Keywords: anal sphincter; database; episiotomy; health services administration; obstetric injury.

CLINICAL ARTICLE

Introduction : To assess the link between mediolateral episiotomy and the occurrence of obstetrical anal sphincter injury (OASIS).

Méthode : Data were collected from the national database (PMSI; Programme de Médicalisation des Systèmes d'Information). Women between 18 and 50 years old, undergoing a vaginal delivery in France in 2018 were included. The main outcome was factors associated with a higher adjusted OASIS rate after a vaginal delivery.

Résultats : Of 623 003 women with a vaginal delivery, 239 949 were primiparous (38.5%), 62 310 experienced mediolateral episiotomy (10.0%) and 7077 had a third- or fourth-degree perineal tear (1.14%). Risk factors for OASIS were primiparity (adjusted odds ratio [OR] 2.97), shoulder dystocia (aOR 2.57), instrumental delivery (aOR 2.81), gestational diabetes (aOR 1.20), and post-term delivery (aOR 1.53). Mediolateral episiotomy increased the occurrence of OASIS for women without an instrumental delivery, either for parous (OR 1.32, 95% confidence interval [CI] 1.07-1.62) or primiparous (OR 1.26, 95% CI 1.13-1.39) women. In contrast, episiotomy among primiparous women with episiotomy and a vacuum or forceps delivery significantly decreased the risk for OASIS (OR 0.62, 95% CI 0.56-0.67).

Conclusion : The practice of routine episiotomy should be discouraged. Selective mediolateral episiotomy should be considered with extreme caution and mainly for primiparous women during instrumental vaginal delivery. Further randomized trial may confirm such results.

Conclusion (proposition de traduction) : La pratique de l'épisiotomie systématique doit être déconseillée. L'épisiotomie médiolatérale sélective doit être envisagée avec une extrême prudence et principalement pour les femmes primipares lors d'un accouchement vaginal instrumental. D'autres essais randomisés pourraient confirmer ces résultats.

Review of knowledge and professional practices on the obstacle médico-légal of post-graduate doctors and residents in four hospitals in Maine-et-Loire.
Bonnot E, Zabet D, Jousset N. | Med Droit. 2022 Aug;175:59–70
DOI: https://doi.org/10.1016/j.meddro.2022.05.002
Keywords: Death certificate

Exercice professionnel

Introduction : Le constat de décès est une responsabilité incombant à tout médecin. En cas de décès suspect, inattendu ou violent, l’obstacle médico-légal (OML) doit être coché sur le certificat de décès. Les études françaises publiées sur l’OML concernent exclusivement les médecins pré-hospitaliers. L’objectif principal de notre étude était d’évaluer les connaissances et les pratiques actuelles des médecins intra-hospitaliers concernant l’OML.

Méthode : Nous avons réalisé une étude descriptive, quantitative, multicentrique comprenant d’abord un recueil rétrospectif du nombre de certificats avec OML reçus à la chambre mortuaire du CHUd’Angers provenant de quatre hôpitaux du Maine-et-Loire (CHU d’Angers, CH de Cholet, CH de Saumur, CESAME) entre 2017 et 2020 puis un questionnaire anonyme adressé aux médecins thésés et internes de ces mêmes hôpitaux, les interrogeant sur leurs connaissances et expériences sur le sujet et comportant huit cas cliniques fictifs sur les situations les plus fréquemment rencontrées en pratique. Les réponses libres aux cas cliniques ont été classées en quatre catégories avec aussi la possibilité de répondre « ne sait pas ».

Résultats : De 2017 à 2020, 1,7 % (131/7484) des décès survenus au CHU d’Angers ont été concernés par un OML. Le questionnaire a permis de recueillir, au total, 386 réponses sur 1596 personnes contactées (24,2 %). Le frein principal à la pose d’un OML était une « méconnaissance globale sur l’OML » (80,1 % des participants). Avoir une formation antérieure en médecine légale était à l’origine d’une influence significative sur la pose d’OML. Presque 50 % des participants ne poseraient pas d’OML en cas de suspicion de faute durant la prise en charge. Tous cas cliniques confondus, la réponse majoritaire était la catégorie1 (37 % des réponses).

Conclusion (proposition de traduction) : Notre étude apporte des résultats similaires aux publications actuelles de la littérature française concernant les médecins pré-hospitaliers. Un renforcement des connaissances des cliniciens sur l’OML et l’incitation à une prise d’avis auprès du légiste d’astreinte du CHU d’Angers sont à promouvoir. Notre étude a également permis d’aborder la problématique des situations de suspicions de faute médicale qui représentent une difficulté supplémentaire pour les médecins du fait du conflit d’intérêt généré et pour lesquelles le procédé d’OML semble peu adapté.

Prehospital Epinephrine Use in Pediatric Anaphylaxis by Emergency Medical Services.
Lowing D, Chung S, Luk J, Dingeldein L. | Pediatr Emerg Care. 2022 Aug 1;38(8):367-371
DOI: https://doi.org/10.1097/pec.0000000000002783
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Anaphylaxis requires prompt assessment and management with epinephrine to reduce its morbidity and mortality. This study examined the prehospital management of pediatric anaphylactic reactions in Northeast Ohio.

Méthode : This is a retrospective chart review using emergency medical service (EMS) run charts of patients 18 years and younger from February 2015 to April 2019. Patient charts with the diagnosis of "anaphylaxis" or "allergic reaction" were reviewed and confirmed that symptoms met anaphylaxis criteria. Information regarding epinephrine administration before EMS arrival and medications given by EMS providers was collected. Analysis was performed using descriptive statistics.

Résultats : From 646 allergic/anaphylactic reaction EMS run charts, 150 (23%) met the guideline criteria for anaphylaxis. The median patient age was 12 years. Only 57% (86/150) of these patients received intramuscular epinephrine, and the majority received it before EMS arrival. Epinephrine was administered by EMS to 32% (30/94; 95% confidence interval [CI], 22.7% to 42.3%) of patients who had not already received epinephrine. The odds of receiving prehospital epinephrine were significantly lower for patients 5 years and younger (risk difference [RD], -0.23; 95% CI, -0.43 to -0.04), those with no history of allergic reaction (RD, -0.20; 95% CI, -0.38 to -0.03), those who presented with lethargy (RD, -0.43; 95% CI, -0.79 to -0.06), and those whose trigger was a medication or environmental allergen (RD, -0.47; 95% CI, -0.72 to -0.23 for each).

Conclusion : Emergency medical service providers in this region demonstrated similar use of epinephrine as reported elsewhere. However, 43% (64/150) of pediatric patients meeting anaphylaxis criteria did not receive prehospital epinephrine, and 10% (15/150) received no treatment whatsoever. Efforts to improve EMS provider recognition and prompt epinephrine administration in pediatric cases of anaphylaxis seem necessary.

Conclusion (proposition de traduction) : Les prestataires de services médicaux d'urgence de cette région ont fait une utilisation de l'adrénaline similaire à celle rapportée ailleurs. Cependant, 43% (64/150) des patients pédiatriques répondant aux critères d'anaphylaxie n'ont pas reçu d'adrénaline préhospitalière, et 10% (15/150) n'ont reçu aucun traitement. Il semble nécessaire de déployer des efforts pour améliorer la reconnaissance par les prestataires de SMU et l'administration rapide d'adrénaline dans les cas d'anaphylaxie pédiatrique.

Evaluation of Pelvic Circular Compression Devices in Severely Injured Trauma Patients with Pelvic Fractures.
Berger-Groch J, Rueger JM, Czorlich P, Frosch KH, Lefering R, Hoffmann M; Trauma Register DGU. | Prehosp Emerg Care. 2022 Jul-Aug;26(4):547-555
DOI: https://doi.org/10.1080/10903127.2021.1945717
Keywords: Abbreviated Injury Scale of the pelvis; ISS; mortality; pelvic fracture; polytrauma; registry.

Article

Introduction : The role of pelvic circumferential compression devices (PCCD) is to temporarily stabilize the pelvic ring, reduce its volume and to tamponade bleeding. The purpose of this study was to evaluate the effect of PCCDs on mortality and bleeding in severely injured trauma patients, using a large registry database.

Méthode : We performed a retrospective analysis of all patients registered in the Trauma Register DGU® between 2015 and 2016. The study was limited to directly admitted patients who were alive on admission, with an injury severity score (ISS) of 9 or higher, with an Abbreviated Injury Scale AISpelvis of 3-5, aged at least 16, and with complete status documentation on pelvic circular compression devices (PCCD) and mortality. A cohort analysis was undertaken of patients suffering from relevant pelvic fractures. Data were collected on mortality and requirements for blood transfusion. The observed outcome was compared with the expected outcome as derived from version II of the Revised Injury Severity Classification (RISC II) and adjusted accordingly. A Standardized Mortality Ratio (SMR) was also calculated.

Résultats : A total of 9,910 patients were included. 1,103 of 9,910 patients suffered from a relevant pelvic trauma (AISpelvis = 3-5). Only 41% (454 cases) of these received a PCCD. PCCD application had no significant effect on mortality and did not decrease the need for blood transfusion in the multivariate regression analysis. However, in this cohort, the application of a PCCD is a general indicator for a critical patient with increased mortality (12.0% no PCCD applied vs. 23.2% PCCD applied prehospital vs. 27.1% PCCD applied in the emergency department). The ISS was higher in patients with PCCD (34.12 ± 16.4 vs. 27.9 ± 13.8; p < 0.001).

Conclusion : PCCD was applied more often in patients with severe pelvic trauma according to ISS and AISpelvis as well with deterioration in circulatory status. PCCDs did not reduce mortality or reduce the need for blood transfusion.

Conclusion (proposition de traduction) : Les ceintures pelviennes ont été appliqués plus souvent chez les patients souffrant de traumatismes pelviens graves selon le score de gravité des blessures (ISS) et l'échelle abrégée des blessures (AISpelvis), ainsi qu'en cas de détérioration de l'état circulatoire. Les ceintures pelviennes n'ont pas réduit la mortalité ni le besoin en transfusion sanguine.

Need for Emergent Intervention within 6 Hours: A Novel Prediction Model for Hospital Trauma Triage.
Morris R, Karam BS, Zolfaghari EJ, Chen B, Kirsh T, Tourani R, Milia DJ, Napolitano L, de Moya M, Conterato M, Aliferis C, Ma S, Tignanelli C. | Prehosp Emerg Care. 2022 Jul-Aug;26(4):556-565
DOI: https://doi.org/10.1080/10903127.2021.1958961
Keywords: resource allocation; trauma; triage.

Article

Introduction : A tiered trauma team activation system allocates resources proportional to patients' needs based upon injury burden. Previous trauma hospital-triage models are limited to predicting Injury Severity Score which is based on > 10% all-cause in-hospital mortality, rather than need for emergent intervention within 6 hours (NEI-6). Our aim was to develop a novel prediction model for hospital-triage that utilizes criteria available to the EMS provider to predict NEI-6 and the need for a trauma team activation.

Méthode : A regional trauma quality collaborative was used to identify all trauma patients ≥ 16 years from the American College of Surgeons-Committee on Trauma verified Level 1 and 2 trauma centers. Logistic regression and random forest were used to construct two predictive models for NEI-6 based on clinically relevant variables. Restricted cubic splines were used to model nonlinear predictors. The accuracy of the prediction model was assessed in terms of discrimination.

Résultats : Using data from 12,624 patients for the training dataset (62.6% male; median age 61 years; median ISS 9) and 9,445 patients for the validation dataset (62.6% male; median age 59 years; median ISS 9), the following significant predictors were selected for the prediction models: age, gender, field GCS, vital signs, intentionality, and mechanism of injury. The final boosted tree model showed an AUC of 0.85 in the validation cohort for predicting NEI-6.

Conclusion : The NEI-6 trauma triage prediction model used prehospital metrics to predict need for highest level of trauma activation. Prehospital prediction of major trauma may reduce undertriage mortality and improve resource utilization.

Conclusion (proposition de traduction) : Le modèle de prédiction de la nécessité d'une intervention urgente dans les 6 heures pour le triage des traumatisés utilise des paramètres préhospitaliers pour prédire la nécessité de l'activation du plus haut niveau de traumatisme. La prédiction préhospitalière des traumatismes majeurs peut réduire la mortalité liée au sous-triage et améliorer l'utilisation des ressources.

Prehospital Lactate is Associated with the Need for Blood in Trauma.
Zadorozny EV, Weigel T, Stone A, Gruen DS, Galvagno SM Jr, Yazer MH, Brown JB, Guyette FX. | Prehosp Emerg Care. 2022 Jul-Aug;26(4):590-599
DOI: https://doi.org/10.1080/10903127.2021.1983096
Keywords: emergency medical services; hemorrhagic shock; hospital blood use; normotensive subgroup; prehospital lactate.

Article

Introduction : Traumatic hemorrhage is the leading cause of preventable death, and its effects are often evident within the first 24 hours of hospital admission. We investigated the relationship between prehospital lactate measurement and administration of hospital blood products and life-saving interventions (LSIs) within 24 hours of hospital admission.

Méthode : We included trauma patients with recorded prehospital venous lactate transported by a single critical care transport service to a Level I trauma center between 2012 and 2019. We abstracted vital signs, mission type, anatomic location of injury, prehospital administration of crystalloid and blood products, and hospital LSIs started within 24 hours of admission. We used logistic regression to determine the association of prehospital lactate and in-hospital administration of blood products in groups with or without hypotensive patients. We investigated the effect of prehospital lactate concentration on secondary outcomes such as LSIs and mortality.

Résultats : We included 2,170 patients transported from the scene or emergency department (ED), of whom 1,821 (84%) were normotensive. The median concentration of prehospital lactate was 2.10 mmol/L for the main population (IQR = 1.40-3.30) and 2.00 mmol/L for the normotensive subgroup (IQR = 1.30-2.90). A higher prehospital lactate concentration was associated with higher odds of needing early hospital blood products in the whole study population (OR = 1.12, (95% CI 1.06-1.20), p < 0.01) and in the normotensive subgroup (OR = 1.13, (95% CI 1.03-1.22), p = 0.01). These positive associations were also observed with the secondary outcome of hospital LSIs, and higher prehospital lactate was also associated with higher odds of mortality (OR = 1.32, (95% CI 1.20-1.45), p < 0.01).

Conclusion : Higher concentrations of prehospital lactate were associated with the need for in-hospital blood transfusion within 24 hours of admission. The relationship between lactate and blood transfusion persisted among normotensive patients. Further work is needed to incorporate prehospital lactate into decision support tools for prehospital blood administration.

Conclusion (proposition de traduction) : Des concentrations plus importantes de lactate préhospitalier ont été associées à la nécessité d'une transfusion sanguine à l'hôpital dans les 24 heures suivant l'admission. La relation entre le lactate et la transfusion sanguine persistait chez les patients normotendus. Des travaux supplémentaires sont nécessaires pour intégrer le lactate préhospitalier dans les outils d'aide à la décision pour l'administration préhospitalière de sang.

Association between trajectories of end-tidal carbon dioxide and return of spontaneous circulation among emergency department patients with out-of-hospital cardiac arrest.
Wang CH, Lu TC, Tay J, Wu CY, Wu MC, Chong KM, Chou EH, Tsai CL, Huang CH, Ma MH, Chen WJ. | Resuscitation. 2022 Aug;177:28-37
DOI: https://doi.org/10.1016/j.resuscitation.2022.06.013
Keywords: Cardiopulmonary resuscitation; End-tidal carbon dioxide; Group-based trajectory modelling; Neurological outcome; Out-of-hospital cardiac arrest; Survival; Trajectory.

Clinical Paper

Introduction : We aimed to identify distinct trajectories of end-tidal carbon dioxide (EtCO2) during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest (OHCA) and to investigate the association between EtCO2 trajectories and OHCA outcomes.

Méthode : This was a secondary analysis of a prospectively collected database on adult patients with OHCA who had been resuscitated in the emergency department of a tertiary medical center between 2015 and 2020. The primary outcome was the return of spontaneous circulation (ROSC). Group-based trajectory modelling was used to identify the EtCO₂ trajectories. Multivariable logistic regression analysis was performed to evaluate the association between EtCO₂ trajectories and ROSC. The predictive performance of the EtCO₂ trajectories was assessed using the area under the receiver operating characteristic curve (AUC).

Résultats : The study comprised 655 patients with OHCA. In the primary analysis, three distinct EtCO2 trajectories, including 10-mmHg, 30-mmHg, and 50-mmHg trajectories, were identified. Compared with the 10-mmHg trajectory, both 30-mmHg (odds ratio [OR]: 4.66, 95% confidence interval [CI]: 3.15-6.90) and 50-mmHg (OR: 7.58, 95% CI: 4.30-13.35) trajectories were associated with a higher likelihood of ROSC. In a sensitivity analysis of excluding EtCO₂ measured before tracheal intubation or after sodium bicarbonate administration, the predictive ability of the identified EtCO₂ trajectories remained. As a single predictor of ROSC, EtCO₂ trajectories had an acceptable discriminative performance (AUC: 0.69, 95% CI: 0.66-0.73).

Conclusion : Three distinct EtCO₂ trajectories during cardiopulmonary resuscitation were identified and significantly associated with outcomes. Early identification of these EtCO₂ trajectories could potentially guide the ongoing resuscitation efforts.

Conclusion (proposition de traduction) : Trois valeurs distinctes de l'EtCO2 pendant la réanimation cardio-pulmonaire ont été identifiées et associées de manière significative aux résultats. L'identification précoce de ces valeurs d'EtCO2 pourrait potentiellement guider les efforts de réanimation en cours.

Commentaire : Des valeurs distinctes d'EtCO₂ - 10 mmHg, 30 mmHg et 50 mmHg - ont été identifiées pendant la RCP. Par rapport à la valeur de 10 mmHg, les valeurs d'EtCO₂ de 30 et 50 mmHg étaient significativement associées à des chances plus élevées de retour à une activité circulatoire spontanée (RACS).

An increased potential for organ donors may be found among patients with out-of-hospital cardiac arrest.
Rasmussen MA, Moen HS, Milling L, Munthe S, Rosenlund C, Poulsen FR, Brøchner AC, Mikkelsen S. | Scand J Trauma Resusc Emerg Med. 2022 Aug 17;30(1):50
DOI: https://doi.org/10.1186/s13049-022-01037-x  | Télécharger l'article au format  
Keywords: Intubation; Level of treatment; Organ donation; Prehospital emergency care.

Original research

Introduction : A prehospital system where obvious futile cases may be terminated prehospitally by physicians may reduce unethical treatment of dying patients. Withholding treatment in futile cases may seem ethically sound but may keep dying patients from becoming organ donors. The objective of this study was to characterise the prehospital patients who underwent organ donation. The aim was to alert prehospital physicians to a potential for an increase in the organ donor pool by considering continued treatment even in some prehospital patients with obvious fatal lesions or illness.

Méthode : This is a retrospective register-based study from the Region of Southern Denmark. The prehospital medical records from patients who underwent organ donation after prehospital care from 1st of January 2016-31st of December 2020 were screened for inclusion. The outcome measures were prehospital diagnosis, vital parameters, and critical interventions.

Résultats : In the five year period, one-hundred-and-fifty-one patients were entered into a donation process in the health region following prehospital care. Sixteen patients were excluded due to limitations in data availability. Of the 135 patients included, 36.3% had a stroke. 36.7% of these patients were intubated prehospitally. 15.6% had subarachnoideal haemorrhage. 66.7% of these were intubated prehospitally. 10.4% suffered from head trauma. 64.3% of these patients were intubated at the scene. In 21.5% of the patients, the prehospitally assigned tentative diagnosis was missing or included a diverse spectrum of medical and surgical emergencies. Twenty-two patients (16.3%) were resuscitated from cardiac arrest. 81.8% were intubated at the scene.

Conclusion : In the five year period, one-hundred-and-fifty-one patients were entered into a donation process in the health region following prehospital care. Sixteen patients were excluded due to limitations in data availability. Of the 135 patients included, 36.3% had a stroke. 36.7% of these patients were intubated prehospitally. 15.6% had subarachnoideal haemorrhage. 66.7% of these were intubated prehospitally. 10.4% suffered from head trauma. 64.3% of these patients were intubated at the scene. In 21.5% of the patients, the prehospitally assigned tentative diagnosis was missing or included a diverse spectrum of medical and surgical emergencies. Twenty-two patients (16.3%) were resuscitated from cardiac arrest. 81.8% were intubated at the scene.

Conclusion (proposition de traduction) : Au cours de la période de cinq ans, cent cinquante et un patients ont été inscrits dans un processus de don dans la région sanitaire à la suite de soins préhospitaliers. Seize patients ont été exclus en raison de la disponibilité limitée des données. Sur les 135 patients inclus, 36,3 % avaient subi un accident vasculaire cérébral. 36,7% de ces patients ont été intubés en préhospitalier. 15,6 % ont eu une hémorragie sous-arachnoïdienne. 66,7% d'entre eux ont été intubés en préhospitalier. 10,4 % ont souffert d'un traumatisme crânien. 64,3 % de ces patients ont été intubés sur place. Chez 21,5 % des patients, le diagnostic provisoire établi avant l'intervention n'était pas connu ou comprenait un large éventail d'urgences médicales et chirurgicales. Vingt-deux patients (16,3 %) ont été réanimés après un arrêt cardiaque. 81,8 % ont été intubés sur place.

Evaluation of abdominal compression-decompression combined with chest compression CPR performed by a new device: Is the prognosis improved after this combination CPR technique?.
Li H, Wang C, Zhang H, Cheng F, Zuo S, Xu L, Chen H, Wang X. | Scand J Trauma Resusc Emerg Med. 2022 Aug 13;30(1):49
DOI: https://doi.org/10.1186/s13049-022-01036-y  | Télécharger l'article au format  
Keywords: Abdominal compression–decompression; Chest compression; Out-of-hospital cardiac arrest; Prognosis; Resuscitation.

ORIGINAL RESEARCH

Introduction : This study was designed to compare the outcomes of standard cardiopulmonary resuscitation (STD-CPR) and combined chest compression and abdominal compression-decompression cardiopulmonary resuscitation (CO-CPR) with a new device following out-of-hospital cardiac arrest (OHCA). Moreover, we investigated whether patient prognosis improved with this combination treatment.

Méthode : This trial was a single-centre, prospective, randomized trial, and a blinded assessment of the outcomes was performed. A total of 297 consecutive patients with OHCA were initially screened, and 278 were randomized to the STD-CPR group (n = 135) or the CO-CPR group (n = 143). We compared the proportions of patients who achieved a return of spontaneous circulation (ROSC), survived to hospital admission and survived to hospital discharge. In addition, we also performed the Kaplan-Meier analysis with a log-rank test at the end of the follow-up period to compare the survival curves of the two groups.

Résultats : The differences were not statistically significant in the proportion of patients who achieved ROSC [31/135 (23.0%) versus 35/143 (24.5%)] and survived to hospital admission [28/135 (20.7%) versus 33/143 (23.1%)] between the CO-CPR group and STD-CPR group. However, there was a significant difference in the proportion of patients who survived to hospital discharge [16/135 (11.9%) versus 7/143 (4.9%)] between the two groups. Nine patients (6.7%) in the CO-CPR group and 2 patients (1.4%) in the STD group showed good neurological outcomes according to the cerebral performance category (CPC) scale score, and the difference was statistically significant (P = 0.003). The Kaplan-Meier curves showed that the patients in the CO-CPR group achieved better survival benefits than those in the STD-CPR group at the end of the follow-up period (log-rank P = 0.007).

Conclusion : CO-CPR was more beneficial than STD-CPR in terms of survival benefits in patients who have suffered out-of-hospital cardiac arrest.

Conclusion (proposition de traduction) : La réanimation cardio-pulmonaire combinant la compression thoracique et la compression-décompression abdominale s'est avérée plus bénéfique que la réanimation cardio-pulmonaire standard en termes de survie chez les patients ayant subi un arrêt cardiaque extra-hospitalier.

Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department.
Hasbrouck M, Nguyen TT. | Am J Emerg Med. 2022 Aug;58:39-42
DOI: https://doi.org/10.1016/j.ajem.2022.03.058
Keywords: Atrial fibrillation; Beta blocker; Calcium channel blocker; Diltiazem; Ejection fraction; Heart failure; Metoprolol.

Research article

Introduction : Acute heart rate control for atrial fibrillation (AF) with rapid ventricular response (RVR) in the emergency department (ED) is often achieved utilizing intravenous (IV) non-dihydropyridine calcium channel blockers (CCB) or beta blockers (BB). For patients with concomitant heart failure with a reduced ejection fraction (HFrEF), the American Heart Association and other clinical groups note that CCB should be avoided due to their potential negative inotropic effects. However, minimal evidence exists to guide this current recommendation. The primary objective of this study was to compare the incidence of adverse effects in the HFrEF patient population whose AF with RVR was treated with IV diltiazem or metoprolol in the ED.

Méthode : This single center, retrospective review included patients ≥18 years old with HFrEF who presented in AF with RVR and received IV diltiazem or metoprolol in the ED. The primary outcome was adverse effects of therapy defined as: 1) hypotension (systolic blood pressure < 90 mmHg requiring fluid bolus or vasopressors) or bradycardia (heart rate < 60 beats/min) within 60 min of medication administration 2) worsening heart failure symptoms defined as increased oxygen requirements within four hours or inotropic support within 48 h. Secondary outcomes included the incidence of rate control failure, patient disposition, ED length of stay, hospital length of stay, and in-hospital mortality.

Résultats : One hundred and twenty-five patients met inclusion criteria, with 57 receiving diltiazem and 68 receiving metoprolol. Overall adverse effects for diltiazem and metoprolol were similar (32% vs. 21%, P = 0.217). However, there was a significantly higher incidence of worsening heart failure symptoms within the diltiazem group (33% vs 15%, P = 0.019). Rate control failure at 60 min did not differ significantly between diltiazem and metoprolol (51% vs 62%, P = 0.277).

Conclusion : In HFrEF patients with AF, there was no difference in total adverse events in patients treated with IV diltiazem compared to metoprolol. However, the diltiazem group had a higher incidence of worsening CHF symptoms defined as increased oxygen requirement within four hours or initiation of inotropic support within 48 h.

Conclusion (proposition de traduction) : Chez les patients souffrant d'insuffisance cardiaque à fraction d'éjection altérée et présentant une FA, il n'y a pas eu de différence dans le total des événements indésirables chez les patients traités par diltiazem IV par rapport au métoprolol. Cependant, le groupe diltiazem présentait une incidence plus élevée d'aggravation des symptômes d'insuffisance cardiaque congestive définie par une augmentation des besoins en oxygène dans les quatre heures ou par la mise en place d'un soutien inotrope dans les 48 heures.

Experience of carbon monoxide poisoning and the outcome predicting score: A multicenter retrospective study.
Chi YJ, Pan HY, Cheng FJ, Chang YI, Chuang PC. | Am J Emerg Med. 2022 Aug;58:73-78
DOI: https://doi.org/10.1016/j.ajem.2022.05.012
Keywords: Carbon monoxide poisoning; Hyperbaric oxygen therapy; Outcome; Score; mini-mental state examination.

Research article

Introduction : Carbon monoxide poisoning (COP), resulting from accidental and intentional exposure, is a leading cause of fatal poisoning worldwide. Except for early death, neurological sequelae are common and impose a large burden on patients, caregivers, and the society.

Méthode : This retrospective study included patients who visited the emergency departments (EDs) of the medical institutes of Chang Gung Memorial Hospital after COP with a carboxyhemoglobin level > 10% between January 2009 and October 2018. Patients who experienced out-of-hospital cardiac arrest (OHCA) were excluded. Poor outcome was defined as mortality or a Glasgow coma scale (GCS) <13 at discharge. Stepwise regression analysis was performed, and a receiver operating characteristic (ROC) curve was applied to analyze our newly created scoring system for prognosis prediction.

Résultats : This study enrolled 1171 patients. Fire scene (F) (aOR, 20.635; 95% CI, 8.345-51.023), intentional CO exposure (I) (aOR, 2.634; 95% CI, 1.335-5.196), respiratory failure (R) (aOR, 9.944; 95% CI, 5.533-17.873), every point of reduced GCS (E) (aOR, 1.253; 95% CI, 1.186-1.323), and diabetes mellitus (D) (aOR, 2.749; 95% CI, 1.201-6.292) were identified as predictors of poor outcomes. The FIRED score was created.

Conclusion : The FIRED score could predict the outcomes of non-OHCA patients with a carboxyhemoglobin level > 10% after COP using five factors that can be obtained by history taking and basic examination. An FIRED score ≥ 10 was associated with a poor outcome (sensitivity, 89.6%; specificity, 82.4%; AUC0.930).

Conclusion (proposition de traduction) : Le score FIRED pouvait prédire le devenir des patients victimes d'un arrêt cardiaque non extrahospitalier avec un taux de carboxyhémoglobine > 10 % après une intoxication au monoxyde de carbone en utilisant cinq paramètres qui peuvent être obtenus par l'anamnèse et l'examen de base. Un score FIRED ≥ 10 était associé à un mauvais résultat (sensibilité, 89,6 % ; spécificité, 82,4 % ; AUC0,930).

Commentaire : 
Le patient provenait d'une scène d'incendie (F)
Intoxication intentionnelle au monoxyde de carbone (I)
Présence d'une insuffisance respiratoire (R)
Chaque point de réduction du score de Glasgow (E)
Et la présence d'un diabète sucré (D)
ont été identifiés comme des prédicteurs de mauvais résultats.

The necessity of lumbar puncture in adult emergency patients with fever-associated seizures.
Mizu D, Matsuoka Y, Huh JY, Kamitani Y, Fujiwara S, Ariyoshi K. | Am J Emerg Med. 2022 Aug;58:120-125
DOI: https://doi.org/10.1016/j.ajem.2022.05.055  | Télécharger l'article au format  
Keywords: Adult patients; Central nervous system infection; Fever; Lumbar puncture; Seizure.

Research article

Introduction : Central nervous system (CNS) infections are often suspected in adult patients with fever-associated seizures. However, it is unclear whether lumbar puncture (LP) is routinely required in patients with fever-associated seizures. This study aimed to examine the prevalence of meningitis and encephalitis in adult patients with fever-associated seizures and to evaluate whether LP is routinely required.

Méthode : We retrospectively studied patients aged ≥16 years who presented to the emergency department with complaints of seizures and fever above 37.5 °C who were admitted to the hospital between January 2017 and December 2019. LP was performed when the emergency physician suspected meningitis or encephalitis. Neurologists assessed patients with normal cerebrospinal fluid (CSF) findings and those admitted without LP after hospitalization. A neurologist confirmed the diagnoses of meningitis and encephalitis.

Résultats : The study included 148 patients. Ninety-seven patients (65.5%) were male, and the median age was 60 years. LP was performed in 105 patients (70.9%), and 14 (13.4%) had CSF pleocytosis. Meningitis and encephalitis were diagnosed in nine patients (6.1%), of whom four (2.8%) had CNS infections. Patients diagnosed with meningitis and encephalitis were more likely to have Glasgow Coma Scale <13 (P = 0.03) and less likely to have a history of seizures or epilepsy (P = 0.04) and had higher C-reactive protein levels than the other patients (P = 0.02).

Conclusion : The prevalence of meningitis or encephalitis is relatively low in adult patients with fever-associated seizures. Lumbar puncture is considered unnecessary to be performed routinely, but its indication should be carefully considered with reference to the clinical course, comorbidities, and blood tests. Further validation studies with larger sample sizes are needed to confirm the findings of this study.

Conclusion (proposition de traduction) : La prévalence de la méningite ou de l'encéphalite est relativement faible chez les patients adultes présentant des crises associées à la fièvre. On considère que la ponction lombaire n'est pas nécessaire pour être effectuée de manière systématique, mais son indication doit être soigneusement étudiée en fonction de l'évolution clinique, des comorbidités et des analyses sanguines. D'autres études de validation avec des échantillons de plus grande taille sont nécessaires pour confirmer les résultats de cette étude.

Prognostic value of the shock index and modified shock index in survivors of out-of-hospital cardiac arrest: A retrospective cohort study.
van Bergen KMG, van Kooten L, Eurlings CGMJ, Foudraine NA, Lameijer H, Meeder JG, Rahel BM, Versteegen MGJ, van Osch FHM, Barten DG. | Am J Emerg Med. 2022 Aug;58:175-185
DOI: https://doi.org/10.1016/j.ajem.2022.05.039  | Télécharger l'article au format  
Keywords: Modified shock index; Out-of-hospital cardiac arrest; Prognosis; Resuscitation; Shock index; Survival.

Research article

Introduction : There is a lack of rapid, non-invasive tools that aid early prognostication in patients with return of spontaneous circulation (ROSC) after Out-of-Hospital Cardiac Arrest (OHCA). The shock index (SI) and modified shock index (MSI) have shown to be useful in several medical conditions, including myocardial infarction. In this study, we assessed the prognostic value of SI and MSI at Emergency Department (ED) triage on survival to discharge of OHCA patients.

Méthode : A single-center retrospective observational cohort study. All OHCA patients with a period of ROSC between 2014 and 2019 were included. Data collection was based on the Utstein criteria. The SI and MSI at ED triage were calculated by dividing heart rate by systolic blood pressure or mean arterial pressure. Survival rates were compared between patients with a high and low SI and MSI. Subsequent Cox regression analysis was performed.

Résultats : A total of 403 patients were included, of which 46% survived until hospital discharge. An elevated SI and MSI was defined by SI ≥ 1.00 and MSI ≥ 1.30. Survival to discharge, 30-day- and one-year survival were significantly lower in patients with an elevated SI and MSI (p < 0.001). An elevated SI and MSI was also associated with a higher rate of recurrent loss of circulation in the ED (p < 0.001). The 30-day survival hazard ratio was 2.24 (1.56-3.22) for SI and 2.46 (1.71-3.53) for MSI; the one-year survival hazard ratio was 2.20 (1.54-3.15) for SI and 2.38 (1.66-3.40) for MSI.

Conclusion : Survival to discharge and 30-day survival are lower in OHCA patients with an elevated SI and MSI at ED triage. Further studies are warranted to elucidate the causational mechanisms underlying the association between elevated SI or MSI and worse outcomes.

Conclusion (proposition de traduction) : La survie à la sortie de l'hôpital et à 30 jours sont plus faibles chez les patients victimes d'un arrêt cardiaque extrahospitalier dont le shock index et le shock index modifié sont élevés au moment du triage aux urgences. D'autres études sont nécessaires pour élucider les mécanismes de causalité qui sous-tendent l'association entre un ishock index élevé ou un shock index modifié et des résultats plus mauvais.

Point-of-care ultrasound may expedite diagnosis and revascularization of occult occlusive myocardial infarction.
Xu C, Melendez A, Nguyen T, Ellenberg J, Anand A, Delgado J, Herbst MK. | Am J Emerg Med. 2022 Aug;58:186-191
DOI: https://doi.org/10.1016/j.ajem.2022.06.010
Keywords: Occlusive myocardial infarction; Point-of-care ultrasound; Wall motion abnormality.

Research article

Introduction : Electrocardiographically occult occlusive myocardial infarction (OOMI), defined as coronary artery occlusion requiring revascularization without ST-segment elevation on electrocardiogram (ECG), is associated with delayed diagnosis resulting in higher morbidity. Left ventricular (LV) wall motion abnormalities (WMA) appreciated on echocardiography can expedite OOMI diagnosis. We sought to determine whether point-of-care ultrasound (PoCUS) demonstrating WMA expedites revascularization time when performed on emergency department patients being evaluated for OOMI.

Méthode : This was a single-site retrospective cohort study over a 38-month period. All admitted adult ED patients ≥35 years of age evaluated by the emergency physician with PoCUS for LV function, an ECG, and a standard troponin I biomarker assay were included. Patients with ST-segment elevation myocardial infarction (STEMI), prior LV dysfunction, fever ≥100.4 °F, or hypotension were excluded. A structured chart abstraction was performed for relevant demographic and clinical characteristics.

Résultats : We screened 1561 ED patients who underwent cardiac PoCUS for eligibility: 874 met exclusion criteria, 453 were discharged, and 234 were included in the analysis. Twenty-three patients had coronary interventions, of which 14 had WMA. PoCUS was performed 36 min (IQR -9-68) before troponin resulted (n = 234) and 39 min (IQR -23-96) before the first troponin elevation (n = 85). Twenty of the 23 patients diagnosed with OOMI had elevated troponins prior to catheterization with time from PoCUS to first troponin elevation of 43 min (IQR 9-263). Of these patients, 11 had WMA identified on PoCUS, and the WMA was appreciated 47 min (IQR 26-255) prior to troponin elevation. The time from ED arrival to revascularization was 673 min (IQR 251-2158); 432 min (IQR 209-1300) among patients with WMA (n = 14) compared with 2158 min (IQR 552-3390) for those without WMA (n = 9).

Conclusion : Cardiac PoCUS may identify OOMI earlier than standard evaluation and may expedite definitive management.

Conclusion (proposition de traduction) : L'échographie cardiaque au point d'intervention peut identifier un infarctus du myocarde occlusif occulte plus tôt que l'évaluation standard et accélérer la prise en charge définitive.

Risk factors associated with peri-intubation cardiac arrest in the emergency department.
Yang TH, Chen KF, Gao SY, Lin CC. | Am J Emerg Med. 2022 Aug;58:229-234
DOI: https://doi.org/10.1016/j.ajem.2022.06.013  | Télécharger l'article au format  
Keywords: Airway; Cardiac arrest; Intubation; Shock.

Research article

Introduction : Peri-intubation cardiac arrest is an uncommon, serious complication following endotracheal intubation in the emergency department. Although several risk factors have been previously identified, this study aimed to comprehensively identify risk factors associated with peri-intubation cardiac arrest.

Méthode : This retrospective, nested case-control study conducted from January 1, 2016 to December 31, 2020 analyzed variables including demographic characteristics, triage, and pre-intubation vital signs, medications, and laboratory data. Univariate analysis and multivariable logistic regression models were used to compare clinical factors between the patients with peri-intubation cardiac arrest and patients without cardiac arrest.

Résultats : Of the 6983 patients intubated during the study period, 5130 patients met the inclusion criteria; 92 (1.8%) patients met the criteria for peri-intubation cardiac arrest and 276 were age- and sex-matched to the control group. Before intubation, systolic blood pressure and diastolic blood pressure were lower (104 vs. 136.5 mmHg, p < 0.01; 59.5 vs. 78 mmHg, p < 0.01 respectively) and the shock index was higher in the patients with peri-intubation cardiac arrest than the control group (0.97 vs. 0.83, p < 0.0001). Cardiogenic pulmonary edema as an indication for intubation (adjusted odds ratio [aOR]: 5.921, 95% confidence interval [CI]: 1.044-33.57, p = 0.04), systolic blood pressure < 90 mmHg before intubation (aOR: 5.217, 95% CI: 1.484-18.34, p = 0.01), and elevated lactate levels (aOR: 1.012, 95% CI: 1.002-1.022, p = 0.01) were independent risk factors of peri-intubation cardiac arrest.

Conclusion : Patients with hypotension before intubation have a higher risk of peri-intubation cardiac arrest in the emergency department. Future studies are needed to evaluate the influence of resuscitation before intubation and establish airway management strategies to avoid serious complications.

Conclusion (proposition de traduction) : Les patients présentant une hypotension avant l'intubation ont un risque plus élevé d'arrêt cardiaque péri-intubation aux urgences. Des études futures sont nécessaires pour évaluer l'influence de la réanimation avant l'intubation et établir des stratégies de gestion des voies aériennes pour éviter les complications graves.

The association between blood pressure and in-hospital mortality in traumatic brain injury: Evidence from a 10-year analysis in a single-center.
Huang HK, Liu CY, Tzeng IS, Hsieh TH, Chang CY, Hou YT, Lin PC, Chen YL, Chien DS, Yiang GT, Wu MY. | Am J Emerg Med. 2022 Aug;58:265-274
DOI: https://doi.org/10.1016/j.ajem.2022.05.047
Keywords: Blood pressure; Glasgow coma scale; Mortality; Resuscitation protocols; Traumatic brain injury.

Research article

Introduction : Blood pressure in patients with traumatic brain injury (TBI) is associated with clinical outcome. However, evidence of blood pressure (BP) range is scarce and the association between BP and clinical outcome is mostly controversial. We aimed to investigate the association between blood pressure and clinical outcome in TBI.

Méthode : This is a retrospective cohort study using the Taipei Tzu Chi Hospital trauma database from January 2009 to June 2019; totally, 13,114 patients were examined. The primary outcome of this investigation was in-hospital mortality and the secondary outcomes were intensive care unit (ICU) admission rate and prolong ICU stay (defined as stay in ICU ≥ 14 days). Subgroups analysis of Glasgow Coma Scale (GCS) and Triage SBP was also conducted.

Résultats : A total of 1782 traumatic adult patients with TBI (AIS score < 3) were finally included. The cut-off points are 130 mmHg to 149 mmHg in all TBI patients with lower odds ratio of mortality. In different TBI severity, U-shape relationship also presented and we also found that cut-off points of 130 to 149 mmHg in mild TBI and 110 to 129 mmHg in moderate TBI have lower odds ratio of mortality. The mortality is significantly increased in BP below 90 mmHg and above 190 mmHg in TBI patients.

Conclusion : Traumatic brain injury population presented a U-shape relationship between triage SBP and in-hospital mortality. Early resuscitation and correct hypotension/hypertension in TBI population with BP below 90 mmHg and above 190 mmHg may prevent from increased mortality.

Conclusion (proposition de traduction) : La population victime d'un traumatisme crânien présente une relation en forme de U entre la pression artérielle systolique au triage et la mortalité à l'hôpital. Une réanimation précoce et la correction de l'hypotension/hypertension chez les traumatisés crâniens dont la pression artérielle est inférieure à 90 mmHg et supérieure à 190 mmHg peuvent prévenir une augmentation de la mortalité.

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation.
Chavez S, Brady WJ, Gottlieb M, Carius BM, Liang SY, Koyfman A, Long B. | Am J Emerg Med. 2022 Aug;58:43-51
DOI: https://doi.org/10.1016/j.ajem.2022.05.011  | Télécharger l'article au format  
Keywords: COVID-19; Coronavirus-2019; SARS-CoV-2; Severe acute respiratory syndrome coronavirus 2.

Review article

Introduction : Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved.

Méthode : This narrative review provides emergency clinicians with a focused update of the resuscitation and airway management of COVID-19.

Discussion : Patients with COVID-19 and septic shock should be resuscitated with buffered/balanced crystalloids. If hypotension is present despite intravenous fluids, vasopressors including norepinephrine should be initiated. Stress dose steroids are recommended for patients with severe or refractory septic shock. Airway management is the mainstay of initial resuscitation in patients with COVID-19. Patients with COVID-19 and ARDS should be managed similarly to those ARDS patients without COVID-19. Clinicians should not delay intubation if indicated. In patients who are more clinically stable, physicians can consider a step-wise approach as patients' oxygenation needs escalate. High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) are recommended over elective intubation. Prone positioning, even in awake patients, has been shown to lower intubation rates and improve oxygenation. Strategies consistent with ARDSnet can be implemented in this patient population, with a goal tidal volume of 4-8 mL/kg of predicted body weight and targeted plateau pressures <30 cm H2O. Limited data support the use of neuromuscular blocking agents (NBMA), recruitment maneuvers, inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation (ECMO).

Conclusion : This review presents a concise update of the resuscitation strategies and airway management techniques in patients with COVID-19 for emergency medicine clinicians.

Conclusion (proposition de traduction) : Cette revue propose aux urgentistes une mise à jour concise des stratégies de réanimation et des techniques de gestion des voies aériennes chez les patients atteints de la COVID-19.

Commentaire :  Algorithme pour la prise en charge du patient COVID-19 hypoxique.
Les médecins doivent d'abord évaluer la nécessité d'une intubation. Si l'état du patient ne nécessite pas une intubation immédiate, les médecins doivent utiliser une approche progressive en augmentant l'oxygénothérapie si nécessaire. Les patients doivent être surveillés de près pour évaluer le risque d'intubation et la réponse aux interventions sur les voies respiratoires.

Indications et contre-indications de l'HFNC et du VNI dans la COVID-19

Indications pour l'Optiflow
- Saturation en oxygène < 90 % sous oxygène supplémentaire
- Fréquence respiratoire >25/min
- Augmentation du travail respiratoire malgré la supplémentation en oxygène
- SDRA léger (PaO₂/FiO₂ 200-300)

Indications de la VNI
- Antécédents du patient en matière de maladie pulmonaire obstructive, d'insuffisance cardiaque congestive, d'œdème pulmonaire
- Insuffisance respiratoire hypercapnique
- Dyspnée sévère/augmentation du travail respiratoire lors de l'HFNC

Contre-indications à l'Optiflow et à la VNI
- Arrêt cardiaque/respiratoire
- Altération significative de l'état mental
- Incapacité à tolérer l'équipement facial de la VNI
- Sécrétions respiratoires mal contrôlées
- Vomissements récurrents, saignements gastro-intestinaux supérieurs, aspiration
- Traumatisme facial ou chirurgie faciale

Pericardial tamponade: A comprehensive emergency medicine and echocardiography review.
Alerhand S, Adrian RJ, Long B, Avila J. | Am J Emerg Med. 2022 Aug;58:159-174
DOI: https://doi.org/10.1016/j.ajem.2022.05.001
Keywords: Cardiac tamponade; Echocardiography; Electrical alternans; POCUS; Pericardial decompression syndrome; Pericardial drainage; Pericardial effusion; Pericardial tamponade; Pericardiocentesis; Point-of-care ultrasound; Pulsus paradoxus; Ventricular interdependence.

Review article

Introduction : Pericardial tamponade requires timely diagnosis and management. It carries a high mortality rate.

Méthode : This review incorporates available evidence to clarify misconceptions regarding the clinical presentation, while providing an in-depth expert guide on bedside echocardiography. It also details the decision-making strategy for emergency management including pericardiocentesis, along with pre- and peri-procedural pearls and pitfalls.

Discussion : Pericardial effusions causing tamponade arise from diverse etiologies across acute and sub-acute time courses. The most frequently reported symptom is dyspnea. The classically taught Beck's triad (which includes hypotension) does not appear commonly. Echocardiographic findings include: a pericardial effusion (larger size associated with tamponade), diastolic right ventricular collapse (specific), systolic right atrial collapse (sensitive), a plethoric non-collapsible inferior vena cava (sensitive), and sonographic pulsus paradoxus. Emergent pericardiocentesis is warranted by hemodynamic instability, impending deterioration, or cardiac arrest. Emergent surgical indications include type A aortic dissection causing hemopericardium, ventricular free wall rupture after acute myocardial infarction, severe chest trauma, and iatrogenic hemopericardium when bleeding cannot be controlled percutaneously. Pre-procedure management includes blood products for patients with traumatic hemopericardium; gentle intravenous fluids to hypotensive, hypovolemic patients with consideration for vasoactive medications; treatment of anticoagulation, coagulopathies, and anemia. Positive-pressure ventilation and intravenous sedation can lower cardiac output and should be avoided if possible. Optimal location for echocardiography-guided pericardiocentesis is the largest, shallowest fluid pocket with no intervening vital structures. Patient positioning to prevent hypoxia and liberal amounts of local anesth

Conclusion : An understanding of the pathophysiology, clinical presentation, echocardiographic findings, and time-sensitive management of pericardial tamponade is essential for emergency physicians.

Conclusion (proposition de traduction) : Il est essentiel pour les médecins urgentistes de comprendre la physiopathologie, la présentation clinique, les résultats échocardiographiques et la prise en charge rapide de la tamponnade péricardique.

High risk and low prevalence diseases: Eclampsia.
Boushra M, Natesan SM, Koyfman A, Long B. | Am J Emerg Med. 2022 Aug;58:223-228
DOI: https://doi.org/10.1016/j.ajem.2022.06.004
Keywords: Eclampsia; Postpartum; Preeclampsia; Pregnancy; Seizures.

Review article

Introduction : Eclampsia is a rare partum and puerperal condition that carries a high rate of morbidity and mortality.

Méthode : This review highlights the pearls and pitfalls of the care of patients with eclampsia, including presentation, evaluation, and evidence-based management in the emergency department (ED).

Discussion : Eclampsia is a hypertensive disease of pregnancy defined by new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a pregnant or postpartum patient in the absence of other causative etiologies. However, signs and symptoms of preeclampsia and prodromes of eclampsia are often subtle and non-specific, making the diagnosis difficult. Thus, it should be considered in pregnant and postpartum patients who present to the ED. Laboratory testing including complete blood cell count, renal and liver function panels, electrolytes, glucose, coagulation panel, fibrinogen, lactate dehydrogenase, uric acid, and urinalysis, as well as imaging to include head computed tomography, can assist, but these evaluations should not delay management. Components of treatment include emergent obstetric specialist consultation, magnesium administration, and blood pressure control in patients with hypertension. Definitive treatment of eclampsia requires emergent delivery in pregnant patients. If consultants are not in-house, emergent stabilization and immediate transfer are required.

Conclusion : An understanding of eclampsia can assist emergency clinicians in rapid recognition and timely management of this potentially deadly disease.

Conclusion (proposition de traduction) : Une bonne compréhension de l'éclampsie peut aider les urgentistes à reconnaître rapidement et à prendre en charge cette maladie potentiellement mortelle

Commentaire : Points importants à retenir sur l'éclampsie
- L'éclampsie est une manifestation grave des maladies hypertensives de la grossesse et se définit par l'apparition de convulsions tonico-cloniques, focales ou multifocales ou d'une altération inexpliquée de l'état mental chez une patiente enceinte ou en post-partum, en l'absence d'autres étiologies.
- L'éclampsie doit être envisagée chez les patientes enceintes ou en post-partum se présentant aux urgences, même en l'absence des symptômes classiques de pré-éclampsie. Les symptômes de prééclampsie et les prodromes de l'éclampsie sont souvent subtils et non spécifiques.
- Les tests de laboratoire et l'imagerie peuvent aider, mais ils ne doivent pas retarder le diagnostic et la prise en charge de l'éclampsie.
- La prise en charge se concentre sur la consultation urgente d'un spécialiste en obstétrique, l'administration de magnésium et la réduction de la pression artérielle chez les patientes hypertendues.
- Surveiller étroitement les patientes sous perfusion de magnésium afin d'identifier les premiers signes et symptômes de toxicité. Réduire la dose de magnésium chez les patientes souffrant d'insuffisance rénale.
- Tenir compte des antécédents médicaux de la mère lors du choix d'un agent hypotenseur, car certains peuvent exacerber des pathologies sous-jacentes. Ne pas utiliser de médicaments de type IEC ou ARA chez les patientes enceintes. Le labétalol, l'hydralazine, la nicardipine et la nifédipine peuvent être utilisés.
- Pour les patientes qui ne s'améliorent pas avec le contrôle des crises et la gestion de la pression artérielle et qui présentent une altération continue de la conscience ou des crises, il faut envisager un état épileptique non convulsif, une infection du système nerveux central, un syndrome d'encéphalopathie réversible postérieure, une hémorragie intracrânienne et d'autres pathologies intracrâniennes. Chez ces patientes, une consultation neurologique et une neuro-imagerie sont recommandées.

High risk and low prevalence diseases: Acute chest syndrome in sickle cell disease.
Koehl JL, Koyfman A, Hayes BD, Long B. | Am J Emerg Med. 2022 Aug;58:235-244
DOI: https://doi.org/10.1016/j.ajem.2022.06.018
Keywords: Acute chest syndrome; Hematology; Pulmonary; Respiratory; Sickle cell disease.

Review article

Introduction : Acute chest syndrome (ACS) in sickle cell disease (SCD) is a serious condition that carries with it a high rate of morbidity and mortality.

Méthode : This review highlights the pearls and pitfalls of ACS in SCD, including diagnosis and management in the emergency department (ED) based on current evidence.

Discussion : ACS is defined by respiratory symptoms and/or fever and a new radiodensity on chest imaging in a patient with SCD. There are a variety of inciting causes, including infectious and non-infectious etiologies. Although ACS is more common in those with homozygous SCD, clinicians should consider ACS in all SCD patients, as ACS is a leading cause of death in SCD. Patients typically present with or develop respiratory symptoms including fever, cough, chest pain, and shortness of breath, which can progress to respiratory failure requiring mechanical ventilation in 20% of adult patients. However, the initial presentation can vary. While the first line imaging modality is classically chest radiograph, lung ultrasound has demonstrated promise. Further imaging to include computed tomography may be necessary. Management focuses on analgesia, oxygen supplementation, incentive spirometry, bronchodilators, rehydration, antibiotics, consideration for transfusion, and specialist consultation. Empiric antibiotics that cover atypical pathogens are necessary along with measures to increase oxygen-carrying capacity in those with hypoxemia such as simple transfusion or exchange transfusion.

Conclusion : An understanding of ACS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Conclusion (proposition de traduction) : Une bonne compréhension du syndrome thoracique aigu peut aider les urgentistes à diagnostiquer et à gérer cette maladie potentiellement mortelle.

Commentaire : Points importants à retenir sur le syndrome thoracique aigu
- Le syndrome thoracique aigu est défini comme une maladie aiguë caractérisée par de la fièvre et/ou de nouveaux symptômes respiratoires accompagnés d'une nouvelle radiodensité à l'imagerie. symptômes respiratoires accompagnés d'une nouvelle radiodensité à l'imagerie.
- Il existe une variété de déclencheurs, dont l'infection (la plus fréquente chez les patients pédiatriques), l'embolie graisseuse, la crise douloureuse vaso-occlusive, l'embolie pulmonaire, etc.
- Les signes et les symptômes comprennent la douleur thoracique, la dyspnée, la fièvre, la toux, l'hémoptysie, la douleur aux extrémités et les symptômes neurologiques ; ils peuvent survenir soudainement ou s'aggraver progressivement au fil des jours.
- Bien que la radiographie pulmonaire soit souvent la modalité d'imagerie de première intention, l'échographie pulmonaire est plus sensible et peut détecter les anomalies pulmonaires plus tôt ; la tomodensitométrie doit être envisagée si l'imagerie initiale est négative ou si l'on craint une embolie pulmonaire.
- Les marqueurs d'une maladie grave sont l'hypoxémie, l'augmentation de la fréquence respiratoire ou du travail respiratoire, la diminution de la numération plaquettaire et/ou de l'Hb, et une atteinte multilobaire sur la radiographie pulmonaire ou l'échographie pulmonaire.
- La prise en charge comprend l'instauration rapide d'agents opioïdes et non opioïdes pour traiter la douleur associée à la crise vaso-occlusive, une couverture antimicrobienne, une spirométrie incitative, une supplémentation en oxygène pour maintenir une saturation > 95 %, une resus citation des fluides en fonction de l'état volumique, la prise en compte des transfusions et la consultation d'un spécialiste. spécialiste.
- Les antibiotiques ciblant les pneumonies communautaires ou acquises à l'hôpital sont recommandés, y compris une couverture atypique. recommandée, y compris la couverture atypique.
- Une simple transfusion sanguine doit être envisagée dès le début chez le patient hypoxémique avec une évolution vers l'échange de globules rouges s'il existe des caractéristiques cliniques d'une pathologie grave ou des signes de progression malgré la transfusion simple initiale.

Hyperoxemia is Associated With Poor Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Rescued by Extracorporeal Cardiopulmonary Resuscitation: Insight From the Nationwide Multicenter Observational JAAM-OHCA (Japan Association for Acute Medicine) Registry.
Nishihara M, Hiasa KI, Enzan N, Ichimura K, Iyonaga T, Shono Y, Kashiura M, Moriya T, Kitazono T, Tsutsui H. | J Emerg Med. 2022 Aug;63(2):221-231
DOI: https://doi.org/10.1016/j.jemermed.2022.05.018  | Télécharger l'article au format  
Keywords: extracorporeal cardiopulmonary resuscitation; hyperoxemia; neurological outcome; out-of-hospital cardiac arrest.

Research article

Introduction : Previous studies have shown an association between hyperoxemia and mortality in patients with out-of-hospital cardiac arrest (OHCA) after cardiopulmonary resuscitation (CPR); however, evidence is lacking in the extracorporeal CPR (ECPR) setting.
Objective: The aim of this study was to test the hypothesis that hyperoxemia is associated with poor neurological outcomes in patients treated by ECPR.

Méthode : The Japanese Association for Acute Medicine OHCA Registry is a multicenter, prospective, observational registry of patients from 2014 to 2017. Adult (18 years or older) patients who had undergone ECPR after OHCA were included. Eligible patients were divided into two groups based on the partial pressure of oxygen in arterial blood (PaO2) levels at 24 h after ECPR: the high-PaO2 group (n = 242) defined as PaO2 ≥ 157 mm Hg (median) and the low-PaO2 group (n = 211) defined as PaO2 60 to < 157 mm Hg. The primary outcome was the favorable neurological outcome, defined as a Cerebral Performance Categories Scale score of 1 to 2 at 30 days after OHCA.

Résultats : Of 34,754 patients with OHCA, 453 patients were included. The neurological outcome was significantly lower in the high-PaO2 group than in the low-PaO2 group (15.9 vs. 33.5%; p < 0.001). After adjusting for potential confounders, high PaO2 was negatively associated with favorable neurological outcomes (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI] 0.24-0.97; p = 0.040). In a multivariate analysis with multiple imputation, high PaO2 was also negatively associated with favorable neurological outcomes (aOR 0.63; 95% CI 0.49-0.81; p < 0.001).

Conclusion : Hyperoxemia was associated with worse neurological outcomes in OHCA patients with ECPR.

Conclusion (proposition de traduction) : L'hyperoxémie est associée à une détérioration des résultats neurologiques chez les patients victimes d'un arrêt cardiaque en dehors de l'hôpital ayant bénéficié d'une réanimation cardio-pulmonaire extracorporelle.

The Use of a Suprascapular Nerve Block to Facilitate the Reduction of an Anterior Shoulder Dislocation: An Alternative for Elderly and Patients With Cardiopulmonary Comorbidities?.
Hassen GW, Bergmann-Dumont D, Duvvi A, Sudol S, Choy D, Yeo T, Viswanath A, Roffe E, Kim CL, Elnatour A, Arias MG, Kalantari H. | J Emerg Med. 2022 Aug;63(2):265-271
DOI: https://doi.org/10.1016/j.jemermed.2022.04.010  | Télécharger l'article au format  
Keywords: shoulder dislocation; suprascapular nerve block.

Research article

Introduction : Anterior shoulder dislocation is a common presentation to the emergency department (ED). Dislocations are spontaneous or traumatic. Generally, a reduction is performed under procedural sedation and analgesia (PSA). Other approaches include the use of intra-articular lidocaine or, in rare instances, nerve blocks. Here we discuss the case of a 66-year-old female patient who presented with left shoulder pain and limited range of motion after a fall. After discussing potential treatment options to reduce the dislocation, the patient agreed to a nerve block.

Discussion : The dislocation was reduced successfully with a suprascapular nerve block (SSNB) without complications. The duration of the patient's ED stay was shorter than those who had received PSA.

Conclusion : SSNB could be an alternative method for shoulder dislocation reduction, particularly for patients who are obese, older, or have cardiopulmonary comorbidities.

Conclusion (proposition de traduction) : Le bloc du nerf suprascapulaire pourrait être une méthode alternative pour la réduction de la luxation de l'épaule, en particulier pour les patients obèses, âgés ou présentant des comorbidités cardio-pulmonaires.

Commentaire : Le bloc du nerf supra-scapulaire
Le nerf supra-scapulaire, sensitivo-moteur, est issu des racines C5 et C6 du tronc supérieur du plexus brachial. En plus de l’innervation motrice du muscle infra-spinatus, il donne une branche sensitive supérieure innervant l’articulation acromio-claviculaire et une branche sensitive inférieure innervant la partie postérieure de la capsule articulaire. C’est le nerf le plus important de la sensibilité de l’épaule.
Le bloc du nerf supra-scapulaire peut être abordé au niveau de la fossette supra-épineuse de la scapula où il chemine parallèlement à l’artère supra-scapulaire. Une approche plus antérieure, au niveau de la fosse supra-claviculaire a récemment été décrite. Cette technique fait écho à une meilleure compréhension de la systématisation du plexus brachial. Selon ces données récentes, la division postérieure du tronc supérieur semblerait plus proche du nerf supra-scapulaire et un anesthésique local délivré au niveau du nerf supra- scapulaire antérieur, près de son origine proximale le long du plexus brachial, serait susceptible de diffuser à la division postérieure du tronc supérieur. Les nerfs axillaire et sous-scapulaire émergeant depuis cette division postérieure, la nécessité d’un blocage sélectif de ces nerfs serait inutile. Toutefois, cette approche est grevée d’un risque de pneumothorax supérieur au bloc interscalénique.
In: Maurice-Szamburski A. Anesthésie pour chirurgie de l’épaule. SFAR - Le Congrès 2018  .

Trajet du nerf suprascapulaire.

Site d’infiltration du nerf suprascapulaire.

Pour mémoire : Les blocs périphériques des membres chez l’adulte. RPC SFAR. Annales Françaises d’Anesthésie et de Réanimation 22 (2003) 567–581  .

Ring Removal: A Comprehensive Review of Techniques.
Gottlieb M, Casteel C, Ramsay N. | J Emerg Med. 2022 Aug;63(2):272-282
DOI: https://doi.org/10.1016/j.jemermed.2022.04.013  | Télécharger l'article au format  
Keywords: Caterpillar technique; Compression; Ring cutter; Ring removal; String.

Research article

Introduction : Entrapped rings can be dangerous, leading to increased pressure and damage to soft tissue, nerves, and vasculature. In order to properly care for these injuries, it is important for emergency medicine clinicians to be aware of the different approaches to remove entrapped rings.

Méthode : We searched PubMed to determine the different techniques and supporting literature for ring removal.

Discussion : There are a number of approaches that can be used to remove an entrapped ring. Clinicians should first consider the role of lubricants to reduce surface tension. Specific removal techniques include compression-based methods, traction-based techniques, rotation-based approaches, and the use of ring-cutting devices. There are unique advantages and limitations of each technique that are important to consider.

Conclusion : Emergency medicine clinicians need to be familiar with several different approaches to ring removal. This article summarizes the key techniques, variations on these techniques, advantages, and disadvantages for each approach.

Conclusion (proposition de traduction) : Les urgentistes doivent être familiarisés avec plusieurs approches différentes de retrait des bagues. Cet article résume les principales techniques, les variantes de ces techniques, les avantages et les inconvénients de chaque approche.