Physician gestalt for emergency department triage: A prospective videotaped study.
Cheng MT, Sung CW, Ko CH, Chen YC, Liew CQ, Ling DA, Liao EC, Lu TC, Ku NW, Fu LC, Huang CH, Tsai CL. | Acad Emerg Med. 2022 Sep;29(9):1050-1056
DOI: https://doi.org/10.1111/acem.14557  | Télécharger l'article au format  
Keywords: emergency department; physician gestalt; triage

ORIGINAL CONTRIBUTION

Introduction : Appropriate triage in patients presenting to the emergency department (ED) is often challenging. Little is known about the role of physician gestalt in ED triage. We aimed to compare the accuracy of emergency physician gestalt against the currently used computerized triage process.

Méthode : We conducted a prospective observational study in the ED at an academic medical center. Adult patients aged ≥20 years were included and underwent a standard triage protocol. The patients underwent system-based triage using the computerized software the Taiwan Triage and Acuity Scale. The entire triage process was recorded, and triage data were collected. Five physician raters provided triage levels (physician-based) according to their perceived urgency after reviewing videos. The primary outcome was hospital admission. The secondary outcomes were ED length of stay (EDLOS) and charges.

Résultats : In total, 656 patients were recruited (mean age 52 years, 50% male). The median system-based triage level was 3. By contrast, the median physician-based triage level was 4. The physician raters tended to provide lower triage levels than the system, with an average difference of 1. There was modest concordance between the two triage methods (correlation coefficient 0.30), with a weighted kappa coefficient of 0.18. The area under the receiver operating curve for the system- and physician-based triage in predicting hospital admission were similar (0.635 vs. 0.631, p = 0.896). Attending physicians appeared to have better performance than residents in predicting admission. The variation explained (R2 ) in EDLOS and charges were similar between the two triage methods (R² = 3% for EDLOS, 7%-9% for charges).

Conclusion : Emergency physician gestalt for triage showed similar performance to a computerized system; however, physicians redistributed patients to lower triage levels. Physician gestalt has advantages for identifying low-risk patients. This approach may avoid undue time pressure for health care providers and promote rapid discharge.

Conclusion (proposition de traduction) : Le jugement du clinicien d'urgence pour le triage a montré des performances similaires à celles d'un système informatisé ; cependant, les médecins ont redistribué les patients à des niveaux de triage inférieurs. Limpression clinique des médecins présente des avantages pour l'identification des patients à faible risque. Cette approche peut éviter une pression excessive en termes de temps pour les professionnels de la santé et favoriser une sortie rapide.

Galinski M, Galinski M. | Ann. Fr. Med. Urgence. 2022;12:313–320
DOI: https://doi.org/10.3166/afmu-2022-0433
Keywords: Tracheal intubation; Out-of-hospital emergency medicine; Bougie

Mise au point / Update

Editorial : L’intubation trachéale (IT) est un geste fréquent en médecine d’urgence extra-hospitalière (MUEH) mais elle est associée à un taux élevé d’échec de la première tentative et à certaines complications graves. Le taux de ces dernières augmente avec le nombre de tentative d’IT. La Société française d’anesthésie et de réanimation (SFAR) et la Société de réanimation de langue française (SRLF) avec la collaboration de la Société française de médecine d’urgence (SFMU) ont publié en 2016 des recommandations formalisées d’experts (RFE) sur l’intubation du patient de réanimation. La question qui se pose est la pertinence de ces recommandations pour la MUEH. En effet, la mesure du risque de difficulté est basée sur le score de MACOCHA et en cas de difficulté prévue les outils à utiliser d’emblée sont le vidéo-laryngoscope ou le mandrin long béquillé en laryngoscopie directe. Or il apparait que le score de MACOCHA n’est pas adapté à la MUEH et de façon plus générale, il est complexe de mesurer le risque d’intubation difficile (ID) dans ce contexte. La vidéolaryngoscopie n’a pas encore fait la preuve de sa supériorité par rapport à la laryngoscopie directe en MUEH. Par contre des travaux récents en médecine d’urgence ont démontré que l’utilisation en première intention du mandrin long béquillé augmente significativement le taux de succès de la première tentative de l’IT, même en l’absence de facteur de risque d’ID.

Conclusion : In total, one could consider each TI in OHEM as a priori at risk of difficulty which would justify the use of the bougie from the outset. In the other hand, it is necessary to propose specific guidelines for out-of-hospital emergency medicine.

Conclusion (proposition de traduction) : Au total, on pourrait considérer chaque intubation trachéale en médecine d’urgence extra-hospitalière comme a priori à risque de difficulté ce qui justifierait une utilisation d’emblée du mandrin long béquillé. Il semble nécessaire de proposer des recommandations spécifiques à la médecine d’urgence.

Eye involvement in burns: incidence, risk factors and prognosis.
Essid J, Mokline A, Fraj H, Aloui A, Mayoufi H, Eljemi I, Saad M.B, Messadi A.A.. | Ann Burn Fire Disasters. 2022 Sept;23(3):194-8
DOI: NC  | Télécharger l'article au format  
Keywords: burns; ocular lesions; risk factors; prognosis

Article

Editorial : L'atteinte oculaire chez les brûlés est assez fréquente. Son diagnostic est souvent tardif, pouvant engager les pronostics fonctionnel et esthétique. Nous avons mené une étude descriptive rétrospective intéressant des patients brûlés ayant présenté une atteinte oculaire, pris en charge dans le service de réanimation des brûlés de Tunis entre le 01/01/2013 et le 30/09/2020. Vingt-six dossiers associant brûlure et atteinte oculaire ont été revus. L'âge moyen de nos patients était de 26 ans, avec un sex-ratio de 3,3/1. La surface cutanée brûlée moyenne était de 22 +/- 13%, l'origine thermique dans 16 cas. Une brûlure de la face a été retrouvée chez 23 patients, un recours à la ventilation mécanique a été nécessaire pour 10 patients. Le délai médian de découverte de l'atteinte oculaire était de 4,5 heures [1-33 h]. Les principaux signes cliniques évocateurs étaient : une rougeur oculaire (n=5) et un écoulement oculaire (n=4). Les lésions étaient principalement des abcès (n=6) et des ulcères cornéens (n=6). Le traitement était basé sur une antibiothérapie locale (n=16) associée à une antibiothérapie systémique (n=10). Un traitement chirurgical a été nécessaire dans 2 cas. L'évolution a été favorable chez 18 patients, deux patients ont perdu la vue. Les facteurs de risque prédictifs d'atteinte oculaire étaient : la brûlure de la face (p=0,01), la profondeur des brûlures (p=0,02), et la ventilation mécanique (p=0,04).

Conclusion (proposition de traduction) : Dans notre série, l’atteinte oculaire a été rapportée chez 88,4 % des patients ayant une brûlure de la face. Il s’agissait essentiellement d’un abcès ou d’un ulcère cornéen. Les principaux facteurs prédictifs de cette complication étaient: la brûlure de la face, la profondeur des brûlures, et la ventilation mécanique. Une prise en charge précoce et adaptée permettra de minimiser les séquelles fonctionnelles qui peuvent être très invalidantes.

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

Research article

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

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

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

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

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

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

Research article

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

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

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

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

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

Factors associated with time delay to angiography in acute ST-elevation myocardial infarction - A retrospective cohort study in Northern Finland.
Aitavaara-Anttila MK, Pernu HH, Rumpunen TK, Similä JPO, Liisanantti JH, Kaakinen TI, Erkinaro TM, Raatiniemi LV. | Australas Emerg Care. 2022 Sep;25(3):213-218
DOI: https://doi.org/10.1016/j.auec.2021.11.003  | Télécharger l'article au format  
Keywords: Delayed treatment; Emergency medical services; Pre-hospital care; ST-elevation myocardial infarction.

Research paper

Introduction : The delay of percutaneous coronary intervention increases the risk of heart failure and mortality in STEMI. The aim of this study was to examine the time intervals of EMS and the factors associated with the time delay to angiography in patients with STEMI.

Méthode : The present study was conducted in Northern Ostrobothnia, Finland in 2014-2016. All patients transported to the hospital by EMS who were diagnosed with STEMI and underwent a primary angiography within 24 h of arrival were included. Angiography was defined as delayed if it was performed over 120 min of the first medical contact (FMC).

Résultats : 310 patients met the inclusion criteria during the study period. Time from the FMC to angiography was less than 120 min in 231 patients (74.5%). In multivariate analysis, the factors associated with delayed angiography were the absence of chest pain (OR 2.46 (1.18-5.13),p = 0.016), dyspnea (OR 3.11 (1.54-6.28),p = 0.002), the treatment protocol violations by EMS (OR 2.41 (0.99-5.80),p = 0.050), treatment initiation at a primary health care center (OR 3.64 (1.39-9.48),p = 0.008), and the distance to hospital of over 100 km (OR 11.87 (6.14-22.93),p < 0.001).

Conclusion : In our study, treatment protocol violations, non-specific symptoms, and the distance to hospital of over 100 km were associated with primary angiography in patients with STEMI transported to the hospital by EMS.

Conclusion (proposition de traduction) : Dans notre étude, les violations du protocole de traitement, les symptômes non spécifiques et la distance de plus de 100 km jusqu'à l'hôpital étaient associés à l'angiographie primaire chez les patients atteints de STEMI transportés à l'hôpital par le SAMU.

Just the facts: point‐of‐care ultrasound in cardiac arrest.
Gottlieb M, Sundaram T, Olszynski P, Atkinson P. | CJEM. 2022 Sep;24(6):579-581
DOI: https://doi.org/10.1007/s43678-022-00336-7  | Télécharger l'article au format  
Keywords: Aucun

Just the Facts

Editorial : A 58-year-old man presents to the emergency department for sudden-onset chest pain and dyspnea. Shortly after being brought to a room, he has a cardiac arrest. Chest compres- sions are initiated. You wonder whether ultrasound could assist with managing this patient in cardiac arrest.

Conclusion : Despite widespread use for intra-arrest prognostication, there is a lack of high-quality evidence supporting the independent use of cardiac ultrasound for this purpose. Although cardiac activity seen on ultrasound is associated with improved odds for return of spontaneous circulation and survival in non-traumatic, non-shockable cardiac arrest, and may provide valuable information in the management of non-traumatic pulseless electrical activity (PEA) or asys- tole, ultrasound should not be viewed as the sole predictor in determining outcome. Patients with traumatic cardiac arrest without cardiac activity on ultrasound have a high likelihood of death and negligible chance of survival [9]. Importantly, cardiac activity should involve visualized motion of the cardiac walls (e.g., isolated valve movements would not qualify as cardiac activity). To improve the reli- ability of ultrasound as a prognostic tool in cardiac arrest, future research should focus on standardizing the definition of cardiac motion, strengthening study quality, and assess- ing transesophageal versus transthoracic echocardiography during CPR. Currently, a Bayesian approach is reasonable, including ultrasound as one tool in the prognostic process.

Conclusion (proposition de traduction) : Malgré une utilisation répandue pour le pronostic intra-arrêt, il y a un manque de preuves de haute qualité soutenant l'utilisation indépendante de l'échographie cardiaque à cette fin. Bien que l'activité cardiaque observée à l'échographie soit associée à de meilleures chances de retour à la circulation spontanée et de survie en cas d'arrêt cardiaque non traumatique et non choquable, et qu'elle puisse fournir des informations précieuses pour la gestion de l'activité électrique sans pouls (AES) ou de l'asystolie non traumatique, l'échographie ne doit pas être considérée comme le seul facteur prédictif pour déterminer l'issue. Les patients victimes d'un arrêt cardiaque traumatique sans activité cardiaque à l'échographie ont une forte probabilité de décès et des chances de survie négligeables [9]. Il est important de noter que l'activité cardiaque doit impliquer un mouvement visualisé des parois cardiaques (par exemple, les mouvements isolés des valves ne sont pas considérés comme une activité cardiaque). Pour améliorer la fiabilité de l'échographie en tant qu'outil pronostique dans l'arrêt cardiaque, les recherches futures devraient se concentrer sur la normalisation de la définition du mouvement cardiaque, le renforcement de la qualité des études et l'évaluation de l'échocardiographie transœsophagienne par rapport à l'échocardiographie transthoracique pendant la RCP. Actuellement, une approche bayésienne est raisonnable, incluant l'échographie comme un outil dans le processus pronostique.

Effect of noninvasive respiratory strategies on intubation or mortality among patients with acute hypoxemic respiratory failure and COVID-19: The RECOVERY-RS randomized clinical trial.
Durr KM, Yadav K, Rosenberg H. | CJEM. 2022 Sep;24(6):582-584
DOI: https://doi.org/10.1007/s43678-022-00327-8  | Télécharger l'article au format  
Keywords: Aucun

Need to Know: CJEM Journal Club

Introduction : Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended modalities for managing acute hypoxemic respiratory failure in COVID-19 patients. However, their effectiveness and safety remain unknown.

Méthode : Determine the effectiveness of CPAP or HFNO, compared with conventional oxygen therapy, in patients hospitalized with acute hypoxemic respiratory failure secondary to COVID-19.
Design and setting: A parallel group, adaptive, open-label, randomized clinical trial conducted in 48 acute care hospitals in the United Kingdom and Jersey.
Subjects: Hospitalized adults with known or suspected COVID-19-related acute hypoxemic respiratory failure (defined as having an oxygen saturation of ≤ 94% despite receiving a fraction of inspired oxygen of at least 0.40).
Intervention: CPAP or HFNO.
Comparison: Conventional oxygen therapy.
Outcomes: The primary outcome was a composite of tracheal intubation or mortality within 30 days of randomization. Secondary outcomes included tracheal intubation within 30 days, mortality within 30 days, time to tracheal intubation, duration of invasive mechanical ventilation, time to death, in-intensive care unit (ICU) mortality, in-hospital mortality, ICU admission, ICU length of stay, and hospital length of stay.

Résultats : Of the 1278 participants randomized for the study, 1273 (CPAP 380, HFNO 418, control 475) were included, with primary outcome data available for 1260 (CPAP 377, HFNO 415, conventional oxygen 468). For the primary outcome, CPAP demonstrated a statistically significant reduction in the composite outcome of tracheal intubation or mortality within 30 days (36.3% vs. 44.4%; − 8 [95% CI − 15 to − 1%], P = 0.03), whereas HFNO did not (44.3% vs. 45.1%; − 1% [95% CI − 8 to 6%], P = 0.83).
The secondary outcomes for the individual components of the primary outcome for the CPAP and HFNO intervention arms are presented in Tables 1 and 2, respectively.

Conclusion : The RECOVERY-RS randomized trial identified a significant reduction for the composite outcome of tracheal intubation or mortality within 30 days when using CPAP in COVID-19-associated acute hypoxemic respiratory failure. The reduction in the primary outcome is primarily driven by the decreased tracheal intubation rates. Despite this benefit, the increased prevalence of adverse events with CPAP must be noted. In contrast, no significant benefit was seen with HFNO.
Based on the available evidence, we recommend considering CPAP early when managing COVID-19-associated acute hypoxemic respiratory failure [4]. HFNO can also be considered based on individual patient factors and location [4].

Conclusion (proposition de traduction) : L'essai randomisé RECOVERY-RS a identifié une réduction significative du résultat composite de l'intubation trachéale ou de la mortalité dans les 30 jours lors de l'utilisation de la CPAP dans l'insuffisance respiratoire hypoxémique aiguë associée au COVID-19. La réduction du résultat primaire est principalement due à la diminution des taux d'intubation trachéale. Malgré ce bénéfice, il faut noter la prévalence accrue d'événements indésirables avec la CPAP. En revanche, aucun avantage significatif n'a été observé avec la HFNO.
Sur la base des preuves disponibles, nous recommandons d'envisager la CPAP dès le début de la prise en charge de l'insuffisance respiratoire hypoxémique aiguë associée au COVID-19 [4]. L'HFNO peut également être envisagée en fonction des facteurs individuels du patient et de sa localisation.

Thresholds for Hypertension Definition, Treatment Initiation, and Treatment Targets: Recent Guidelines at a Glance.
Vidal-Petiot E | Circulation. C2022 Sep 13;146(11):805-807
DOI: https://doi.org/10.1161/circulationaha.121.055177  | Télécharger l'article au format  
Keywords: antihypertensive agents; blood pressure; cardiovascular diseases; hypertension; life style; practice guideline; public health.

PERSPECTIVE

Editorial : The American College of Cardiology (ACC)/American Heart Association (AHA) issued their guideline on high blood pressure (BP) in 2017.1 The 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guideline for the management of arterial hypertension was released a few months later.2 Both documents similarly emphasized important considerations for hypertension management, such as BP measurement and lifestyle intervention. However, they displayed more or less subtle quantitative variations in threshold values used for clinical decision. In 2020, the International Society of Hypertension (ISH) global hypertension practice guideline displayed strong similarities with both documents for what they refer to as “optimal” care.

Conclusion : In conclusion, further harmonization of these major influential documents, as advocated by Whelton and colleagues in this issue, is desirable. Indeed, discrepancies (even slight) between guidelines may generate confusion and contribute to blurring the main messages and slowing down implementation of evidence-based care in daily clinical practice, eventually contributing to insufficient worldwide BP control. Meanwhile, this graphical summary is meant to help clinicians have a clear overview.

Conclusion (proposition de traduction) : En conclusion, il est souhaitable d'harmoniser davantage ces documents importants, comme le préconisent Whelton et ses collègues dans ce numéro. En effet, les divergences (même légères) entre les recommandations peuvent générer de la confusion et contribuer à brouiller les messages principaux et à ralentir la mise en œuvre de soins fondés sur des preuves dans la pratique clinique quotidienne, contribuant finalement à un contrôle insuffisant de la pression artérielle dans le monde. En attendant, ce résumé graphique a pour but d'aider les cliniciens à avoir une vue d'ensemble claire.

Commentaire :  Seuils pour la définition de l'hypertension, l'initiation du traitement et les objectifs thérapeutiques : aperçu des recommandations récentes.
ACC signifie American College of Cardiology ; AHA, American Heart Association ; ASCVD, maladie cardiovasculaire athéroscléreuse ; BP, pression artérielle ; CAD, maladie coronarienne ; CKD, maladie rénale chronique ; CVD, maladie cardiovasculaire ; ESC, European Society of Cardiology ; ESH, European Society of Hypertension ; HTN, hypertension ; HMOD, lésions organiques médiées par l'hypertension ; et ISH, International Society of Hypertension.
*La catégorie de pression artérielle est donnée par la composante de la catégorie la plus élevée (systolique ou diastolique). Une composante de la pression artérielle mesurée à la valeur seuil exacte classe le patient dans la catégorie supérieure à ce seuil.
†Les patients à haut risque (patients atteints d'une maladie cardiovasculaire, d'un diabète, d'une maladie rénale chronique ou d'un risque de maladie cardiovasculaire athéroscléreuse sur 10 ans ≥10 % [équations de cohorte regroupées] et les adultes non institutionnalisés de 65 ans ou plus ayant une pression artérielle systolique ≥130 mm Hg) doivent être pris en charge par un traitement pharmacologique immédiat (en plus des conseils sur le mode de vie). Chez les adultes de moins de 65 ans présentant un risque de maladie cardiovasculaire athéroscléreuse à 10 ans < 10 % et qui ne sont toujours pas contrôlés après 3 à 6 mois de traitement axé sur le mode de vie, une déclaration récente de l'AHA ajoute qu'il faut "envisager l'ajout de médicaments". Il convient de noter que le code couleur est défini par les lignes directrices de 2017, bien qu'avec cette récente déclaration de l'AHA, cette catégorie (130/139/80-89 mm Hg) serait mieux codée par le code couleur plus foncé "traitement médicamenteux pour tous : immédiatement ou après une intervention sur le mode de vie en fonction du risque."
‡Les médicaments hypotenseurs peuvent être envisagés chez les patients à très haut risque souffrant d'une maladie cardiovasculaire, en particulier d'une maladie coronarienne, et dont la tension artérielle est normale.
$Un traitement médicamenteux immédiat chez les patients à risque élevé ou très élevé (évalué à l'aide du système SCORE [Systematic Coronary Risk Evaluation]), ou présentant un diabète, une maladie cardiovasculaire, une maladie rénale chronique ou des lésions organiques dues à l'hypertension, en même temps qu'une intervention sur le mode de vie ; chez les patients à risque faible ou modéré, les médicaments hypotenseurs doivent être introduits après 3 à 6 mois d'intervent

Early Rhythm Control in Patients With Atrial Fibrillation and High Comorbidity Burden.
Rillig A, Borof K, Breithardt G, Camm AJ, Crijns HJGM, Goette A, Kuck KH, Metzner A, Vardas P, Vettorazzi E, Wegscheider K, Zapf A, Kirchhof P. | Circulation. 2022 Sep 13;146(11):836-847
DOI: https://doi.org/10.1161/circulationaha.122.060274  | Télécharger l'article au format  
Keywords: anti-arrhythmia agents; atrial fibrillation; atrial fibrillation ablation; comorbidity; death; stroke.

ORIGINAL RESEARCH ARTICLE

Introduction : The randomized EAST-AFNET4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial-Atrial Fibrillation Network) demonstrated that early rhythm control (ERC) reduces adverse cardiovascular outcomes in patients with recently diagnosed atrial fibrillation and stroke risk factors. The effectiveness and safety of ERC in patients with multiple cardiovascular comorbidities is not known.

Méthode : These prespecified subanalyses of EAST-AFNET4 compared the effectiveness and safety of ERC with usual care (UC) stratified into patients with higher (CHA2DS2-VASc score ≥4) and lower comorbidity burden. Sensitivity analyses ignored sex (CHA2DS2-VA score).

Résultats : EAST-AFNET4 randomized 1093 patients with CHA2DS2-VASc score ≥4 (74.8±6.8 years, 61% female) and 1696 with CHA2DS2-VASc score <4 (67.4±8.0 years, 37% female). ERC reduced the composite primary efficacy outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome in patients with CHA2DS2-VASc score ≥4 (ERC, 127/549 patients with events; UC, 183/544 patients with events; hazard ratio [HR], 0.64 [0.51-0.81]; P < 0.001) but not in patients with CHA2DS2-VASc score <4 (ERC, 122/846 patients with events; UC, 133/850 patients with events; HR, 0.93 [0.73-1.19]; P=0.56, Pinteraction=0.037). The primary safety outcome (death, stroke, or serious adverse events of rhythm control therapy) was not different between study groups in patients with CHA2DS2-VASc score ≥4 (ERC, 112/549 patients with events; UC, 132/544 patients with events; HR, 0.84 [0.65, 1.08]; P=0.175), but occurred more often in patients with CHA2DS2-VASc scores <4 randomized to ERC (ERC, 119/846 patients with events; UC, 91/850 patients with events; HR, 1.39 [1.05-1.82]; P=0.019, Pinteraction=0.008). Life-threatening events or death were not different between groups (CHA2DS2-VASc score ≥4, ERC, 84/549 patients with event, UC, 96/544 patients with event; CHA2DS2-VASc scores <4, ERC, 75/846 patients with event, UC, 73/850 patients with event). When female sex was ignored for the creation of higher and lower risk groups (CHA2DS2-VA score), the Pinteraction was not significant for the primary efficacy outcome (P=0.25), but remained significant (P=0.044) for the primary safety outcome.

Conclusion : Patients with recently diagnosed atrial fibrillation and CHA2DS2-VASc score ≥4 should be considered for ERC to reduce cardiovascular outcomes, whereas those with fewer comorbidities may have less favorable outcomes with ERC.

Conclusion (proposition de traduction) : Les patients présentant une fibrillation auriculaire récemment diagnostiquée et un score CHA2DS2-VASc ≥4 devraient bénéficier d'un contrôle précoce du rythme afin de réduire les conséquences cardiovasculaires, tandis que les patients présentant moins de comorbidités pourraient avoir des résultats moins favorables avec le contrôle précoce du rythme.

The management of acute meningitis: an update.
Carter E, McGill F. | Clin Med (Lond). 2022 Sept;22(5):396–400
DOI: https://doi.org/10.7861/clinmed.2022-cme-meningitis  | Télécharger l'article au format  
Keywords: infectious diseases, meningitis, Streptococcus pneumoniae, Neisseria meningitidis, enteroviruses

CME: INFECTIOUS DISEASES

Editorial : Meningitis remains an important cause of mortality and morbidity. Clinicians should be alert to this diagnosis and have a low threshold for investigation and treatment of meningitis. This article provides an update of current evidence and existing guidelines for the management of suspected acute meningitis in adults in the UK.

Conclusion : Key points
Lumbar puncture should be performed as soon as possible in all cases of suspected meningitis, unless contraindicated, in order to determine the aetiology, guide treatment decisions, and prevent unnecessary treatment and prolonged hospital stays.
Brain imaging is not required in the majority of cases prior to lumbar puncture and results in unnecessary delays in lumbar puncture and antibiotic initiation.
Steroids should be initiated just prior to or in conjunction with antibiotics in all cases of suspected bacterial meningitis.
Important risk factors for specific aetiologies should be ascertained and guide empirical antibiotic decisions; for example, relative immunocompromise including age >60 years, chronic disease and alcohol excess (risk of Listeria monocytogenes) and a travel history to areas with a high incidence of penicillin-resistant Streptococcus pneumoniae.
Mortality from bacterial meningitis remains significant and future treatments are being developed that aim to reduce the inflammation associated with the disease.

Conclusion (proposition de traduction) : Points clés
La ponction lombaire doit être réalisée le plus rapidement possible dans tous les cas de suspicion de méningite, sauf contre-indication, afin de déterminer l'étiologie, d'orienter les décisions thérapeutiques et d'éviter les traitements inutiles et les séjours hospitaliers prolongés.
L'imagerie cérébrale n'est pas nécessaire dans la majorité des cas avant la ponction lombaire et entraîne des retards inutiles dans la ponction lombaire et l'initiation des antibiotiques.
Les stéroïdes doivent être initiés juste avant ou en même temps que les antibiotiques dans tous les cas de suspicion de méningite bactérienne.
Les facteurs de risque importants pour des étiologies spécifiques doivent être déterminés et guider les décisions d'antibiothérapie empirique ; par exemple, une immunodépression relative, y compris un âge supérieur à 60  ans, une maladie chronique et un éthylisme chronique (risque de Listeria monocytogenes) et des antécédents de voyage dans des régions à forte incidence de Streptococcus pneumoniae résistant à la pénicilline.
La mortalité liée à la méningite bactérienne reste importante et de futurs traitements sont en cours de développement, visant à réduire l'inflammation associée à la maladie.

Commentaire :  Antimicrobial treatment algorithm.
^aSerum vancomycin trough concentrations of 15–20 μg/mL should be aimed for. bd = twice a day; IV = intravenous; MIC = minimal inhibitory concentration; PO = per oral; tds = three times a day.

Sepsis and the brain: a review for acute and general physicians.
Carter BL, Underwood J. | Clin Med (Lond). 2022 Sep;22(5):392-395
DOI: https://doi.org/10.7861/clinmed.2022-0346  | Télécharger l'article au format  
Keywords: brain; delirium; encephalopathy; sepsis.

CME: Infectious diseases

Editorial : Sepsis-associated encephalopathy (SAE) describes acute cognitive dysfunction secondary to systemic or peripheral infection occurring outside of the central nervous system (CNS). Symptoms can range from mild confusion to coma and may precede the clinical signs of sepsis. Recognition that SAE is a potential differential diagnosis in patients presenting with delirium is important, as SAE is a diagnosis of exclusion. Physicians should also be aware that severe SAE is associated with a high mortality. Although mortality is often secondary to multiorgan failure rather than neurological sequelae, long-term cognitive and psychological morbidities have been reported in sepsis survivors. Early treatment (which can include prompt identification and source control of the infection) and good supportive care might improve cognitive outcomes. Future work should aim to improve understanding of both acute and chronic SAE with a focus on therapeutic interventions and improving patient outcomes.

Conclusion : SAE is a heterogenous condition due to variability in culprit pathogens, pathophysiology and treatment. It remains a frequent, acute complication of sepsis with chronic sequelae in some, highlighting that the brain is an organ that can be profoundly affected during episodes of infection.

Conclusion (proposition de traduction) : L'encéphalopathie associée au sepsis est une affection hétérogène en raison de la variabilité des agents pathogènes coupables, de la physiopathologie et du traitement. Elle reste une complication fréquente et aiguë de la septicémie, avec des séquelles chroniques chez certains, ce qui montre que le cerveau est un organe qui peut être profondément affecté lors d'épisodes infectieux.

The management of acute meningitis: an update.
Carter E, McGill F. | Clin Med (Lond). 2022 Sep;22(5):396-400
DOI: https://doi.org/10.7861/clinmed.2022-cme-meningitis  | Télécharger l'article au format  
Keywords: Neisseria meningitidis; Streptococcus pneumoniae; enteroviruses; infectious diseases; meningitis.

CME: INFECTIOUS DISEASES

Editorial : Meningitis remains an important cause of mortality and morbidity. Clinicians should be alert to this diagnosis and have a low threshold for investigation and treatment of meningitis. This article provides an update of current evidence and existing guidelines for the management of suspected acute meningitis in adults in the UK.

Conclusion : Key points
Lumbar puncture should be performed as soon as possible in all cases of suspected meningitis, unless contraindicated, in order to determine the aetiology, guide treatment decisions, and prevent unnecessary treatment and prolonged hospital stays.
Brain imaging is not required in the majority of cases prior to lumbar puncture and results in unnecessary delays in lumbar puncture and antibiotic initiation.
Steroids should be initiated just prior to or in conjunction with antibiotics in all cases of suspected bacterial meningitis.
Important risk factors for specific aetiologies should be ascertained and guide empirical antibiotic decisions; for example, relative immunocompromise including age >60 years, chronic disease and alcohol excess (risk of Listeria monocytogenes) and a travel history to areas with a high incidence of penicillin-resistant Streptococcus pneumoniae.
Mortality from bacterial meningitis remains significant and future treatments are being developed that aim to reduce the inflammation associated with the disease.

Conclusion (proposition de traduction) : Points clés
La ponction lombaire doit être réalisée le plus rapidement possible dans tous les cas de suspicion de méningite, sauf contre-indication, afin de déterminer l'étiologie, d'orienter les décisions thérapeutiques et d'éviter les traitements inutiles et les séjours hospitaliers prolongés.
L'imagerie cérébrale n'est pas nécessaire dans la majorité des cas avant la ponction lombaire et entraîne des retards inutiles dans la ponction lombaire et l'initiation des antibiotiques.
Les corticoïdes doivent être initiés juste avant ou en même temps que les antibiotiques dans tous les cas de suspicion de méningite bactérienne.
Les facteurs de risque importants pour des étiologies spécifiques doivent être déterminés et guider les décisions d'antibiothérapie empirique ; par exemple, une immunodépression relative, y compris un âge supérieur à 60 ans, une maladie chronique et un excès d'alcool (risque de Listeria monocytogenes) et des antécédents de voyages dans des régions à forte incidence de Streptococcus pneumoniae résistant à la pénicilline.
La mortalité due à la méningite bactérienne reste importante et des traitements futurs sont en cours de développement afin de réduire l'inflammation associée à la maladie.

A practical update on the management of patients with COVID-19.
Mehta M, Navarra A, Mogal R. | Clin Med (Lond). 2022 Sep;22(5):468-474
DOI: https://doi.org/10.7861/clinmed.2022-0080  | Télécharger l'article au format  
Keywords: COVID-19; monoclonal antibodies; treatments.

CONCISE GUIDANCE

Editorial : While vaccines against COVID-19 are being rolled out, an ongoing need remains for therapies to treat patients who have symptomatic COVID-19 before vaccination or in whom breakthrough infection develops. Dexamethasone and interleukin-6 inhibitors have been the mainstay of treatment for severe to critical COVID-19 requiring hospitalisation. However, in the previous few months, several therapies have been approved in the UK for hospitalised and non-hospitalised patients with COVID-19. In particular, the development of neutralising monoclonal antibodies and novel antivirals represents a welcome expansion in the armamentarium against COVID-19, not only therapeutically to reduce mortality but also because they can be used in mild or moderate disease to prevent hospitalisation. This update is based on guidance from NHS England as well as the World Health Organization, and provides practical support and guidance to all clinicians involved or interested in the management of COVID-19 patients, whether based in community, outpatient or inpatient settings.

Conclusion : The recent approval of sotrovimab for use in non-hospitalised patients, together with Paxlovid, remdesivir and molnupiravir, are important developments in the fight against COVID-19. Their rapid provision and delivery have the potential to reduce hospitalisations, severe disease and death, while also reducing pressure on other NHS services. The therapies available for the treatment of hospitalised patients have become increasingly complex. We hope this rapid update provides useful guidance on the management of COVID-19 to physicians across the healthcare spectrum.

Conclusion (proposition de traduction) : La récente approbation du sotrovimab pour une utilisation chez les patients non hospitalisés, ainsi que le Paxlovid, le remdesivir et le molnupiravir, sont des développements importants dans la lutte contre la COVID-19. Leur mise à disposition et leur délivrance rapides ont le potentiel de réduire les hospitalisations, les maladies graves et les décès, tout en réduisant la pression sur les autres services du système de Santé Publique du Royaume-Uni. Les traitements disponibles pour prendre en charge les patients hospitalisés sont devenus de plus en plus complexes. Nous espérons que cette mise à jour rapide fournira des conseils utiles sur la gestion de la COVID-19 aux médecins de tous les secteurs de la santé.

Commentaire : Procédure de prise en charge des patients ayant contracté le COVID-19 à l'hôpital ^aRemdesivir est une recommandation faite dans les directives du NHS mais pas dans celles de l'Organisation mondiale de la santé
nMAB = anticorps monoclonal neutralisant.

CT imaging in idiopathic out-of-hospital cardiac arrest: An assessment of current practice and diagnostic utility.
Harper I, Easterford K, Reed M. | Emergency Care Journal. 2022 Sep 27;18(3):10669
DOI: https://doi.org/10.4081/ecj.2022.10669  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Idiopathic out-of-hospital cardiac arrest (OHCA) requires urgent treatment. Early computed tomography (CT) imaging may be useful to aid diagnosis. We aimed to determine current CT imaging practice, safety, and diagnostic value in this patient population.

Méthode : Single-centre, retrospective cohort study of patients presenting to the Emergency Department (ED) of the Royal Infirmary of Edinburgh with idiopathic non-traumatic OHCA and return of spontaneous circulation (ROSC).

Résultats : Between 1st January 2016 and 31st December 2019, 140 of 156 (90%) eligible patients underwent 195 CT scans identifying the cause of OHCA in 6 (4%). CT head diagnosed one ischaemic and three haemorrhagic strokes, and CT pulmonary angiogram diagnosed one acute coronary syndrome and one pulmonary embolism. CT head (134), CT pulmonary angiogram (25) and CT cervical spine (16) were the commonest scans. 68 of 195 (35%) CT scans showed important pathology, mostly secondary to OHCA. CT imaging was safe with no cases of contrast nephropathy, allergic reaction, or other complications.

Conclusion : 9 in 10 patients presenting to the ED with idiopathic non-traumatic OHCA and ROSC underwent CT imaging. The diagnostic value of CT in this patient population was limited, with arrest cause identified in 4% of patients. Imaging was a valuable method of identifying other relevant pathology due to arrest or resuscitation in 37% of patients. Patients with asystole, patients not in VF, patients with a longer downtime, patients who rearrested and patients with unreactive pupils in the ED were more likely to have positive findings on CT imaging. CT head and CTPA were most performed. Imaging was safe with no recorded cases of contrast nephropathy, allergic reactions, complications, or inappropriate treatments.
The diagnostic value of CT imaging in this patient population was limited. However, imaging was a valuable method of identifying other important secondary pathology.

Conclusion (proposition de traduction) : 9 patients sur 10 se présentant aux urgences avec un arrêt cardiaque idiopathique non traumatique hors de l'hôpital et un retour à la circulation spontanée ont subi une imagerie par tomographie assistée par ordinateur. Tomographie informatisée précoce et 2016 et 31décembre 2019, 140 ont subi une imagerie par tomographie informatisée. La valeur diagnostique de la tomographie informatisée dans cette population de patients était limitée, avec une cause d'arrêt identifiée chez 4% des patients. L'imagerie a été une méthode précieuse pour identifier d'autres pathologies pertinentes dues à l'arrêt ou à la réanimation chez 37 % des patients. Les patients en asystolie, les patients qui n'étaient pas en FV, les patients dont la durée d'arrêt était plus longue, les patients qui se sont réarrêtés et les patients dont les pupilles ne réagissaient pas aux urgences étaient plus susceptibles d'avoir des résultats positifs à l'imagerie par scanner. La tomographie par ordinateur de la tête et la tomographie par ordinateur de l'embolie pulmonaire ont été les plus pratiquées. L'imagerie était sûre, aucun cas de néphropathie de contraste, de réactions allergiques, de complications ou de traitements inappropriés n'ayant été enregistré.
La valeur diagnostique de l'imagerie par tomodensitométrie dans cette population de patients était limitée. Cependant, l'imagerie était une méthode précieuse pour identifier d'autres pathologies secondaires importantes.

Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial.
Zwaans JJM, Raven W, Rosendaal AV, Van Lieshout EMM, Van Woerden G, Patka P, Haagsma JA, Rood PPM. | Emerg Med J. 2022 Sep;39(9):650-654
DOI: https://doi.org/10.1136/emermed-2021-211540  | Télécharger l'article au format  
Keywords: emergency department; wounds and injuries.

Original research

Introduction : Patients with traumatic wounds frequently present to the ED. Literature on whether to treat these wounds sterile or non-sterile is sparse. Non-sterile treatment has the advantage of saving resources and costs, and could be of value in health settings where sterile materials are not readily available. Our objective was to compare the rate of wound infection after suturing traumatic lacerations with non-sterile gloves and dressings versus sterile gloves, dressings and drapes in the ED. We hypothesised that non-sterile gloves and dressings would be non-inferior to sterile gloves, dressings and drapes. The non-inferiority margin was set at 2%.

Méthode : A multicentre single-blinded randomised controlled trial testing for non-inferiority of non-sterile gloves and dressings versus sterile gloves, dressings and drapes for suturing of traumatic wounds was performed in 3 EDs in The Netherlands. Adults with uncomplicated wounds were included from July 2012 to December 2016. At the time of treatment, patient and wound characteristics and management were documented. The outcome was wound infection, which was identified during follow-up in the treating ED at 5-14 days postprocedure.

Résultats : From 2468 eligible patients, 1480 were randomised in a sterile (n=747) or non-sterile (n=733) protocol. Baseline characteristics were similar in both study arms. The observed wound infection rate in the non-sterile group was 5.7% (95% CI 4.0% to 7.5%) vs 6.8% (95% CI 5.1% to 8.8%) in the sterile group. The mean difference of the wound infection rate of the two groups was -1.1% (95% CI -3.7% to 1.5%).

Conclusion : Although recruitment ceased prior to reaching our planned sample size, the findings suggest that there is unlikely to be a large difference between the non-sterile gloves and dressings for suturing of traumatic wounds and sterile gloves, dressings and drapes for suturing of traumatic wounds in the ED.

Conclusion (proposition de traduction) : Bien que les inclusions ait cessé avant d'atteindre la taille d'échantillon prévue, les résultats suggèrent qu'il est peu probable qu'il y ait une grande différence entre les gants et pansements non stériles pour la suture des plaies traumatiques et les gants, pansements et draps stériles pour la suture des plaies traumatiques aux urgences.

Commentaire : Voir les commentaires dans :
Metcalfe D, Parsons NR, Costa ML. Sterile versus non-sterile gloves for traumatic wounds in the ED. Emerg Med J  . 2022 Sep;39(9):648-649

Risk factors for the presence of important fractures in ED patients with shoulder dislocation: a retrospective cohort study.
Delattre Sousa S, Houze-Cerfon CH, Le Gourrierec T, Charpentier S, Dubucs X, Balen F. | Emerg Med J. 2022 Sep;39(9):662-665
DOI: https://doi.org/10.1136/emermed-2021-211772
Keywords: clinical assessment; emergency department.

Original research

Introduction : Prereduction shoulder X-rays are frequently done to rule out an important fracture that might preclude reduction of a shoulder dislocation in the ED. Our objective was to determine the risk factors for an important fracture in patients admitted to the ED with shoulder dislocation.

Méthode : This retrospective cohort study was conducted at the Toulouse University Hospital from 1 January 2017 to 31 December 2018. All patients admitted to the ED with clinical presentation of shoulder dislocation were included. The primary end point was the presence of an important fracture (excluding Bankart and Hill-Sachs fractures). Logistic regression was used to determine independent risk factors for the presence of an important fracture.

Résultats : Six hundred and two patients were included in the study and 81 (13%) had an important fracture. Three risk factors were associated with important fracture: age over 40 years (adjusted OR (aOR)=2.7; 95% CI 1.5 to 4.8), first incident (aOR=4.3; 95% CI 1.7 to 10.8) and the circumstances in which the trauma occurred (fall from a height or direct impact, fall of over 1 m, road accident or epilepsy) (aOR=5.5; 95% CI 2.6 to 30). One hundred sixty-six patients (28%) had no risk factors in our cohort. In the absence of these risk factors, the risk of an important fracture was found to be 0.6% (95% CI 0 to 3.3).

Conclusion : We describe 3 independent clinical risk factors associated with an important fracture in ED patients with shoulder dislocation: age >40 years, first incident and a traumatic circumstance. Prereduction radiography may be safely avoided when these factors are absent.

Conclusion (proposition de traduction) : Nous décrivons trois facteurs de risque cliniques indépendants associés à une fracture importante chez les patients des urgences souffrant d'une luxation de l'épaule  : âge >40 ans, premier incident et circonstances traumatiques. La radiographie avant traitement peut être évitée en toute sécurité lorsque ces facteurs sont absents.

Commentaire : Voir :
Hendey GW. Necessity of radiographs in the emergency department management of shoulder dislocations. Ann Emerg Med. 2000 Aug;36(2):108-113  .

Impact of Macintosh blade size on endotracheal intubation success in intensive care units: a retrospective multicenter observational MacSize-ICU study.
Godet T, De Jong A, Garin C, Guérin R, Rieu B, Borao L, Pereira B, Molinari N, Bazin JE, Jabaudon M, Chanques G, Futier E, Jaber S. | Intensive Care Med. 2022 Sep;48(9):1176-1184
DOI: https://doi.org/10.1007/s00134-022-06832-9  | Télécharger l'article au format  
Keywords: Complications; Intensive care unit; Intubation; Laryngoscopy; Macintosh blade.

Original

Introduction : To investigate the impact of Macintosh blade size used during direct laryngoscopy (DL) on first-attempt intubation success of orotracheal intubation in French intensive care units (ICUs). We hypothesized that success rate would be higher with Macintosh blade size No3 than with No4.

Méthode : Multicenter retrospective observational study based on data from prospective trials conducted in 48 French ICUs of university, and general and private hospitals. After each intubation using Macintosh DL, patients' and operators' characteristics, Macintosh blade size, results of first DL and alternative techniques used, as well as the need of a second operator were collected. Complications rates associated with intubation were investigated. Primary outcome was success rate of first DL using Macintosh blade.

Résultats : A total of 2139 intubations were collected, 629 with a Macintosh blade No3 and 1510 with a No4. Incidence of first-pass intubation after first DL was significantly higher with Macintosh blade No3 (79.5 vs 73.3%, p = 0.0025), despite equivalent Cormack-Lehane scores (p = 0.48). Complications rates were equivalent between groups. Multivariate analysis concluded to a significant impact of Macintosh blade size on first DL success in favor of blade No3 (OR 1.44 [95% CI 1.14-1.84]; p = 0.0025) without any significant center effect on the primary outcome (p = 0.18). Propensity scores and adjustment analyses concluded to equivalent results.

Conclusion : In the present study, Macintosh blade No3 was associated with improved first-passed DL in French ICUs. However, study design requires the conduct of a nationwide prospective multicenter randomized trial in different settings to confirm these results.

Conclusion (proposition de traduction) : Dans cette étude, la lame Macintosh n°3 a été associée à une meilleure laryngoscopie directe au premier essai dans les unités de soins intensifs françaises. Cependant, la conception de l'étude nécessite la réalisation d'un essai randomisé prospectif multicentrique à l'échelle nationale dans différents établissements pour confirmer ces résultats.

Cardiac arrest and complications during non-invasive ventilation: a systematic review and meta-analysis with meta-regression.
Rolle A, De Jong A, Vidal E, Molinari N, Azoulay E, Jaber S. | Intensive Care Med. 2022 Nov;48(11):1513-1524
DOI: https://doi.org/10.1007/s00134-022-06821-y  | Télécharger l'article au format  
Keywords: Cardiac arrest; Complications; ICU; Meta-analysis; Non-invasive ventilation.

SYSTEMATIC REVIEW

Introduction : The aim of this study was to perform a systematic review and meta-analysis to investigate the incidence rate of cardiac arrest and severe complications occurring under non-invasive ventilation (NIV).

Méthode : We performed a systematic review and meta-analysis of studies between 1981 and 2020 that enrolled adults in whom NIV was used to treat acute respiratory failure (ARF). We generated the pooled incidence and confidence interval (95% CI) of NIV-related cardiac arrest per patient (primary outcome) and performed a meta-regression to assess the association with study characteristics. We also generated the pooled incidences of NIV failure and hospital mortality.

Résultats : Three hundred and eight studies included a total of 7,601,148 participants with 36,326 patients under NIV (8187 in 138 randomized controlled trials, 9783 in 99 prospective observational studies, and 18,356 in 71 retrospective studies). Only 19 (6%) of the analyzed studies reported the rate of NIV-related cardiac arrest. Forty-nine cardiac arrests were reported. The pooled incidence was 0.01% (95% CI 0.00-0.02, I2 = 0% (0-15)). NIV failure was reported in 4371 patients, with a pooled incidence of 11.1% (95% CI 9.0-13.3). After meta-regression, NIV failure and the study period (before 2010) were significantly associated with NIV-related cardiac arrest. The hospital mortality pooled incidence was 6.0% (95% CI 4.4-7.9).

Conclusion : Cardiac arrest related to NIV occurred in one per 10,000 patients under NIV for ARF treatment. NIV-related cardiac arrest was associated with NIV failure.

Conclusion (proposition de traduction) : Un arrêt cardiaque imputable à la VNI est survenu chez un patient sur 10 000 sous VNI pour le traitement de l'insuffisance respiratoire aiguë. Les arrêts cardiaques liés à la VNI étaient associés à l'échec de la VNI.

Noninvasive respiratory support in intensive care medicine.
Rittayamai N, Grieco DL, Brochard L. | Intensive Care Med. 2022 Sep;48(9):1211-1214.
DOI: https://doi.org/10.1007/s00134-022-06762-6  | Télécharger l'article au format  
Keywords: Aucun

Lasting Legacy in Intensive Care Medicine

Editorial : Before the widespread introduction of positive-pressure ventilation in intensive care after the polio epidemics in the 1950’s, most forms of ventilatory support have been “non invasive” or “external” without direct access to the lower air- ways, using face mask for positive pressure, or techniques generating negative pressure around the chest from thoracic cuirass to whole body tank. In the late 19th century, ventila- tors simulating negative pressure around the chest have been designed, including the first workable iron lung designed by Alfred Woillez, to help save drowning victims. The first iron lung to be widely used was developed in Boston by Drinker and Shaw in 1928, and largely used to treat patients with polio. It was difficult, however, to nurse patients in the iron lungs or to clear secretions, and airways were not protected. In parallel, the short-term application of positive end-expira- tory pressure (PEEP) by face mask was first described in the 1930s, especially to treat cardiogenic pulmonary edema.

Conclusion : As illustrated on Fig. 1, in the acute care setting, NIV should be considered as the first-line approach to treat patients with hypercapnic respiratory failure and CPAP or NIV for respiratory failure due to acute cardiogenic pulmonary edema. Weaning or extubation can be facili- tated by HFNC and NIV especially for high-risk or obese patients. The optimal noninvasive support strategy for de novo hypoxemic respiratory failure remains debated: HFNC and helmet support are promising techniques, but careful patient selection and clinical monitoring remain always warranted to best balance between the benefits and risks of these approaches.

Conclusion (proposition de traduction) : Comme l'illustre la figure ci-dessous, dans le cadre des soins intensifs, la VNI doit être considérée comme l'approche de première intention pour traiter les patients présentant une insuffisance respiratoire hypercapnique et la CPAP ou la VNI pour l'insuffisance respiratoire imputable à un œdème pulmonaire cardiogénique aigu. Le sevrage ou l'extubation peuvent être facilités par l'HFNC et la VNI, en particulier chez les patients à haut risque ou obèses. La stratégie optimale d'assistance non invasive pour l'insuffisance respiratoire hypoxémique de novo reste débattue : L'HFNC et l'assistance par casque sont des techniques prometteuses, mais une sélection minutieuse des patients et une surveillance clinique restent toujours nécessaires pour assurer le meilleur équilibre entre les avantages et les risques de ces approches.

Commentaire : 

Erratum in: Intensive Care Med. 2022 Sep;48(9):1211-1214  

Blood transfusion: the search for the sweet spot.
Vlaar APJ | Intensive Care Med. 2022 Sep;48(9):1218-1221
DOI: https://doi.org/10.1007/s00134-022-06799-7
Keywords: Aucun

LASTING LEGACY IN INTENSIVE CARE MEDICINE

Editorial : To understand our current point of view regarding allo- geneic blood transfusion, we need to dive back into his- tory (Figure S1). The quest to be able to transfuse goes back centuries. Human interest in blood dates back to Egyptian times. The first recorded attempt to transfuse blood human to human was in 1492, when blood was taken from three young men and given to the stricken Pope Innocent VII in the hope of curing him. Unfortu- nately, all four died. The first successful transfusion from human to human was in 1818, when British obstetrician James Blundell transfused human blood to a patient who had peri-partum hemorrhage. This was a milestone after centuries of unsuccessful and proved fatal attempts. It took almost another century until Karl Landsteiner identified the three main human blood groups in 1901 and the Rhesus factor in 1940, which paved the road to transfuse in a seemingly safe way. The development of blood bags and additive storage solutions was the start- ing point of applying blood donation and transfusion in an industrialized matter.

Conclusion : The past decades, insight in transfusion-related morbidity and mortality next to awareness for donor burden has led to balance the per- ceived upside of allogeneic blood transfusion. These insights have in general led to the application of restrictive transfusion strategies

Conclusion (proposition de traduction) : Au cours des dernières décennies, la connaissance de la morbidité et de la mortalité liées à la transfusion ainsi que la prise de conscience de la contrainte imposée aux donneurs ont conduit à équilibrer les avantages perçus de la transfusion sanguine allogénique. Ces connaissances ont en général conduit à l'application de stratégies transfusionnelles restrictives.

Commentaire : 

High-dose intravenous vitamin C decreases rates of mechanical ventilation and cardiac arrest in severe COVID-19.
Hess AL, Halalau A, Dokter JJ, Paydawy TS, Karabon P, Bastani A, Baker RE, Balla AK, Galens SA. | Intern Emerg Med. 2022 Sep;17(6):1759-1768
DOI: https://doi.org/10.1007/s11739-022-02954-6  | Télécharger l'article au format  
Keywords: Ascorbic acid; Intensive care; SARS-CoV-2; Treatment; Vitamin C.

EM - ORIGINAL

Introduction : ntravenous vitamin C (IV-VitC) has been suggested as a treatment for severe sepsis and acute respiratory distress syndrome; however, there are limited studies evaluating its use in severe COVID-19. Efficacy and safety of high-dose IV-VitC (HDIVC) in patients with severe COVID-19 were evaluated.

Méthode : This observational cohort was conducted at a single-center, 530 bed, community teaching hospital and took place from March 2020 through July 2020. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes in patients with severe COVID-19 treated with and without HDIVC. Patients were enrolled if they were older than 18 years of age and were hospitalized secondary to severe COVID-19 infection, indicated by an oxygenation index < 300. Primary study outcomes included mortality, mechanical ventilation, intensive care unit (ICU) admission, and cardiac arrest.

Résultats : From a total of 100 patients enrolled, 25 patients were in the HDIVC group and 75 patients in the control group. The average time to death was significantly longer for HDIVC patients (P = 0.0139), with an average of 22.9 days versus 13.7 days for control patients. Patients who received HDIVC also had significantly lower rates of mechanical ventilation (52.93% vs. 73.14%; ORIPTW = 0.27; P = 0.0499) and cardiac arrest (2.46% vs. 9.06%; ORIPTW = 0.23; P = 0.0439).

Conclusion : HDIVC may be an effective treatment in decreasing the rates of mechanical ventilation and cardiac arrest in hospitalized patients with severe COVID-19. A longer hospital stay and prolonged time to death may suggest that HDIVC may protect against clinical deterioration in severe COVID-19.

Conclusion (proposition de traduction) : La vitamine C à haute dose par voie intraveineuse peut être un traitement efficace pour réduire les taux de ventilation mécanique et d'arrêt cardiaque chez les patients hospitalisés souffrant de COVID-19 sévère. Un séjour plus long à l'hôpital et un délai prolongé jusqu'au décès peuvent suggérer que la vitamine C intraveineuse à haute dose peut protéger contre la détérioration clinique dans les cas graves de COVID-19.

Correlation of SpO₂/FiO₂ and PaO₂/FiO₂ in patients with symptomatic COVID-19: An observational, retrospective study.
Bonaventura A, Mumoli N, Mazzone A, Colombo A, Evangelista I, Cerutti S, Brivio L, Vecchié A, Bonomi A, Para O, Bellizzi A, Cei M, Fenu P, Tangianu F, Dentali F, Cei F. | Intern Emerg Med. 2022 Sep;17(6):1769-1775
DOI: https://doi.org/10.1007/s11739-022-02981-3  | Télécharger l'article au format  
Keywords: ARDS; COVID-19; Cytokine storm; Diagnosis; Respiratory failure; SARS-CoV-2.

EM - ORIGINAL

Introduction : Some patients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) experience acute hypoxemic respiratory failure progressing toward atypical acute respiratory distress syndrome (ARDS).

Méthode : The aim of the study is to evaluate whether a correlation between ratio of peripheral saturation of oxygen (SpO₂) and fraction of inspired oxygen (S/F) and ratio of arterial partial pressure of oxygen and fraction of inspired oxygen (P/F) exists in COVID-19-related ARDS as already known in classical ARDS. In this multicenter, retrospective, observational study, consecutive, adult (≥ 18 years) patients with symptomatic coronavirus disease 2019 (COVID-19) admitted to different COVID-19 divisions in Italy between March and December 2020 were included. Patients with SpO₂ > 97% or missing information were excluded.

Résultats : We included 1,028 patients (median age 72 years, prevalence of males [62.2%]). A positive correlation was found between P/F and S/F (r = 0.938, p < 0.0001). A receiver operating characteristic (ROC) curve analysis showed that S/F accurately recognizes the presence of ARDS (P/F ≤ 300 mmHg) in COVID-19 patients, with a cut-off of ≤ 433% showing good sensitivity and specificity. S/F was also tested against P/F values ≤ 200 and ≤ 100 mmHg (suggestive for moderate and severe ARDS, respectively), the latter showing great accuracy for S/F ≤ 178%. S/F was accurate in predicting ARDS for SpO₂ ≥ 92%.

Conclusion : In conclusion, our findings support the routine use of S/F as a reliable surrogate of P/F in patients with COVID-19-related ARDS.

Conclusion (proposition de traduction) : En conclusion, nos résultats soutiennent l'utilisation systématique de la SpO₂/FiO₂ comme substitut fiable de la PaO₂/FiO₂ chez les patients souffrant de SDRA lié à la COVID-19.

Predictors of neurological outcome after out-of-hospital cardiac arrest: sex-based analysis: do males derive greater benefit from hypothermia management than females?.
Awad EM, Humphries KH, Grunau BE, Norris CM, Christenson JM. | Int J Emerg Med. 2022 Sep 5;15(1):43
DOI: https://doi.org/10.1186/s12245-022-00447-z  | Télécharger l'article au format  
Keywords: Cardiac arrest; Neurological outcome; Resuscitation; Sex differences.

RESEARCH

Introduction : Previous studies of the effect of sex on after out-of-hospital cardiac arrest (OHCA) outcomes focused on survival to hospital discharge and 1-month survival. Studies on the effect of sex on neurological function after OHCA are still limited. The objective of this study was to identify the predictors of favorable neurological outcome and to examine the association between sex as a biological variable and favorable neurological outcome OHCA.

Méthode : Retrospective analyses of clustered data from the Resuscitation Outcomes Consortium multi-center randomized controlled trial (2011-2015). We included adults with non-traumatic OHCA and EMS-attended OHCA. We used multilevel logistic regression to examine the association between sex and favorable neurological outcomes (modified Rankin Scale) and to identify the predictors of favorable neurological outcome.

Résultats : In total, 22,416 patients were included. Of those, 8109 (36.2%) were females. The multilevel analysis identified the following variables as significant predictors of favorable neurological outcome: younger age, shorter duration of EMS arrival to the scene, arrest in public location, witnessed arrest, bystander CPR, chest compression rate (CCR) of 100-120 compressions per minute, induction of hypothermia, and initial shockable rhythm. Two variables, insertion of an advanced airway and administration of epinephrine, were associated with poor neurological outcome. Our analysis showed that males have higher crude rates of survival with favorable neurological outcome (8.6 vs. 4.9%, p < 0.001). However, the adjusted rate was not significant. Further analyses showed that hypothermia had a significantly greater effect on males than females.

Conclusion : Males had significantly higher crude rates of survival with favorable neurological outcome. However, the adjusted rate was not statistically significant. Males derived significantly greater benefit from hypothermia management than females, but this can possibly be explained by differences in arrest characteristics or in-hospital treatment. In-depth confirmatory studies on the hypothermia effect size by sex are required.

Conclusion (proposition de traduction) : Les hommes avaient des taux bruts de survie significativement plus élevés avec une issue neurologique favorable. Cependant, le taux ajusté n'était pas statistiquement significatif. Les hommes ont tiré un bénéfice significativement plus important de la gestion de l'hypothermie que les femmes, mais cela peut s'expliquer par des différences dans les caractéristiques de l'arrêt ou le traitement hospitalier. Des études de confirmation approfondies sur l'ampleur de l'effet de l'hypothermie en fonction du sexe sont nécessaires.

Intra‐Articular Lidocaine versus Procedural Sedation for Shoulder Dislocation Reduction: A Randomized Trial.
Zitek T, Koneri N, Georges N, Slane M. | J Emerg Trauma Shock. 2022 Jul-Sep;15(3):135-138
DOI: https://doi.org/10.4103/jets.jets_49_22  | Télécharger l'article au format  
Keywords: Intra-articular injection; procedural sedation; shoulder dislocation.

Original Article

Introduction : Two common ways of providing anesthesia for shoulder dislocation reductions in the emergency department (ED) are intra-articular lidocaine (IAL) injections and procedural sedation (PS). We sought to compare PS with propofol or etomidate to IAL for shoulder dislocation reductions in the ED.

Méthode : This was an open-label, randomized controlled trial of patients aged 18-70 years with anterior shoulder dislocations who presented to a single ED. We randomized patients to either PS or IAL for their shoulder dislocation reduction. The primary outcome measure was ED length of stay (LOS). Secondarily, we assessed patient satisfaction and the number of attempts required for successful reduction.

Résultats : We identified 60 patients who met the criteria for enrollment, and were able to enroll 43. We randomized 23 patients to IAL and 20 to PS. In the IAL group, the mean ED LOS was 133 min as compared to 124 min for the PS group (difference 9 min [95% confidence interval (CI)-22-41], P = 0.54). Patients in the IAL group required an average of 1.9 reduction attempts as compared to 1.2 in the PS group (difference of 0.7 [95% CI 0.2-1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and PS groups, respectively.

Conclusion : This study lacked a sufficient sample size to detect small differences but found no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL as compared to PS. Patients in the PS group required fewer attempts for successful reduction.

Conclusion (proposition de traduction) : La taille de l'échantillon de cette étude n'était pas suffisante pour détecter de petites différences, mais elle n'a révélé aucune différence statistiquement significative dans la durée moyenne du séjour aux urgences ou dans la satisfaction des patients ayant reçu de la lidocaïne intra-articulaire par rapport à la sédation procédurale. Les patients du groupe sédation procédurale ont eu besoin de moins de tentatives pour réussir la réduction.

Effect of Helmet Noninvasive Ventilation vs Usual Respiratory Support on Mortality Among Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19: The HELMET-COVID Randomized Clinical Trial.
Arabi YM, Aldekhyl S, Al Qahtani S, Al-Dorzi HM, Abdukahil SA, Al Harbi MK, Al Qasim E, Kharaba A, Albrahim T, Alshahrani MS, Al-Fares AA, Al Bshabshe A, Mady A, Al Duhailib Z, Algethamy H, Jose J, Al Mutairi M, Al Zumai O, Al Haji H, Alaqeily A, Al Aseri Z, Al-Omari A, Al-Dawood A, Tlayjeh H; Saudi Critical Care Trials Group. | JAMA. 2022 Sep 20;328(11):1063-1072
DOI: https://doi.org/10.1001/jama.2022.15599
Keywords: Aucun

Original Investigation

Introduction : Helmet noninvasive ventilation has been used in patients with COVID-19 with the premise that helmet interface is more effective than mask interface in delivering prolonged treatments with high positive airway pressure, but data about its effectiveness are limited.
Objective: To evaluate whether helmet noninvasive ventilation compared with usual respiratory support reduces mortality in patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia.

Méthode : This was a multicenter, pragmatic, randomized clinical trial that was conducted in 8 sites in Saudi Arabia and Kuwait between February 8, 2021, and November 16, 2021. Adult patients with acute hypoxemic respiratory failure (n = 320) due to suspected or confirmed COVID-19 were included. The final follow-up date for the primary outcome was December 14, 2021.
Interventions: Patients were randomized to receive helmet noninvasive ventilation (n = 159) or usual respiratory support (n = 161), which included mask noninvasive ventilation, high-flow nasal oxygen, and standard oxygen.
Main outcomes and measures: The primary outcome was 28-day all-cause mortality. There were 12 prespecified secondary outcomes, including endotracheal intubation, barotrauma, skin pressure injury, and serious adverse events.

Résultats : Among 322 patients who were randomized, 320 were included in the primary analysis, all of whom completed the trial. Median age was 58 years, and 187 were men (58.4%). Within 28 days, 43 of 159 patients (27.0%) died in the helmet noninvasive ventilation group compared with 42 of 161 (26.1%) in the usual respiratory support group (risk difference, 1.0% [95% CI, -8.7% to 10.6%]; relative risk, 1.04 [95% CI, 0.72-1.49]; P = .85). Within 28 days, 75 of 159 patients (47.2%) required endotracheal intubation in the helmet noninvasive ventilation group compared with 81 of 161 (50.3%) in the usual respiratory support group (risk difference, -3.1% [95% CI, -14.1% to 7.8%]; relative risk, 0.94 [95% CI, 0.75-1.17]). There were no significant differences between the 2 groups in any of the prespecified secondary end points. Barotrauma occurred in 30 of 159 patients (18.9%) in the helmet noninvasive ventilation group and 25 of 161 (15.5%) in the usual respiratory support group. Skin pressure injury occurred in 5 of 159 patients (3.1%) in the helmet noninvasive ventilation group and 10 of 161 (6.2%) in the usual respiratory support group. There were 2 serious adverse events in the helmet noninvasive ventilation group and 1 in the usual respiratory support group.

Conclusion : Results of this study suggest that helmet noninvasive ventilation did not significantly reduce 28-day mortality compared with usual respiratory support among patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia. However, interpretation of the findings is limited by imprecision in the effect estimate, which does not exclude potentially clinically important benefit or harm.

Conclusion (proposition de traduction) : Les résultats de cette étude suggèrent que la ventilation non invasive avec un casque n'a pas réduit de manière significative la mortalité à 28 jours par rapport à l'assistance respiratoire habituelle chez les patients présentant une insuffisance respiratoire hypoxémique aiguë due à une pneumonie COVID-19. Cependant, l'interprétation des résultats est limitée par l'imprécision de l'estimation de l'effet, qui n'exclut pas un bénéfice ou un préjudice potentiellement important sur le plan clinique.

Effect of High-Flow Nasal Cannula Oxygen vs Standard Oxygen Therapy on Mortality in Patients With Respiratory Failure Due to COVID-19: The SOHO-COVID Randomized Clinical Trial.
Frat JP, Quenot JP, Badie J, Coudroy R, Guitton C, Ehrmann S, Gacouin A, Merdji H, Auchabie J, Daubin C, Dureau AF, Thibault L, Sedillot N, Rigaud JP, Demoule A, Fatah A, Terzi N, Simonin M, Danjou W, Carteaux G, Guesdon C, Pradel G, Besse MC, Reignier J, Beloncle F, La Combe B, Prat G, Nay MA, de Keizer J, Ragot S, Thille AW; SOHO-COVID Study Group and the REVA Network. | JAMA. 2022 Sep 27;328(12):1212-122
DOI: https://doi.org/10.1001/jama.2022.15613
Keywords: Aucun

Original Investigation

Introduction : The benefit of high-flow nasal cannula oxygen (high-flow oxygen) in terms of intubation and mortality in patients with respiratory failure due to COVID-19 is controversial.
Objective: To determine whether the use of high-flow oxygen, compared with standard oxygen, could reduce the rate of mortality at day 28 in patients with respiratory failure due to COVID-19 admitted in intensive care units (ICUs).

Méthode : The SOHO-COVID randomized clinical trial was conducted in 34 ICUs in France and included 711 patients with respiratory failure due to COVID-19 and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen equal to or below 200 mm Hg. It was an ancillary trial of the ongoing original SOHO randomized clinical trial, which was designed to include patients with acute hypoxemic respiratory failure from all causes. Patients were enrolled from January to December 2021; final follow-up occurred on March 5, 2022.
Interventions: Patients were randomly assigned to receive high-flow oxygen (n = 357) or standard oxygen delivered through a nonrebreathing mask initially set at a 10-L/min minimum (n = 354).
Main outcomes and measures: The primary outcome was mortality at day 28. There were 13 secondary outcomes, including the proportion of patients requiring intubation, number of ventilator-free days at day 28, mortality at day 90, mortality and length of stay in the ICU, and adverse events.

Résultats : Among the 782 randomized patients, 711 patients with respiratory failure due to COVID-19 were included in the analysis (mean [SD] age, 61 [12] years; 214 women [30%]). The mortality rate at day 28 was 10% (36/357) with high-flow oxygen and 11% (40/354) with standard oxygen (absolute difference, -1.2% [95% CI, -5.8% to 3.4%]; P = .60). Of 13 prespecified secondary outcomes, 12 showed no significant difference including in length of stay and mortality in the ICU and in mortality up until day 90. The intubation rate was significantly lower with high-flow oxygen than with standard oxygen (45% [160/357] vs 53% [186/354]; absolute difference, -7.7% [95% CI, -14.9% to -0.4%]; P = .04). The number of ventilator-free days at day 28 was not significantly different between groups (median, 28 [IQR, 11-28] vs 23 [IQR, 10-28] days; absolute difference, 0.5 days [95% CI, -7.7 to 9.1]; P = .07). The most common adverse events were ventilator-associated pneumonia, occurring in 58% (93/160) in the high-flow oxygen group and 53% (99/186) in the standard oxygen group.

Conclusion : Among patients with respiratory failure due to COVID-19, high-flow nasal cannula oxygen, compared with standard oxygen therapy, did not significantly reduce 28-day mortality.

Conclusion (proposition de traduction) : Chez les patients souffrant d'insuffisance respiratoire due à la COVID-19, l'oxygénothérapie nasale à haut débit, comparée à l'oxygénothérapie standard, n'a pas réduit de manière significative la mortalité à 28 jours.

Ketamine for Management of Neonatal and Pediatric Refractory Status Epilepticus.
Jacobwitz M, Mulvihill C, Kaufman MC, Gonzalez AK, Resendiz K, MacDonald JM, Francoeur C, Helbig I, Topjian AA, Abend NS. | Neurology. 2022 Sep 20;99(12):e1227-e1238
DOI: https://doi.org/10.1212/wnl.0000000000200889
Keywords: Aucun

RESEARCH ARTICLE

Introduction : Few data are available regarding the use of anesthetic infusions for refractory status epilepticus (RSE) in children and neonates, and ketamine use is increasing despite limited data. We aimed to describe the impact of ketamine for RSE in children and neonates.

Méthode : Retrospective single-center cohort study of consecutive patients admitted to the intensive care units of a quaternary care children's hospital treated with ketamine infusion for RSE.

Résultats : Sixty-nine patients were treated with a ketamine infusion for RSE. The median age at onset of RSE was 0.7 years (interquartile range 0.15-7.2), and the cohort included 13 (19%) neonates. Three patients (4%) had adverse events requiring intervention during or within 12 hours of ketamine administration, including hypertension in 2 patients and delirium in 1 patient. Ketamine infusion was followed by seizure termination in 32 patients (46%), seizure reduction in 19 patients (28%), and no change in 18 patients (26%).

Conclusion : Ketamine administration was associated with few adverse events, and seizures often terminated or improved after ketamine administration. Further data are needed comparing first-line and subsequent anesthetic medications for treatment of pediatric and neonatal RSE.

Conclusion (proposition de traduction) : L'administration de kétamine a été associée à peu d'effets indésirables, et les crises ont souvent cessé ou se sont améliorées après l'administration de kétamine. D'autres données sont nécessaires pour comparer les médicaments anesthésiques de première intention et les suivants pour le traitement de l'état de mal épileptique réfractaire pédiatrique et néonatal.

Survival Rates After Pediatric Traumatic Out-of-Hospital Cardiac Arrest Suggest an Underappreciated Therapeutic Opportunity.
Lanyi M, Elmer J, Guyette FX, Martin-Gill C, Venkat A, Traynor O, Walker H, Seaman K, Kochanek PM, Fink EL. | Pediatr Emerg Care. 2022 Sep 1;38(9):417-422
DOI: https://doi.org/10.1097/pec.0000000000002806
Keywords: Aucun

Original Article

Introduction : Children with traumatic arrests represent almost one third of annual pediatric out-of-hospital cardiac arrests (OHCAs). However, traumatic arrests are often excluded from study populations because survival posttraumatic arrest is thought to be negligible. We hypothesized that children treated and transported by emergency medical services (EMS) personnel after traumatic OHCA would have lower survival compared with children treated after medical OHCA.

Méthode : We performed a secondary, observational study of children younger than 18 years treated and transported by 78 EMS agencies in southwestern Pennsylvania after OHCA from 2010 to 2014. Etiology was determined as trauma or medical by EMS services. We analyzed patient, cardiac arrest, and resuscitation characteristics and ascertained vital status using the National Death Index. We used multivariable logistic regression to test the association of etiology with mortality after covariate adjustment.

Résultats : Forty eight of 209 children (23%) had traumatic OHCA. Children with trauma were older than those with medical OHCA (13.2 [3.8-15.9] vs 0.5 [0.2-2.4] years, P < 0.001). Prehospital return of spontaneous circulation frequency for trauma versus medical etiology was similar (90% vs 87%, P = 0.84). Patients with trauma had higher mortality (69% vs 45% P = 0.004).

Conclusion : More than 8 of 10 children with EMS treated and transported OHCA achieved return of spontaneous circulation. Despite lower survival rates than medical OHCA patients, almost one third of children with a traumatic etiology survived throughout the study period. Future research programs warrant inclusion of children with traumatic OHCA to improve outcomes.

Conclusion (proposition de traduction) : Plus de 8 enfants sur 10 ayant subi un arrêt cardiaque extrahospitalier traité et transporté par le SAMU ont retrouvé une circulation spontanée. Malgré des taux de survie inférieurs à ceux des patients victimes d'un arrêt cardiaque extrahospitalier d'origine médicale, près d'un tiers des enfants ayant une étiologie traumatique ont survécu pendant toute la durée de l'étude. Les futurs programmes de recherche justifient l'inclusion des enfants victimes d'un arrêt cardiaque traumatique en dehors de l'hôpital afin d'améliorer les résultats.

Addition of Midthigh Circumference Improves Predictive Ability of Broselow Tape Weight Estimation.
Saeed W, Akbar A, Waseem M, Kuchinski AM, Xu H, Gibson RW. | Pediatr Emerg Care. 2022 Sep 1;38(9):448-452
DOI: https://doi.org/10.1097/pec.0000000000002770
Keywords: Aucun

Original article

Introduction : This study aimed to improve the accuracy of Broselow tape (BT) weight prediction by adding midthigh circumference (MTC) and to compare and standardize the methods for measuring MTC.

Méthode : This prospective, observational study was conducted in a pediatric emergency department of a tertiary care children's hospital. Children up to 12 years of age presenting to emergency department were included. Children were excluded if obtaining the data would interfere with their acute management. The data collected included MTC, height, BT weight, and actual weight. Three models were built. Broselow tape-only model and MTC plus BT model used 2 methods for MTC measurements: visual approximation of thigh midpoint (visual MTC1) and Centers for Disease Control and Prevention (CDC)-defined method (CDC MTC2).

Résultats : A total of 430 children were enrolled during pre-coronavirus disease era. Of these, 234 were boys (54.4%) and 196 (45.6%) were girls. Data were categorized into children younger than 2 years (224 [52.1%]) and older than 2 years (206 [47.9%]). African American constituted 250 (58%); White, 136 (31%); and unspecified, 27 (6%). For the entire cohort, both models that included MTC were significantly better at weight prediction with larger adjusted R2 (visual MTC1, 0.921; CDC MTC2, 0.928) and smaller root mean squared (RMSE) (visual MTC1, 2.70; CDC MTC2, 2.56) compared with BT-only model (adjusted R2 = 0.843; RMSE, 3.80). Midthigh circumference plus BT models performed even better in children older than 2 years compared with BT-only model with adjusted R2 (visual MTC1, 0.859; CDC MTC2, 0.872 vs 0.616) and RMSE (visual MTC1, 3.18; CDC MTC2, 3.03 vs 5.27).

Conclusion : The inclusion of MTC with BT resulted in a more accurate weight prediction in children especially greater than 2 years old. Midthigh circumference model using CDC-defined method was slightly better predictor of actual weight than visual approximation.

Conclusion (proposition de traduction) : L'inclusion de la circonférence de la mi-cuisse dans le ruban de Broselow a permis une prédiction plus précise du poids chez les enfants, en particulier ceux âgés de plus de 2 ans. Le modèle de la circonférence de la mi-cuisse utilisant la méthode définie par les Centers for Disease Control and Prevention était un prédicteur légèrement meilleur du poids réel que l'approximation visuelle.

Acute Alcohol Intoxication in Pediatric Emergencies.
Castro-Rodríguez C, Lorente-Romero J, Rivas-García A, García-Loygorri CF, Vázquez-López P, Marañón R. | Pediatr Emerg Care. 2022 Sep 1;38(9):e1523-e1528
DOI: https://doi.org/10.1097/pec.0000000000002808
Keywords: Aucun

Original article

Introduction : Alcohol intoxication in pediatrics is a growing problem in our environment. The objectives of this study are to define the prevalence of acute alcohol intoxication in the pediatric emergency department (PED) and to describe the associated symptoms and their relationship with potential risk factors.

Méthode : This cross-sectional study includes patients younger than 16 years with a diagnosis of acute alcohol intoxication between March 2010 and October 2018 in the PED of a tertiary hospital. Patients with concomitant intoxication by other substances were excluded. The association between qualitative variables was determined using the χ 2 or Fisher exact test and quantitative with the Student t , Mann-Whitney U test, and simple linear regression.

Résultats : There were 136 episodes of alcohol intoxication, which represents a prevalence of 24.1/100,000 emergencies. After excluding 10 patients because of positive screening for other drugs, 126 patients with a mean age of 14.5 years (SD, 1.2 years) were included, 57.9% of whom were women. A total of 25.4% of the patients were younger than 14 years. Ethanolemia was determined in 88.9%, and its mean concentration was 195.7 mg/dL (SD, 56.5 mg/dL), with potentially serious levels (>300 mg/dL) being found in 3.6% of the patients. A relationship was found between the Glasgow Coma Scale score and ethanolemia ( B = -12.7; 95% confidence interval, -8.1 to -17.4; P < 0.001), as well as with potassium ( B = -31, 9; 95% confidence interval, -6.6 to -57.3; P = 0.014). No patient had seizures or hypoglycemia. A total of 10.3% of the patients required admission.

Conclusion : Alcohol intoxication is a rare consultation reason in the PED. They usually present with mild and self-limited symptoms, being the decrease in the level of consciousness and hypokalemia the most frequent symptom and analytical alteration.

Conclusion (proposition de traduction) : L'intoxication alcoolique est un motif de consultation rare dans le service des urgences pédiatriques. Elle se présente généralement avec des symptômes légers et autolimités, la diminution du niveau de conscience et l'hypokaliémie étant le symptôme le plus fréquent et l'altération des facultés intellectuelles.

Anaphylaxis in Children.
Tanverdi MS, Wiersma A, Kim KM, Hicks AG, Mistry RD. | Pediatr Emerg Care. 2022 Sep 1;38(9):456-461
DOI: https://doi.org/10.1097/pec.0000000000002812
Keywords: Aucun

CME Review Article

Editorial : Anaphylaxis is a potentially life-threatening event in children, commonly encountered in the prehospital and emergency department settings. Recently published clinical guidelines emphasize early recognition of anaphylaxis and administration of epinephrine as the mainstay of management. Literature regarding adjuvant therapies, biphasic reactions, observation times, and disposition of patients with anaphylaxis remains controversial. In this article, we will review the background and pathophysiology of anaphylaxis, as well as the diagnostic approach, management, and future directions of anaphylaxis in children.

Conclusion : Anaphylaxis is a potentially life-threatening allergic reaction and is diagnosed clinically in the ED setting. Epinephrine is the mainstay of treatment; adjuvant therapies should not delay its administration or be given in lieu of epinephrine. Some amount of observation in the ED is recommended for postanaphylactic patients with duration dependent on historical features and risk factors. Hospital admission is recommended for patients with severe anaphylaxis, worsening symptoms, or history of severe or biphasic reactions. All patients with anaphylaxis should receive a prescription for and extensive education on epinephrine autoinjectors before discharge home.

Conclusion (proposition de traduction) : L'anaphylaxie est une réaction allergique potentiellement mortelle et est diagnostiquée cliniquement au service des urgences. L'adrénaline est le pilier du traitement ; les traitements adjuvants ne doivent pas retarder son administration ou être administrés à la place de l'adrénaline. Une certaine durée d'observation aux urgences est recommandée pour les patients postanaphylactiques, la durée dépendant des caractéristiques historiques et des facteurs de risque. L'admission à l'hôpital est recommandée pour les patients présentant une anaphylaxie sévère, une aggravation des symptômes ou des antécédents de réactions graves ou biphasiques. Tous les patients souffrant d'anaphylaxie doivent bénéficier d'une prescription et d'une formation approfondie sur l'utilisation des auto-injecteurs d'adrénaline avant de rentrer chez eux.

Commentaire : EXAMEN CME : Tanverdi MS, Wiersma A, Kim KM, Hicks AG, Mistry RD. Anaphylaxis in Children.   Pediatr Emerg Care. 2022 Sep 1;38(9):462-463  .

Accuracy of Weight Estimation in Children Using the Broselow, PAWPER XL, PAWPER XL-MAC, and Mercy Tapes.
Cosmos Yakubu R, Ayi-Bisah N, Nguah SB. | Pediatr Emerg Care. 2022 Sep 1;38(9):e1517-e1522
DOI: https://doi.org/10.1097/pec.0000000000002638
Keywords: Aucun

Original article

Introduction : Quick and accurate estimate of a child's weight is often required for medical interventions like drug dose calculation when scale measured weights cannot be obtained safely. Length-based methods of weight estimation are more accurate than age-based methods, with the most accurate being the length-based, habitus-modified methods. This study sought to determine and compare the accuracies of the 2017 Broselow tape, Paediatric Advanced Weight Prediction in the Emergency Room Extra-Long (PAWPER XL) tape, Paediatric Advanced Weight Prediction in the Emergency Room Extra-Long Mid-Arm Circumference (PAWPER XL-MAC) tape, and the 2-dimensional (2D) Mercy tape in Ghanaian children.

Méthode : A cross-sectional study was conducted at the Tamale Teaching Hospital in Ghana. Eight hundred forty children between 2 months and 13 years had their weights estimated by the 2017 Broselow, PAWPER XL, PAWPER XL-MAC, and 2D Mercy tapes. Accuracy of the methods was determined by percentage of weight estimated to within 10% and 20% of actual weight. Mean percentage error and the Bland-Altman analysis were used to assess bias and precision.

Résultats : The proportion of weight estimates within 10% and 20% of actual weight for Broselow tape were 47.5% and 82.3%, for 2D Mercy tape were 73.1% and 96.3%, for PAWPER XL-MAC were 77.6% and 97.5%, and for PAWPER XL were 81.7% and 96.8%, respectively. The Broselow tape had the greatest bias and least precision among the 4 methods. The Mercy, PAWPER XL-MAC, and PAWPER XL tapes had similar performance, but all performed significantly better than the Broselow tape in pairwise comparison. The best weight estimation method overall was the PAWPER XL tape as it also had the least bias and greatest precision.

Conclusion : The Mercy, PAWPER XL-MAC, and PAWPER XL tapes were more accurate than the 2017 Broselow tape and should be used in preference in Ghana and countries with similar population structure.

Conclusion (proposition de traduction) : Les rubans Mercy, PAWPER XL-MAC et PAWPER XL étaient plus précis que le ruban Broselow 2017 et devraient être utilisés de préférence au Ghana et dans les pays ayant une structure de population similaire.

Coronary angiographic findings for out-of-hospital cardiac arrest survivors presenting with nonshockable rhythms and no ST elevation post resuscitation.
Harhash AA, Kluge MA, Muthukrishnan A, Noc M, Radsel P, Jentzer JC, Seder DB, Lee K, Lotun K, Stub D, Hsu CH, Kern KB. | Resuscitation. 2022 Sep;178:63-68
DOI: https://doi.org/10.1016/j.resuscitation.2022.07.023  | Télécharger l'article au format  
Keywords: Cardiac Arrest; Coronary angiography; NSTEMI; Neurological recovery; Non shockable rhythm; Outcomes.

Clinical paper

Introduction : Recent guidelines suggest that coronary angiography (CAG) should be considered for out-of-hospital cardiac arrest (OHCA) survivors, including those without ST elevation (STE) and without shockable rhythms. However, there is no prospective data to support CAG for survivors with nonshockable rhythms and no STE post resuscitation.

Méthode : This was a re-analysis of the PEARL study (randomized OHCA survivors without STE to early CAG versus not). Patients were subdivided by initial rhythm as nonshockable (Nsh) vs shockable (Sh). The primary outcome was coronary angiographic evidence of acute culprit lesion, with secondary outcomes being survival to hospital discharge and neurological recovery.

Résultats : The PEARL study included 99 patients with OHCA from a presumed cardiac etiology, 24 with nonshockable and 75 with shockable rhythms. There was no difference in the frequency of CAG between the two groups [71% (Nsh) and 75% (Sh); p = 0.79], presence of CAD [81% (Nsh) and 68% (sh); p = 0.37, or culprit lesions identified in each group [50% (Nsh) and 45% (Sh); p = 0.78. Nonshockable patients had worse discharge survival [33% (Nsh) vs 57% (Sh); p = 0.04] and those survived, had worse neurological recovery [30% (Nsh) vs 54% (Sh); p = 0.02] compared to shockable patients.

Conclusion : OHCA survivors presenting with nonshockable rhythms and no STE post resuscitation had similar prevalence of culprit coronary lesions to those with shockable rhythms. CAG may be considered in patients with OHCA without STE regardless of initial presenting rhythm. There was no benefit of emergent CAG both in shockable and non-shockable rhythms.

Conclusion (proposition de traduction) : Les survivants d'un arrêt cardiaque extrahospitalier présentant des rythmes non choquables et sans élévation du segment ST après la réanimation présentaient une prévalence de lésions coronaires responsables similaire à celle des survivants présentant des rythmes choquables. Une coronarographie peut être envisagée chez les patients présentant un arrêt cardiaque extrahospitalier sans élévation du segment ST, quel que soit le rythme initial. Il n'y avait aucun avantage à réaliser une coronarographie urgente, que le rythme soit choquable ou non.

Differences in characteristics between patients ≥ 65 and < 65 years of age with orthopaedic injuries after severe trauma.
Slørdal TJ, Brattebø G, Geisner T, Kristoffersen MH. | Scand J Trauma Resusc Emerg Med. 2022 Sep 24;30(1):51
DOI: https://doi.org/10.1186/s13049-022-01038-w  | Télécharger l'article au format  
Keywords: Epidemiology; Injury severity score; Major trauma; Mortality; Multiple trauma; Older adults; Orthopaedic injuries; Polytrauma; Trauma registry; Traumatic.

ORIGINAL RESEARCH

Introduction : Many trauma patients have associated orthopaedic injuries at admission. The existing literature regarding orthopaedic trauma often focuses on single injuries, but there is a paucity of information that gives an overview of this group of patients. Our aim was to describe the differences in characteristics between polytrauma patients ≥ 65 and < 65 years of age suffering orthopaedic injuries.

Méthode : Patients registered in the Norwegian Trauma Registry (NTR) with an injury severity score (ISS) > 15 and orthopaedic injuries, who were admitted to Haukeland University Hospital in 2016-2018, were included. Data retrieved from the patients' hospital records and NTR were analysed. The patients were divided into two groups based on age.

Résultats : The study comprised 175 patients, of which 128 (73%) and 47 (27%) were aged < 65 (Group 1) and ≥ 65 years (Group 2), respectively. The ISS and the new injury severity score (NISS) were similar in both groups. The dominating injury mechanism was traffic-related and thoracic injury was the most common location of main injury in both groups. The groups suffered a similar number of orthopaedic injuries. A significantly higher proportion of Group 1 underwent operative treatment for their orthopaedic injuries than in Group 2 (74% vs. 53%). The mortality in Group 2 was significantly higher than that in Group 1 (15% vs. 3%). In Group 2 most deaths were related to traffic injuries (71%). High energy falls and traffic-related incidents caused the same number of deaths in Group 1. In Group 1 abdominal injuries resulted in most deaths, while head injuries was the primary reason for deaths in Group 2.

Conclusion : Although the ISS and NISS were similar, mortality was significantly higher among patients aged ≥ 65 years compared to patients < 65 years of age. The younger age group underwent more frequently surgery for orthopaedic injuries than the elderly. There may be multiple reasons for this difference, but our study does not have sufficient data to draw any conclusions. Future studies may provide a deeper understanding of what causes treatment variation between age groups, which would hopefully help to further develop strategies to improve outcome for the elderly polytrauma patient.

Conclusion (proposition de traduction) : Bien que l'ISS (Injury severity score) et le NISS (New injury severity score) soient similaires, la mortalité était significativement plus élevée chez les patients âgés de ≥ 65 ans par rapport aux patients < 65 ans. Le groupe d'âge le plus jeune a subi plus fréquemment une intervention chirurgicale pour des blessures orthopédiques que les personnes âgées. Il peut y avoir de multiples raisons à cette différence, mais notre étude ne dispose pas de données suffisantes pour tirer des conclusions. De futures études pourraient permettre de mieux comprendre les causes de la variation des traitements entre les groupes d'âge, ce qui, nous l'espérons, aiderait à développer davantage de stratégies pour améliorer les résultats chez les polytraumatisés âgés.

Effects of vertical compression during pediatric cardiopulmonary resuscitation using the one-handed chest compression technique.
Oh JH, Noh H, Lee JG, Kim DK. | Am J Emerg Med. 2022 Sep;59:24-29
DOI: https://doi.org/10.1016/j.ajem.2022.06.044
Keywords: Cardiopulmonary resuscitation; Pediatrics; Posture.

Research article

Introduction : The posture of the rescuer while performing the one-handed chest compression (OHCC) has not yet been evaluated. This study aimed to investigate the effect of vertical compression during pediatric cardiopulmonary resuscitation (CPR) using the OHCC technique.

Méthode : This was a prospective randomized crossover simulation trial. A total of 42 medical doctors conducted a 2-min single-rescuer CPR using the conventional OHCC (Test 1) or vertical OHCC (Test 2) technique on a pediatric manikin. The chest compression and ventilation parameters were measured in real time during the experiments using sensors embedded in the manikin. In addition, the compression force of each technique was measured using a force plate.

Résultats : The average and adequate chest compression depth (CCD) were significantly higher in Test 2 than in Test 1 (average depth: 54.0 mm (interquartile range [IQR]: 48.5-56.0) in Test 2 vs. 49.0 mm (IQR: 40.0-54.0) in Test 1, P < 0.001; adequate depth: 99.0% (IQR: 36.3-100.0) in Test 2 vs. 52.0% (IQR: 0.0-98.0) in Test 1, P < 0.001). The average force of compression was also significantly higher in vertical OHCC than that in conventional OHCC (25.7 kg ± 4.4 in vertical OHCC vs. 24.5 kg ± 4.2 in conventional OHCC, P < 0.001). The ventilation parameters were not significantly different between Tests 1 and 2.

Conclusion : The vertical OHCC could provide a deeper and more adequate CCD compared with the conventional OHCC, and the advantages of the vertical OHCC originate from the superiority of the compression force.

Conclusion (proposition de traduction) : La compression thoracique verticale à une main permet d'obtenir une profondeur de compression plus importante et plus adéquate que la compression thoracique conventionnelle à une main. Les avantages de la compression thoracique verticale à une main proviennent de la supériorité de la force de compression.

Commentaire :  Postures pendant la compression thoracique à une main.
A : Posture pendant la compression thoracique conventionnelle à une main.
B : Posture pendant la compression thoracique verticale à une main.

La posture de la technique modifiée de compression thoracique à une main

The Effects of Magnesium Coadminstration During Treatment of Hypokalemia in the Emergency Department.
Tuttle A, Fitter S, Hua H, Moussavi K. | J Emerg Med. 2022 Sep;63(3):399-413
DOI: https://doi.org/10.1016/j.jemermed.2022.06.007
Keywords: electrolyte disorders; hypokalemia; magnesium; pharmacology; potassium.

Research article - Pharmacology in Emergency Medicine

Introduction : Hypokalemia is a common disorder that can negatively affect organ function. Magnesium supplementation is frequently recommended despite limited evidence to support its use.
Objectives : The purpose of this study was to evaluate the clinical effects of magnesium coadministration in patients treated for hypokalemia in the emergency department (ED).

Méthode : This retrospective, single-center study evaluated adults treated with intravenous (i.v.) potassium for hypokalemia (serum potassium <3.5 mMol/L) in the ED between July 1, 2016 and June 30, 2020. Patients given magnesium supplementation within 4 h of potassium administration (MG+) were compared with those not given concurrent magnesium (MG-). The primary outcome was time to potassium normalization (≥ 3.5 mMol/L). Secondary outcomes included clinical effects, adverse effects, and dosing of magnesium and potassium.

Résultats : Two hundred patients were included (MG+ = 100; MG- = 100). Patients in the MG- group more frequently had history of myocardial infarction (16% vs. 6%; p = 0.02) and alcoholism (16% vs. 6%; p = 0.02). Patients in the MG+ group had higher incidence of symptomatic hypokalemia (34% vs. 19%; p = 0.02) and severe hypokalemia (serum potassium < 2.5 mMol/L) (15% vs. 8%; p = 0.03). There were no differences in time to serum potassium normalization, change in serum potassium after treatment, or incidence of potassium normalization within 24 h of treatment. MG+ patients required more potassium within 24 h of treatment and more frequently developed hypermagnesemia (serum magnesium >1.1 mMol/L).

Conclusion : Magnesium coadministration during hypokalemia treatment did not affect time to serum potassium normalization but was associated with more hypermagnesemia.

Conclusion (proposition de traduction) : La co-administration de magnésium pendant le traitement de l'hypokaliémie n'a pas modifié le délai de normalisation du potassium sérique mais a été associée à des hypermagnésémies plus importantes.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Hypo-K+ Equals Hypo-Mg++…Right??  . Rédigé par Amanda Mathews, le 31 octobre 2022.
Conclusion de l'auteur :
On m'a appris que "hypo-K+ = hypo-Mg++". Les patients qui ont reçu du magnésium dans cette étude présentaient des valeurs de potassium sérique plus faibles au départ, ce qui peut contribuer à prolonger le délai de normalisation sérique, malgré la co-administration de magnésium. Bien que le groupe d'intervention ait connu plus de cas d'hypermagnésémie, cela n'a pas été associé à une augmentation des résultats négatifs. Je continuerai à administrer à la fois du potassium et du magnésium aux patients présentant une hypokaliémie symptomatique ou une hypokaliémie accompagnée de modifications de l'ECG, même si je compléterai probablement le potassium seul (sans magnésium) chez les patients asymptomatiques présentant une légère carence en potassium (>3,0 mmol/L).

L'hypermagnésémie est rare et se définit par une magnésémie > 1,05 mmol/l. Elle ne devient symptomatique que lorsqu’elle est sévère (> 2 mmol/l).
Les signes neuromusculaires sont les plus fréquents, secondaires à une diminution de transmission de l’influx nerveux au niveau de la plaque neuromusculaire produisant un effet curare-like. Les formes modérées se manifestent par une diminution des réflexes ostéotendineux évoluant vers l’abolition pour les cas sévères. Une somnolence, une paralysie musculaire et respiratoire pouvant aboutir à une tétraplégie flasque ou un arrêt respiratoire caractérisent les hypermagnésémies sévères. On peut observer dans certains cas une dilatation pupillaire fixe liée au blocage parasympathique simulant un engagement cérébral. Les manifestations cardiovasculaires sont liées au blocage des canaux calcique et potassi que par le Mg. Elles vont de la bradycardie et l’hypotension aux modifications ECG (allongement PR et QT, élargissement QRS, BAV, voire arrêt cardiaque).
L’hypocalcémie est transitoire, généralement asymptomatique et serait liée à l’effet inhibiteur de l’hypermagnésémie sur la sécrétion de PTH (...)
Folefack, F., K., Chopard, C., S., Dysmagnésémies, Rev Med Suisse, 2007/101 (Vol.-7), p. 605–611  .

Long-Term Neurological Outcome of Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest Patients With Nonshockable Rhythms: A Single-Center, Consecutive, Retrospective Observational Study.
Takahagi M, Sawano H, Moriyama T. | J Emerg Med. 2022 Sep;63(3):367-375
DOI: https://doi.org/10.1016/j.jemermed.2022.08.005
Keywords: extracorporeal cardiopulmonary resuscitation; nonshockable rhythm; out-of-hospital cardiac arrest.

Brief Report

Introduction : Data on extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) and initially nonshockable rhythms are limited.
Objective: This study aimed to evaluate the long-term neurological outcomes of ECPR for patients with OHCA and initially nonshockable rhythms.

Méthode : In this single-center, consecutive, retrospective, observational study, patients with OHCA and initially nonshockable rhythms who underwent ECPR between January 2012 and December 2017 were included. All patients with refractory cardiopulmonary arrest were transported while undergoing conventional CPR and received ECPR on arrival in the emergency department. We retrospectively collected characteristics at admission and neurological outcomes at the last visit or telephone interview. Cerebral performance category (CPC) scales 1 and 2 were defined as good neurological outcomes and CPC scales 3, 4, and 5 were defined as poor neurological outcomes.

Résultats : Of the 39 patients included in this study, 32 died in the hospital and only 7 survived. There were 4, 0, 0, 3, and 32 patients with CPC 1, 2, 3, 4, and 5, respectively. The proportion of good neurological outcomes for all patients was 10.3% (95% CI 2.9-24.2%) and 14.3% (95% CI 4.0-32.7%) for patients with pulseless electrical activity. No patients with asystole had a good neurological outcome. Median follow-up period was 1052 days (interquartile range 116-1589 days) for those who survived to discharge.

Conclusion : Approximately 10% of initially nonshockable patients with OHCA, generally considered to be a poor prognosis, could acquire good neurological outcomes when they underwent ECPR with our indications.

Conclusion (proposition de traduction) : Environ 10% des patients initialement non choquables victimes d'un arrêt cardiaque extrahospitalier, généralement considérés comme étant de mauvais pronostic, ont pu obtenir de bons résultats neurologiques lorsqu'ils ont été traités par réanimation cardio-pulmonaire extracorporelle selon nos indications.

Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis.
de-Madaria E, Buxbaum JL, Maisonneuve P, García García de Paredes A, Zapater P, Guilabert L, Vaillo-Rocamora A, Rodríguez-Gandía MÁ, Donate-Ortega J, Lozada-Hernández EE, Collazo Moreno AJR, Lira-Aguilar A, Llovet LP, Mehta R, Tandel R, Navarro P, Sánchez-Pardo AM, Sánchez-Marin C, Cobreros M, Fernández-Cabrera I, Casals-Seoane F, Casas Deza D, Lauret-Braña E, Martí-Marqués E, Camacho-Montaño LM, Ubieto V, Ganuza M, Bolado F; ERICA Consortium. | N Engl J Med. 2022 Sep 15;387(11):989-1000
DOI: https://doi.org/10.1056/nejmoa2202884
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Early aggressive hydration is widely recommended for the management of acute pancreatitis, but evidence for this practice is limited.

Méthode : At 18 centers, we randomly assigned patients who presented with acute pancreatitis to receive goal-directed aggressive or moderate resuscitation with lactated Ringer's solution. Aggressive fluid resuscitation consisted of a bolus of 20 ml per kilogram of body weight, followed by 3 ml per kilogram per hour. Moderate fluid resuscitation consisted of a bolus of 10 ml per kilogram in patients with hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml per kilogram per hour in all patients in this group. Patients were assessed at 12, 24, 48, and 72 hours, and fluid resuscitation was adjusted according to the patient's clinical status. The primary outcome was the development of moderately severe or severe pancreatitis during the hospitalization. The main safety outcome was fluid overload. The planned sample size was 744, with a first planned interim analysis after the enrollment of 248 patients.

Résultats : A total of 249 patients were included in the interim analysis. The trial was halted owing to between-group differences in the safety outcomes without a significant difference in the incidence of moderately severe or severe pancreatitis (22.1% in the aggressive-resuscitation group and 17.3% in the moderate-resuscitation group; adjusted relative risk, 1.30; 95% confidence interval [CI], 0.78 to 2.18; P = 0.32). Fluid overload developed in 20.5% of the patients who received aggressive resuscitation and in 6.3% of those who received moderate resuscitation (adjusted relative risk, 2.85; 95% CI, 1.36 to 5.94, P = 0.004). The median duration of hospitalization was 6 days (interquartile range, 4 to 8) in the aggressive-resuscitation group and 5 days (interquartile range, 3 to 7) in the moderate-resuscitation group.

Conclusion : In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes.

Conclusion (proposition de traduction) : Dans cet essai randomisé portant sur des patients présentant une pancréatite aiguë, une réanimation vasculaire agressive précoce a entraîné une incidence plus élevée de surcharge hydrique sans amélioration des résultats cliniques.

Acetazolamide in Acute Decompensated Heart Failure with Volume Overload.
Mullens W, Dauw J, Martens P, Verbrugge FH, Nijst P, Meekers E, Tartaglia K, Chenot F, Moubayed S, Dierckx R, Blouard P, Troisfontaines P, Derthoo D, Smolders W, Bruckers L, Droogne W, Ter Maaten JM, Damman K, Lassus J, Mebazaa A, Filippatos G, Ruschitzka F, Dupont M; ADVOR Study Group. | N Engl J Med. 2022 Sep 29;387(13):1185-1195. N Engl J Med. 2022 Sep 29;387(13):1185-1195
DOI: https://doi.org/10.1056/nejmoa2203094
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Whether acetazolamide, a carbonic anhydrase inhibitor that reduces proximal tubular sodium reabsorption, can improve the efficiency of loop diuretics, potentially leading to more and faster decongestion in patients with acute decompensated heart failure with volume overload, is unclear.

Méthode : In this multicenter, parallel-group, double-blind, randomized, placebo-controlled trial, we assigned patients with acute decompensated heart failure, clinical signs of volume overload (i.e., edema, pleural effusion, or ascites), and an N-terminal pro-B-type natriuretic peptide level of more than 1000 pg per milliliter or a B-type natriuretic peptide level of more than 250 pg per milliliter to receive either intravenous acetazolamide (500 mg once daily) or placebo added to standardized intravenous loop diuretics (at a dose equivalent to twice the oral maintenance dose). Randomization was stratified according to the left ventricular ejection fraction (≤40% or >40%). The primary end point was successful decongestion, defined as the absence of signs of volume overload, within 3 days after randomization and without an indication for escalation of decongestive therapy. Secondary end points included a composite of death from any cause or rehospitalization for heart failure during 3 months of follow-up. Safety was also assessed.

Résultats : A total of 519 patients underwent randomization. Successful decongestion occurred in 108 of 256 patients (42.2%) in the acetazolamide group and in 79 of 259 (30.5%) in the placebo group (risk ratio, 1.46; 95% confidence interval [CI], 1.17 to 1.82; P<0.001). Death from any cause or rehospitalization for heart failure occurred in 76 of 256 patients (29.7%) in the acetazolamide group and in 72 of 259 patients (27.8%) in the placebo group (hazard ratio, 1.07; 95% CI, 0.78 to 1.48). Acetazolamide treatment was associated with higher cumulative urine output and natriuresis, findings consistent with better diuretic efficiency. The incidence of worsening kidney function, hypokalemia, hypotension, and adverse events was similar in the two groups.

Conclusion : The addition of acetazolamide to loop diuretic therapy in patients with acute decompensated heart failure resulted in a greater incidence of successful decongestion.

Conclusion (proposition de traduction) : L'ajout d'acétazolamide au traitement par diurétique de l'anse chez les patients présentant une insuffisance cardiaque aiguë décompensée a permis une plus grande incidence de décongestion efficace.

Commentaire : Voir l'analyse de l'article sur le site Esanum : Insuffisance cardiaque aiguë décompensée : la montagne accouche-t-elle d’une souris ?  . Rédigé par le Pr Nicolas Peschanski, le 12/10/2022.

Posologie du Diamox^® (https://www.vidal.fr/medicaments/gammes/diamox-2779.html)
• Adulte : 1 à 4 comprimés par jour.
• Enfant de plus de 6 ans : 5 à 10 mg par kg et par jour ; soit, pour un enfant de 25 kg : 1/2 comprimé, 1 ou 2 fois par jour.

Feedback of inter-hospital transfer of patients under high-flow nasal cannula oxygen therapy.
Arnaud E, Leclere S, Petitprez M, Vincent G, Ammirati C. | World J Emerg Med. 2022;13(3):219-221
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2022.036  | Télécharger l'article au format  
Keywords: Aucun

Research letter

Editorial : Severe forms of coronavirus disease 2019 (COVID-19) can lead to hypoxemic pneumonia and the need for treatment with high-flow nasal cannula (HFNC) oxygen therapy. This treatment decreases the need for subsequent invasive ventilation in patients with hypoxemic pneumonia. The oxygen flow in the nasal cannula is driven pneumatically or using a turbine. Oxygen and air are mixed (giving the fraction of inspired oxygen [FiO₂]) and propelled at up to 80 L/min. The propelled gases must be heated and humidified. HFNC system is not intended for use outside a hospital environment.

Conclusion : Our pilot study shows that transferring patients on HFNC is possible but we only evaluate the short-term impact. A longer-term, prospective study of the transfer of a larger number of patients on HFNC is now warranted.

Conclusion (proposition de traduction) : Notre étude pilote montre que le transfert des patients sous oxygénothérapie nasale à haut débit est possible mais nous n'évaluons que l'impact à court terme. Une étude prospective à plus long terme sur le transfert d'un plus grand nombre de patients sous oxygénothérapie nasale à haut débit est maintenant justifiée.

Prolonged stay of spontaneous intracranial hemorrhage patients in the emergency department is correlated with worse outcomes.
He Q, Guo R, Zhang K, You C, Liu Y, Zeng Z. | World J Emerg Med. 2022;13(3):222-225
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2022.043  | Télécharger l'article au format  
Keywords: Aucun

Research Letter

Editorial : Spontaneous intracerebral hemorrhage (ICH) represents the second most common type of stroke, with high mortality and disability rates. In 2010, there were approximately 5.3 million ICH cases, with 3 million deaths worldwide. However, there is still no validated medical treatment for ICH, with the role of surgery remaining controversial. Cusack et al demonstrated that lowering blood pressure rapidly in hypertensive ICH patients may be safe and at least partially effective in inhibiting hematoma expansion.

Conclusion : In summary, the present study proves that a prolonged EDLOS may be correlated with mortality and a worse outcome in spontaneous ICH patients.

Conclusion (proposition de traduction) : En résumé, la présente étude prouve qu'une durée de séjour prolongée aux urgences peut être corrélée à la mortalité et à une issue plus défavorable chez les patients souffrant d'une hémorragie intracrânienne spontanée.

Treatment of hyperkalemic emergencies.
Wu Y, Fu YY, Zhu HD, Xu J, Walline JH. | World J Emerg Med. 2022;13(3):232-236
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2022.054  | Télécharger l'article au format  
Keywords: Aucun

Viewpoint

Editorial : Hyperkalemic emergency (HE) refers to life-threatening hyperkalemia consisting of a high serum potassium level with severe complications (e.g., dysrhythmias, cardiac arrest, or myopathy). Hyperkalemic emergencies (HEs) are commonly encountered (2%–3%) in the emergency department (ED). In-hospital mortality rate for hospitalized hyperkalemic patients is about 14.1% and 4.5 times higher than that of those with normal potassium. Quick recognition and treatment are critical for decreasing morbidity and mortality.

Conclusion : Timely treatment can avoid life-threatening complications of hyperkalemia. However, treatment of hyperkalemia in the ED is highly variable, and no agreed flowchart exists because prospective, randomized controlled trials are minimal. Nevertheless, there is widespread agreement on three approaches to treatment: cardiac myocyte protection, shifting serum potassium intracellularly, and removing potassium from the body. Systematic treatment with frequent monitoring and evaluation according to the proposed flowchart might help ED clinicians make quick and reasonable decisions and improve outcomes.

Conclusion (proposition de traduction) : Un traitement rapide peut éviter les complications potentiellement mortelles de l'hyperkaliémie. Cependant, le traitement de l'hyperkaliémie aux urgences est très variable, et il n'existe pas d'organigramme reconnu, car les essais prospectifs randomisés contrôlés sont peu nombreux. Néanmoins, il existe un large consensus sur trois approches du traitement : la protection des myocytes cardiaques, le déplacement du potassium sérique vers les cellules et l'élimination du potassium de l'organisme. Un traitement systématique assorti d'une surveillance et d'une évaluation fréquentes, conformément à l'organigramme proposé, pourrait aider les cliniciens des services d'urgence à prendre des décisions rapides et raisonnables et à améliorer les résultats.

Commentaire : Algorithme pour le traitement d’urgence de l’hyperkaliémie. ECG : électrocardiogramme ; POC : délocalisée au point d'intervention ; K+ : potassium ; IV : intraveineux ; SZC : sodium zirconium cyclosilicate (Lokelma : résine échangeuse de cation).
Attention, les résines échangeuses de cations, utilisées seules, n’ont pas de place dans le traitement d’urgence de l’hyperkaliémie en raison de leur délai d’action.

Facteurs de risque d'hyperkaliémie