Restrictive fluids versus standard care in adults with sepsis in the emergency department (REFACED): A multicenter, randomized feasibility trial.
Jessen MK, Andersen LW, Thomsen MH, Kristensen P, Hayeri W, Hassel RE, Messerschmidt TG, Sølling CG, Perner A, Petersen JAK, Kirkegaard H. | Acad Emerg Med. 2022 Oct;29(10):1172-1184
DOI: https://doi.org/10.1111/acem.14546  | Télécharger l'article au format  
Keywords: Aucun

Original contribution

Introduction : Fluid treatment in sepsis is a challenge and clinical equipoise exists regarding intravenous (IV) volumes. We aimed to determine whether a 24-h protocol restricting IV fluid was feasible in adult patients with sepsis without shock presenting to the emergency department (ED).

Méthode : The REFACED Sepsis trial is an investigator-initiated, multicenter, randomized, open-label, feasibility trial, assigning sepsis patients without shock to 24 h of restrictive, crystal IV fluid administration or standard care. In the IV fluid restriction group fluid boluses were only permitted if predefined criteria for hypoperfusion occurred. Standard care was at the discretion of the treating team. The primary outcome was total IV crystalloid fluid volumes at 24 h after randomization. Secondary outcomes included total fluid volumes, feasibility measures, and patient-centered outcomes.

Résultats : We included 123 patients (restrictive 61 patients and standard care 62 patients) in the primary analysis. A total of 32% (95% confidence interval [CI] 28%-37%) of eligible patients meeting all inclusion criteria and no exclusion criteria were included. At 24 h, the mean (±SD) IV crystalloid fluid volumes were 562 (±1076) ml versus 1370 (±1438) ml in the restrictive versus standard care group (mean difference -801 ml, 95% CI -1257 to -345 ml, p = 0.001). Protocol violations occurred in 21 (34%) patients in the fluid-restrictive group. There were no differences between groups in adverse events, use of mechanical ventilation or vasopressors, acute kidney failure, length of stay, or mortality.

Conclusion : A protocol restricting IV crystalloid fluids in ED patients with sepsis reduced 24-h fluid volumes compared to standard care. A future trial powered toward patient-centered outcomes appears feasible.

Conclusion (proposition de traduction) : Un protocole de restriction du remplissage par cristalloïdes IV chez les patients présentant un sepsis aux urgences a permis de réduire les volumes de liquide sur 24 heures par rapport aux soins standard. Un futur essai axé sur les résultats centrés sur le patient semble réalisable.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : REFACED RCT – Is Fluid Restriction in Sepsis Feasible?  . Rédigé par Alex Clark, le 03 novembre 2022.

Les investigateurs ont randomisé 123 patients (âge médian 76 ans, 58 % d'hommes) dans une cohorte restreignant le remplissage vasculaire ou dans une cohorte de soins standard. Les patients du groupe restrictif étaient limités à des bolus de 250 ml uniquement pour des critères d'hypoperfusion prédéfinis (lactate élevé, SBP < 90 mmHg, marbrures, oligurie sévère). Les critères d'inclusion étaient (1) une admission non planifiée aux urgences, (2) un âge ≥ 18 ans, (3) une septicémie définie comme une infection suspectée, des hémocultures réalisées, des antibiotiques IV ordonnés ou planifiés, et un score SOFA lié à l'infection ≥ 2, et (4) un séjour hospitalier prévu > 24 heures. Les patients exclus (n = 2462) ont reçu ≥ 500 ml de fluides, une ventilation mécanique ou des vasopresseurs avant l'inscription. Ceux qui présentaient une faible probabilité de survie à 24 heures ou d'autres obstacles cliniques logistiques ont également été exclus.
Les investigateurs ont démontré une diminution statistiquement significative du volume de remplissage dans le groupe restrictif (moyenne, 562 ± 1076 ml) par rapport au groupe de soins standard (1370 ± 1438 ml ; p = 0,001). Bien qu'il ne s'agisse pas du critère principal, les auteurs n'ont pas non plus mis en évidence de différences dans les critères secondaires, notamment les mesures de faisabilité, le recours à la ventilation mécanique ou aux vasopresseurs, l'insuffisance rénale aiguë, la durée de séjour à l'hôpital et la mortalité à 30 ou 90 jours. Dans l'ensemble, cet essai de faisabilité a confirmé la capacité de l'urgentiste à s'adapter au comportement clinique et à recruter rapidement des patients, bien qu'il y ait eu quelques violations du protocole (34 %, n = 21). Bien que cette étude en soi ne modifie pas la pratique, je prévois que l'essai REFACED ouvrira la voie à des études ultérieures de grande envergure qui guideront notre gestion des fluides dans le sepsis.

Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis.
Hayashi M, Kano K, Kuroda N, Yamamoto N, Shiroshita A, Kataoka Y. | Acad Emerg Med. 2022 Oct;29(10):1160-1171
DOI: https://doi.org/10.1111/acem.14568  | Télécharger l'article au format  
Keywords: analgesia; conscious sedation; intraarticular injection; nerve block; shoulder dislocation.

SYSTEMATIC REVIEWS (WITH OR WITHOUT META-ANALYSES)

Introduction : We performed a network meta-analysis (NMA) to compare the efficacy and safety of intravenous sedation (IVS), intraarticular anesthetic injection (IAA), and peripheral nerve block (PNB) as sedation or analgesia methods for the reduction of anterior shoulder dislocation.

Méthode : We included randomized controlled trials (RCTs) comparing different sedation or analgesia methods for anterior shoulder dislocation reduction. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar databases were searched in October 2021. We conducted a random-effects NMA within a frequentist framework. We evaluated the confidence in each outcome using the CINeMA tool.

Résultats : Sixteen RCTs (957 patients) were included. Regarding the primary outcomes, the three methods might result in little to no difference in the immediate success rate of reduction and patient satisfaction. The IAA method had a shorter emergency department length of stay than that of the IVS method (mean difference [MD] -107.88 min, 95% confidence interval [CI] -202.58 to -13.18). In the secondary outcomes, the IAA method had a lower pain score than that of the PNB method (standardized MD -1.83, 95% CI -3.64 to -0.02). The IAA and PNB methods might require a longer time for reduction than that of the IVS method (MD 5.3 min, 95% CI 2.4 to 10.36; MD 15.25, 95% CI 5.49 to 25.01). The three methods might result in little to no difference in the number of reduction attempts and total success rate of reduction. However, the confidence ratings for all treatment comparisons were very low. IAA and PNB had no adverse respiratory events.

Conclusion : The results of our NMA indicated that three sedation or analgesia methods (IVS, IAA, and PNB) might result in little to no difference in the success rate of reduction and patient satisfaction. IAA and PNB had no adverse respiratory events.

Conclusion (proposition de traduction) : Les résultats de notre méta-analyse en réseau indiquent que trois méthodes de sédation ou d'analgésie (sédation intraveineuse, injection anesthésique intra-articulaire et bloc nerveux périphérique) pourraient n'entraîner que peu ou pas de différence dans le taux de réussite de la réduction et la satisfaction du patient. L'injection anesthésique intra-articulaire et le bloc nerveux périphérique n'ont entraîné aucun effet indésirable sur le plan respiratoire.

Restrictive fluids versus standard care in adults with sepsis in the emergency department (REFACED): A multicenter, randomized feasibility trial.
Jessen MK, Andersen LW, Thomsen MH, Kristensen P, Hayeri W, Hassel RE, Messerschmidt TG, Sølling CG, Perner A, Petersen JAK, Kirkegaard H. | Acad Emerg Med. 2022 Oct;29(10):1172-1184
DOI: https://doi.org/10.1111/acem.14546  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Fluid treatment in sepsis is a challenge and clinical equipoise exists regarding intravenous (IV) volumes. We aimed to determine whether a 24-h protocol restricting IV fluid was feasible in adult patients with sepsis without shock presenting to the emergency department (ED).

Méthode : The REFACED Sepsis trial is an investigator-initiated, multicenter, randomized, open-label, feasibility trial, assigning sepsis patients without shock to 24 h of restrictive, crystal IV fluid administration or standard care. In the IV fluid restriction group fluid boluses were only permitted if predefined criteria for hypoperfusion occurred. Standard care was at the discretion of the treating team. The primary outcome was total IV crystalloid fluid volumes at 24 h after randomization. Secondary outcomes included total fluid volumes, feasibility measures, and patient-centered outcomes.

Résultats : We included 123 patients (restrictive 61 patients and standard care 62 patients) in the primary analysis. A total of 32% (95% confidence interval [CI] 28%-37%) of eligible patients meeting all inclusion criteria and no exclusion criteria were included. At 24 h, the mean (±SD) IV crystalloid fluid volumes were 562 (±1076) ml versus 1370 (±1438) ml in the restrictive versus standard care group (mean difference -801 ml, 95% CI -1257 to -345 ml, p = 0.001). Protocol violations occurred in 21 (34%) patients in the fluid-restrictive group. There were no differences between groups in adverse events, use of mechanical ventilation or vasopressors, acute kidney failure, length of stay, or mortality.

Conclusion : A protocol restricting IV crystalloid fluids in ED patients with sepsis reduced 24-h fluid volumes compared to standard care. A future trial powered toward patient-centered outcomes appears feasible.

Conclusion (proposition de traduction) : Un protocole de restriction du remplissage vasculaire par cristalloïdes IV chez les patients présentant une septicémie aux urgences a permis de réduire les volumes de remplissage vasculaire sur 24 heures par rapport aux soins standard. Un futur essai axé sur les résultats centrés sur le patient semble réalisable.

Electrocardiographic findings associated with early clinical deterioration in acute pulmonary embolism.
Weekes AJ, Raper JD, Thomas AM, Lupez K, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Abrams E, Kelly C, O'Connell NS. | Acad Emerg Med. 2022 Oct;29(10):1185-1196
DOI: https://doi.org/10.1111/acem.14554  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : We sought to determine associations of early electrocardiogram (ECG) patterns with clinical deterioration (CD) within 5 days and with RV abnormality (abnlRV) by echocardiography in pulmonary embolism (PE).

Méthode : In this prospective, multicenter study of newly confirmed PE patients, early echocardiography and initial ECG were examined. Initial ECG patterns included lead-specific ST-segment elevation (STE) or depression (STD), T-wave inversion (TWI), supraventricular tachycardia (SVT), sinus tachycardia, and right bundle branch block as complete (cRBBB) or incomplete (iRBBB). We defined CD as respiratory failure, hypotension, dysrhythmia, cardiac arrest, escalated PE intervention, or death within 5 days. We calculated odds ratios (ORs) for CD and abnlRV with univariate and full multivariate models in the presence of other variables.

Résultats : Of 1676 patients, 1629 (97.2%) had both ECG and GDE; 415/1676 (24.7%) had CD, and 529/1629 (32.4%) had abnlRV. AbnlRV had an OR for CD of 4.25 (3.35, 5.38). By univariable analysis, the absence of abnormal ECG patterns had OR for CD and abnlRV of 0.34 (0.26, 0.44; p < 0.001) and 0.24 (0.18, 0.31; p < 0.001), respectively. By multivariable analyses, one ECG pattern had a significant OR for CD: SVT 2.87 (1.66, 5.00). Significant ORS for abnlRV were: TWI V2-4 4.0 (2.64, 6.12), iRBBB 2.63 (1.59, 4.38), STE aVR 2.42 (1.58, 3.74), S1-Q3-T3 2.42 (1.70, 3.47), and sinus tachycardia 1.68 (1.14, 2.49).

Conclusion : SVT was an independent predictor of CD. TWI V2-4 , iRBBB, STE aVR, sinus tachycardia, and S1-Q3-T3 were independent predictors of abnlRV. Finding one or more of these ECG patterns may increase considerations for performance of echocardiography to look for RV abnormalities and, if present, inform concerns for early clinical deterioration.

Conclusion (proposition de traduction) : La tachycardie supraventriculaire était un facteur prédictif indépendant de la détérioration clinique. L'inversion de l'onde T en V2-4, le bloc de branche droit incomplet, le sus-décalage du segment ST en aVR, la tachycardie sinusale et l'aspect S1-Q3-T3 étaient des prédicteurs indépendants d'anomalies du ventricule droit. La découverte d'un ou plusieurs de ces tracés ECG peut inciter à réaliser une échocardiographie pour rechercher des anomalies du ventricule droit et, si elles sont présentes, à s'inquiéter d'une détérioration clinique précoce.

Periosteal block versus intravenous regional anesthesia for reduction of distal radius fractures: A randomized controlled trial.
Beck S, Brunner-Parker A, Stamm R, Douglas M, Conboy A. | Acad Emerg Med. 2022 Oct;29(10):1213-1220
DOI: https://doi.org/10.1111/acem.14555  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : We compare periosteal block and intravenous regional anesthesia (IVRA) as anesthetic techniques for reduction of distal radius fractures when performed by emergency department (ED) clinicians following brief training.

Méthode : This was a single-center, nonblinded randomized controlled trial of a convenience sample of patients presenting with distal radius fractures requiring closed reduction. Primary outcome measure was patient reported fracture reduction pain score, rated on a 100-mm visual analog scale. Secondary outcomes included adjunct pain medication use, ED length of stay, remanipulation rates, participant satisfaction, clinician assessed efficacy, and clinician-assessed ease of the procedure.

Résultats : Eighty-one patients were randomized to receive IVRA (n = 41) or periosteal block (N = 40). Reduction pain scores were not normally distributed. Median (25th-75th percentile) pain scores in participants assigned to IVRA and periosteal block were 5 (1-27.5) and 26 (8.5-63) mm, respectively, (p = 0.007). Use of adjunct medications during reduction was higher for the periosteal block group compared with IVRA (57.5% vs. 22.5%, p = 0.003). Remanipulation rates were 17.5% for periosteal block versus 7.5% for IVRA (p = 0.31). There was no difference in length of stay, patient satisfaction, or clinician's assessed ease of the anesthetic technique. There was a difference in clinician's assessment of efficacy between groups, with IVRA described as "extremely effective" by 65% and periosteal block described as "extremely effective" by 25% (p = 0.003).

Conclusion : When performed by a diverse group of ED clinicians periosteal block provided inferior analgesia to IVRA but may provide an alternative when IVRA cannot be performed.

Conclusion (proposition de traduction) : Lorsqu'il est pratiqué par un groupe diversifié de cliniciens des urgences, le bloc périosté procure une analgésie inférieure à l'anesthésie régionale intraveineuse, mais il peut constituer une alternative lorsque l'anesthésie régionale intraveineuse ne peut être pratiquée.

Relationship Between Glottic View and Intubation Force During Macintosh and Airtraq Laryngoscopy and Intubation.
Hindman BJ, Dexter F, Gadomski BC, Puttlitz CM. | Anesth Analg . 2022 Oct 1;135(4):815-819
DOI: https://doi.org/10.1213/ane.0000000000006082  | Télécharger l'article au format  
Keywords: Aucun

Original Clinical Research Report

Introduction : Because intubation-mediated cervical spine and spinal cord injury are likely determined by intubation force magnitude, understanding the determinants of intubation force magnitude is clinically relevant. With direct (Macintosh) laryngoscopy, when glottic view is less favorable, anesthesiologists apply greater force. We hypothesized that, when compared with direct (Macintosh) laryngoscopy, intubation force with an optical indirect laryngoscope (Airtraq) would be less dependent on glottic visualization.

Méthode : Using data obtained in a prior clinical study, we tested whether the slope of the intubation force versus glottic view relationship differed between intubations performed in 14 patients who were intubated twice, once with a Macintosh and once with an Airtraq videolaryngoscope. Slopes were compared using least-squares linear regression and robust regression.

Résultats : The slope of the intubation force (N) versus glottic view (%) relationship with the Macintosh (-0.679 [standard error {SE}, 0.147]) was significantly more negative than that of the Airtraq (-0.076 [SE, 0.246]). The least-squares regression difference in slopes was -0.603 (SE, 0.287); P = .046. The robust regression difference in slopes was -0.747 (SE, 0.187); P = .0005. Thus, when compared with the Macintosh, intubation force magnitude with Airtraq laryngoscopy was less dependent on glottic visualization.

Conclusion : Previously, we reported that intubation force with the Airtraq was less in magnitude compared with the Macintosh. Our current study adds that intubation force also is less dependent on glottic view with Airtraq compared with the Macintosh.

Conclusion (proposition de traduction) : Nous avons déjà signalé que la force d'intubation avec l'Airtraq était moins importante qu'avec le Macintosh. Notre étude actuelle ajoute que la force d'intubation dépend également moins de la vue glottique avec l'Airtraq qu'avec le Macintosh.

Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review.
Crosignani A, Spina S, Marrazzo F, Cimbanassi S, Malbrain MLNG, Van Regenmortel N, Fumagalli R, Langer T. | Ann Intensive Care. 2022 Oct 17;12(1):98
DOI: https://doi.org/10.1186/s13613-022-01072-y  | Télécharger l'article au format  
Keywords: Aucun

REVIEW

Editorial : Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24-48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5-10 ml/kg/h of Ringer's lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24-48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.

Discussion : Fluid therapy is a key treatment of patients admitted to the ICU with severe forms of acute pancreatitis. A broadly accepted early and aggressive fluid therapy has been recently questioned due to potential harm and not definitive efficacy in clinical trials. Since there is a possi- ble risk of under-resuscitation when a fixed infusion rate is used, a more tailored approach is warranted. It should be based on a careful assessment of the patient’s volume status, with enhanced volume expansion in the first hours of admission for the most severe cases. Crystalloids, and in particular RL, are the fluids of choice, with a sug- gested initial fluid rate usually ranging between 5–10 ml/ kg/h. Then, if at any time during the first 24 h resuscita- tion goals are met, it is reasonable to reduce fluid rate to 2–3 ml/kg/h. Patients with SAP should be strictly moni- tored in the ICU, where advanced hemodynamic moni- toring systems are available to guide clinicians.

Conclusion : Le remplissage vasculaire est un traitement clé pour les patients admis aux soins intensifs avec des formes sévères de pancréatite aiguë. Une remplissage vasculaire précoce et agressif largement acceptée a été récemment remise en question en raison des dommages potentiels et de l'absence d'efficacité démontrée dans les essais cliniques. Étant donné qu'il existe un risque possible de sous-réanimation lorsqu'un taux de perfusion fixe est utilisé, une approche plus adaptée est justifiée. Elle doit être basée sur une évaluation minutieuse de l'état volémique du patient, avec une expansion volémique renforcée dans les premières heures de l'admission pour les cas les plus graves. Les cristalloïdes, et en particulier le RL, sont les liquides de rempliossage de choix, avec un taux de remplissage initial suggéré se situant généralement entre 5 et 10 ml/ kg/h. Ensuite, si les objectifs de réanimation sont atteints à tout moment au cours des 24 premières heures, il est raisonnable de réduire le débit à 2-3 ml/kg/h. Les patients présentant une pancréatite aiguë sévère doivent faire l'objet d'une surveillance stricte en soins intensifs, où des systèmes spécialisés de surveillance hémodynamique sont disponibles pour guider les cliniciens.

Conclusion (proposition de traduction) : Acute pancreatitis; Critical illness; Crystalloid solutions; Fluid therapy; Ringer’s lactate.

Commentaire : 

Aromatherapy with Isopropyl Alcohol versus IntravenousOndansetron in Management of Mild Brain Trauma Nau-sea and Vomiting; a Randomized Clinical Trial.
Rezvani Kakhki B, Ghasemi T, Vafadar Moradi E, Abbasi Shaye Z, Mousavi SM. | Arch Acad Emerg Med [Internet]. 2022 Oct.31 [cited 2022Nov.17];10(1):e87
DOI: https://doi.org/10.22037/aaem.v10i1.1792  | Télécharger l'article au format  
Keywords: Aromatherapy; Odorants; Head Injuries, Closed; Brain Injuries, Traumatic; 2-Propanol

BRIEF REPORT

Introduction : Nausea and vomiting are common complaints among patients who refer to the emergency de-partment with head trauma. This study aimed to compare the effect of aromatherapy with isopropyl alcoholversus intravenous ondansetron in management of mild head trauma nausea and vomiting.

Méthode : Thisrandomized clinical trial was conducted on patients with isolated mild head trauma complaining of nausea andvomiting who were referred to emergency department during a 6-month period. Patients were randomly dividedinto control (IV ondansetron + aromatherapy with saline) and intervention (IV saline + aromatherapy with iso-propyl alcohol) groups. The frequency of vomiting and the severity of nausea (from 0 to 100 with the verbalscaling) were written before, and 10 and 30 minutes after intervention and compared between groups.

Résultats : A total of 210 patients (105 patients in each group) with a median age of 38 years were included in the study, 112(54.3%) of which were male. Ten minutes after aromatherapy, no significant difference was observed in nauseaand vomiting between the two groups (p >0.05). Nausea score after 30 minutes (p = 0.015) was significantly lowerin the intervention group compared to the control group, but vomiting after 30 minutes (p <0.001) was higherin the intervention group.

Conclusion : Aromatherapy using isopropyl alcohol significantly reduced nausea ofpatients with mild isolate head trauma after 30 minutes. Regarding vomiting, no favorable result was observedin this study. However, the frequency of vomiting was reduced in both control and intervention groups.

Conclusion (proposition de traduction) : L'aromathérapie avec l'alcool isopropylique a réduit de manière significative les nausées des patients ayant subi un traumatisme crânien isolé léger après 30 minutes. En ce qui concerne les vomissements, aucun résultat favorable n'a été observé dans cette étude. Cependant, la fréquence des vomissements a été réduite dans les groupes de contrôle et d'intervention.

Risk factors for sudden cardiac arrest in patients with ST-segment elevation myocardial infarction: a retrospective cohort study.
Chu CH, Shih HM, Yu SH, Chang SS, Sie JS, Huang FW, Hsu TY.. | BMC Emerg Med.. 2022 Oct 24;22(1):169
DOI: https://doi.org/10.1186/s12873-022-00732-3  | Télécharger l'article au format  
Keywords: Coronary artery disease; Percutaneous coronary intervention; ST-segment elevation myocardial infarction; Sudden cardiac arrest.

RESEARCH

Introduction : Sudden cardiac arrest (SCA) is a critical complication of acute myocardial infarction, especially ST-segment elevation myocardial infarction (STEMI). This study identified the risk factors for SCA in patients with STEMI before receiving catheterization.

Méthode : We retrospectively analyzed the data of patients with STEMI and cardiac arrest who presented to a tertiary care center in Taiwan between January 1, 2016, and December 31, 2019. Only patients with coronary artery disease (CAD) confirmed by coronary angiography were included in this study. We collected the patients' demographic and clinical data, such as age, sex, medical history, estimated glomerular filtration rate (eGFR), and coronary angiographic findings. The primary outcome of this study was SCA in patients with STEMI. Continuous and nominal variables were compared using the two-sample Student's t-test and chi-squared test, respectively. The results of logistic regression were subjected to multivariate analysis with adjustment for possible confounders.

Résultats : A total of 920 patients with STEMI and coronary angiography-documented CAD and 108 patients with SCA who presented between January 1, 2016, and December 31, 2019, were included. The bivariate logistic regression analysis of patients' demographic data revealed that patients with STEMI and SCA were slightly younger, were more likely to have diabetes mellitus, and had a lower eGFR than did the patients without SCA. The coronary angiographic findings indicated a higher prevalence of left main CAD and three-vessel disease in patients with SCA than in patients without SCA. Multivariate logistic regression revealed that left main CAD (odds ratio [OR]: 3.77; 95% confidence interval [CI], 1.84 to 7.72), a lower eGFR (OR: 0.97; 95% CI, 0.96 to 0.98), and younger age (OR: 0.98; 95% CI, 0.96 to 0.99) were the risk factors for SCA in patients with STEMI.

Conclusion : Left main CAD, lower eGFR, and younger age are the risk factors for cardiac arrest in patients with acute myocardial infarction.

Conclusion (proposition de traduction) : L'atteinte de l'IVA, un taux de filtration glomérulaire estimé bas et un âge plus jeune sont les facteurs de risque d'arrêt cardiaque chez les patients ayant subi un infarctus du myocarde aigu.

Management of Life-Threatening Asthma: Severe Asthma Series.
Garner O, Ramey JS, Hanania NA. | Chest. 2022 Oct;162(4):747-756
DOI: https://doi.org/10.1016/j.chest.2022.02.029  | Télécharger l'article au format  
Keywords: critical care medicine; life-threatening asthma; mechanical ventilation; respiratory failure; sedation.

ASTHMA - How I Do It - Review article

Editorial : Asthma exacerbations can be life-threatening, with 25,000 to 50,000 such patients per year requiring admission to an ICU in the United States. Appropriate triage of life-threatening asthma is dependent on both static assessment of airway function and dynamic assessment of response to therapy. Treatment strategies focus on achieving effective bronchodilation with inhaled β2-agonists, muscarinic antagonists, and magnesium sulphate while reducing inflammation with systemic corticosteroids. Correction of hypoxemia and hypercapnia, a key in managing life-threatening asthma, occasionally requires the incorporation of noninvasive mechanical ventilation to decrease the work of breathing. Endotracheal intubation and mechanical ventilation should not be delayed if clinical improvement is not achieved with conservative therapies. However, mechanical ventilation in these patients often requires controlled hypoventilation, adequate sedation, and occasional use of muscle relaxation to avoid dynamic hyperinflation, which can result in barotrauma or volutrauma. Sedation with ketamine or propofol is preferred because of their potential bronchodilation properties. In this review, we outline strategies for the assessment and management of patients with acute life-threatening asthma focusing on those requiring admission to the ICU.

Conclusion : LTAE is a rare complication of asthma, but if not treated in a timely fashion, it can result in death. Patients should be started quickly on inhaled SABA, short-acting muscarinic antagonists, and IV corticosteroids. Systemic infusion of magnesium sulfate can be considered in some patients. In those with severe bronchospasm, heliox can be used to facilitate medication delivery, but therapy should be abandoned if no clinical improvement is seen after 15 min of use. Patients who have progressive respiratory distress should be admitted to the ICU for close monitoring and should be administered NIV if tolerated. However, intubation should not be delayed if the patient does not improve in 30 to 60 min. Extra care should be taken if a patient requires mechanical ventilation. Intubation should be performed in a delayed sequence, and lung protective strategies should be adopted with IMV. Salvage therapies such as the use of inhaled anesthetics, bronchoscopy, and BAL with or without N-acetylcysteine or ECMO can be considered in individual patients with refractory disease.

Conclusion (proposition de traduction) : L'exacerbation de l'asthme menaçant le pronostic vital est une complication rare de l'asthme, mais si elle n'est pas traitée à temps, elle peut entraîner la mort. Les patients doivent être mis rapidement sous traitement inhalé par un b2-agoniste à courte durée d'action, des antagonistes muscariniques à courte durée d'action et des corticostéroïdes IV. Une perfusion systémique de sulfate de magnésium peut être envisagée chez certains patients. Chez les patients présentant un bronchospasme sévère, l'héliox peut être utilisé pour faciliter l'administration des médicaments, mais le traitement doit être abandonné si aucune amélioration clinique n'est observée après 15 minutes d'utilisation. Les patients qui présentent une détresse respiratoire progressive doivent être admis aux soins intensifs pour une surveillance étroite et doivent bénéficier d'une ventilation non invasive si elle est tolérée. Cependant, l'intubation ne doit pas être retardée si l'état du patient ne s'améliore pas après 30 à 60 minutes. Des précautions supplémentaires doivent être prises si le patient nécessite une ventilation mécanique. L'intubation doit être effectuée dans une séquence retardée et des stratégies de protection pulmonaire doivent être adoptées avec la ventilation mécanique invasive. Des thérapies de sauvetage telles que l'utilisation d'anesthésiques inhalés, la bronchoscopie et le lavage broncho-alvéolaire avec ou sans N-acétylcystéine ou l'oxygénation par membrane extracorporelle peuvent être envisagées chez les patients réfractaires.

Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study.
Fuller BM, Pappal RD, Mohr NM, Roberts BW, Faine B, Yeary J, Sewatsky T, Johnson NJ, Driver BE, Ablordeppey E, Drewry AM, Wessman BT, Yan Y, Kollef MH, Carpenter CR, Avidan MS. | Crit Care Med. 2022 Oct 1;50(10):1449-1460
DOI: https://doi.org/10.1097/ccm.0000000000005626
Keywords: Aucun

FEATURE ARTICLES

Introduction : In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.
Design: An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.

Méthode : Setting: The ED of three academic medical centers. PatientsMechanically ventilated adult patients that received neuromuscular blockers. Interventions: None.

Résultats : All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).

Conclusion : AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.

Conclusion (proposition de traduction) : La paralysies en pleine conscience était présente dans une proportion inquiétante de patients sous ventilation mécanique aux urgences, était associée à la prise de rocuronium aux urgences et entraînait une augmentation des niveaux vécu douloureux de l’expérience, exposant les patients à un risque accru de syndrome de stress post-traumatique. Il est urgent d'entreprendre des études visant à quantifier davantage la paralysies en pleine conscience dans cette population vulnérable et à éliminer son apparition.

Commentaire : Voir l'analyse de l'article sur le site Esanum : Induction séquence rapide pour l’intubation aux urgences : Roc(k) the curare ou Keep the Sux ?  . Rédigé par le Pr Nicolas Peschanski, le 14/12/2022.

Continued opioid use following an emergency department presentation for low back pain.
Coombs DM, Maher CG, Collett M, Mathieson S, Abdel Shaheed C, Lin CC, Machado GC. | Emerg Med Australas. 2022 Oct;34(5):694-697
DOI: https://doi.org/10.1111/1742-6723.13979
Keywords: emergency department; low back pain; opioid.

Original Research

Introduction : To investigate the proportion of patients with low back pain who receive an opioid analgesic prescription on hospital discharge, the proportion using opioid analgesics 4 weeks after discharge, and to identify predictors of continued opioid analgesic use at 4 weeks after an ED presentation in opioid-naïve patients.

Méthode : An observational cohort study nested within a randomised controlled trial in four EDs in New South Wales, Australia. Participants were adults who presented to the ED with non-specific low back pain or low back pain with lower limb neurological signs and symptoms. Electronic medical records supplemented the patient-reported pain and use of opioid analgesics at 4-week follow up.

Résultats : Of the 104 patients included, 33 (31.7%, 95% confidence interval [CI] 22.9-41.6) received an opioid analgesic prescription at hospital discharge and 38 (36.5%, 95% CI 27.3-46.6) reported taking an opioid analgesic for pain 4 weeks after the ED presentation. Among opioid-naïve patients (n = 85), older age (odds ratio [OR] 1.04, 95% CI 1.00-1.08, P = 0.031) was the only predictor for continued opioid analgesic use at 4 weeks post-ED presentation.

Conclusion : About one-third of patients who present to the ED with low back pain receive an opioid analgesic prescription on discharge and are taking an opioid analgesic 4 weeks later. These findings justify future research to identify strategies to reduce the risk of long-term opioid use in patients who present to the ED with low back pain.

Conclusion (proposition de traduction) : Environ un tiers des patients qui se présentent aux urgences pour une lombalgie se voient prescrire un analgésique opioïde à leur sortie de l'hôpital et continuent de prendre un analgésique opioïde quatre semaines plus tard. Ces résultats justifient de futures recherches pour identifier des stratégies visant à réduire le risque d'utilisation d'opioïdes à long terme chez les patients qui se présentent aux urgences pour une lombalgie.

Hyperkalaemia in the emergency department: Epidemiology, management and monitoring of treatment outcomes.
Pollack K, Manning KR, Balassone J, Bui C, Taylor DM, Taylor SE. | Emerg Med Australas. 2022 Oct;34(5):751-757
DOI: https://doi.org/10.1111/1742-6723.13971
Keywords: emergency service; hospital; hyperkalaemia/drug therapy; insulin; potassium.

Original Research

Introduction : To describe the epidemiology, treatment and monitoring of treatment outcomes of patients presenting to the ED with hyperkalaemia.

Méthode : We undertook a retrospective observational study in a mixed adult/paediatric ED over five 3-month periods. Consecutive patients were included if they had an initial serum or blood gas potassium ≥6.0 mmol/L. Patients were excluded if their principal diagnosis was diabetic ketoacidosis, their blood sample was haemolysed or the blood gas result was inconsistent with a subsequent serum potassium. Data were extracted from electronic medical records and two senior emergency registrars independently assessed available ECGs. Moderate and severe hyperkalaemia were potassium 6.0-6.4 and ≥6.5 mmol/L, respectively.

Résultats : Overall, 392 patients were included (mean age 73.7 years, triage category 1 or 2 28.3%, admitted 91.3%). Three hundred and twenty-one (81.9%, 95% confidence interval [CI] 77.6-85.5%) patients took one or more medications that predispose to hyperkalaemia and 335 (85.5%, 95% CI 81.5-88.7%) had one or more predisposing comorbidities. Two hundred and seventy-one (69.1%, 95% CI 64.3-73.6%) patients had moderately severe and 121 (30.9%, 95% CI 26.4-35.7%) had severe hyperkalaemia. Two hundred and fifty-nine (66.1%, 95% CI 61.1-70.7%) patients were administered at least one medication in ED to lower the potassium concentration and 51 (13.0%, 95% CI 9.9-16.8%) were dialysed. One hundred and eighty-seven patients received intravenous insulin: 40 (21.4%) had documented biochemical hypoglycaemia, but 45 (24.1%) had no post-insulin blood glucose level documented. Hyperkalaemia-associated ECG changes were uncommon.

Conclusion : Most ED patients with hyperkalaemia have identifiable clinical and medication-related risk factors. Variations in care were widespread and monitoring for iatrogenic adverse events was suboptimal.

Conclusion (proposition de traduction) : La plupart des patients des urgences présentant une hyperkaliémie ont des facteurs de risque cliniques et médicamenteux identifiables. Les disparités dans les soins sont très importantes et la détection des effets indésirables iatrogènes n'est pas optimale.

Point-of-care testing for tetanus immunity: a systematic review and meta-analysis.
Low R, Young K, Verani L, Cotton DT, Welman T, Moore LSP, Horwitz MD. | Emerg Med J. 2022 Apr 4:emermed-2021-211624.
DOI: https://doi.org/10.1136/emermed-2021-211624
Keywords: cost-benefit analysis; infections; trauma; wounds and injuries.

Systematic review

Introduction : The current standard of care for tetanus prophylaxis management in patients with open wounds likely results in overtreatment and unnecessary costs. Point-of-care immunochromatographic tests, known as Tetanus Quick Sticks (TQS), have been developed to qualitatively measure tetanus immunoglobulin levels. Multiple studies advocate their use in EDs. We aim to evaluate the diagnostic accuracy and cost-effectiveness of TQS to assess their relevance in frontline emergency care.

Méthode : A systematic review was undertaken following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was conducted in MEDLINE, Embase, Global Health, The Health Management Information Consortium and The Cochrane Library. Studies were eligible if sensitivity, specificity or cost-efficacy of TQS was reported. At least two authors independently assessed and extracted data from each study. A meta-analysis was conducted to evaluate summary sensitivity and specificity estimates for TQS.

Résultats : 12 studies were suitable for inclusion (n=1 662 865 participants): 1 modelling and 11 prospective observational cohort studies. Eight studies assessed diagnostic accuracy; the summary estimate for sensitivity was 90% (95% CI, 89% to 90%) with specificity 97% (95% CI, 95% to 100%). Six studies investigated cost-efficacy, reporting lower healthcare costs when using TQS instead of the current method of vaccination history, due to a decrease in unnecessary tetanus vaccine and immunoglobulin administration. Based on the current NHS supply chain data, TQS use could save £173.05 per tetanus-prone patient.

Conclusion : TQS could confer the greatest cost savings if used in combination with vaccination history in patients with tetanus-prone wounds. A quality assurance process is recommended prior to implementation of TQS in EDs.

Conclusion (proposition de traduction) : Le Test rapide d'immunisation contre le Tétanos pourrait permettre de réaliser les plus grandes économies s'il est utilisé en combinaison avec les antécédents de vaccination chez les patients présentant des plaies sujettes au tétanos. Un processus d'assurance qualité est recommandé avant la mise en œuvre du Test rapide d'immunisation contre le Tétanos dans les urgences.

Blunt thoracic trauma: role of chest radiography and comparison with CT - findings and literature review.
Polireddy K, Hoff C, Kinger NP, Tran A, Maddu K. | Emerg Radiol. 2022 Aug;29(4):743-755
DOI: https://doi.org/10.1007/s10140-022-02061-1
Keywords: Emergency; Radiology; Trauma.

Review Article

Editorial : In the setting of acute trauma where identification of critical injuries is time-sensitive, a portable chest radiograph is broadly accepted as an initial diagnostic test for identifying benign and life-threatening pathologies and guiding further imaging and interventions. This article describes chest radiographic findings associated with various injuries resulting from blunt chest trauma and compares the efficacy of the chest radiograph in these settings with computed tomography (CT). Common chest radiographic findings in blunt thoracic injuries will be reviewed to improve radiologic identification, expedite management, and improve trauma morbidity and mortality. This article discusses demographic information, mechanism of specific injuries, common imaging findings, imaging pearls, and pitfalls and exhibits several classic imaging findings in blunt chest trauma. Thoracic structures commonly injured in blunt trauma that will be discussed in this article include vasculature structures (aortic trauma), the heart (cardiac contusion, pericardial effusion), the esophagus (esophageal perforation), pleural space and airways (pneumothorax, hemothorax, bronchial injury), lungs (pulmonary contusion), the diaphragm (diaphragmatic rupture), and the chest wall (flail chest). Chest radiography plays an important role in the initial evaluation of blunt chest trauma. While CT imaging has a higher sensitivity than chest radiography, it remains a valuable tool due to its ability to provide rapid diagnostic information in time-sensitive trauma situations and is ubiquitously available in the trauma bay. Familiarity with the gamut of injuries that may occur as well as identification of the associated chest radiograph findings can aid in timely diagnoses and prompt management in the setting of acute blunt chest trauma.

Conclusion : Blunt chest trauma can cause life-threatening pathology, and abnormalities on CXR must be promptly identified. Emergency radiologists play a vital role in identifying these chest radiographic findings as well as knowing the limita- tions of this first-line modality. The CXR is an efficient tool to rapidly diagnose complications of blunt chest trauma and guide recommendations for further imaging or intervention as well as to asses placement of support apparatus. While chest radiographs can identify pneumothoraces, hemotho- races, displaced rib-fractures, and substantial pulmonary contusions and suggest aortic or mediastinal injury based on contour abnormalities, certain areas are relative blind spots including cardiac, esophageal, diaphragmatic, tracheo- bronchial, and chest wall injuries. In these severely injured patients, subsequent cross-sectional imaging can provide a more definite evaluation.

Conclusion (proposition de traduction) : Un traumatisme thoracique contondant peut entraîner une pathologie potentiellement mortelle, et les anomalies de la radiographie thoracique doivent être rapidement identifiées. Les radiologues d'urgence jouent un rôle essentiel dans l'identification de ces résultats radiographiques thoraciques et dans la connaissance des limites de cette modalité de première ligne. La radiographie du thorax est un outil efficace pour diagnostiquer rapidement les complications d'un traumatisme thoracique contondant et pour guider les recommandations d'imagerie ou d'intervention supplémentaire, ainsi que pour évaluer le placement d'un appareil de soutien. Bien que les radiographies du thorax puissent identifier les pneumothorax, les hémothorax, les fractures de côtes déplacées et les contusions pulmonaires importantes, et suggérer des lésions aortiques ou médiastinales sur la base d'anomalies de contour, certaines zones sont des angles morts, notamment les lésions cardiaques, œsophagiennes, diaphragmatiques, trachéo-bronchiques et de la paroi thoracique. Chez ces patients gravement blessés, une imagerie transversale ultérieure peut fournir une évaluation plus précise.

Prehospital extremity tourniquet placements-performance evaluation of non-EMS placement of a lifesaving device.
Mokhtari AK, Mikdad S, Luckhurst C, Hwabejire J, Fawley J, Parks JJ, Mendoza AE, Kaafarani HMA, Velmahos GC, Bloemers FW, Saillant NN. | Eur J Trauma Emerg Surg. 2022 Oct;48(5):4255-4265
DOI: https://doi.org/10.1007/s00068-022-01973-4  | Télécharger l'article au format  
Keywords: Emergency medical services; First responders; Prehospital tourniquets; Tourniquet indications and application.

Original Article

Introduction : The education of civilians and first responders in prehospital tourniquet (PT) utilization has spread rapidly. We aimed to describe trends in emergency medical services (EMS) and non-EMS PT utilization, and their ability to identify proper clinical indications and to appropriately apply tourniquets in the field.

Méthode : A retrospective cohort study was conducted to evaluate all adult patients with PTs who presented at two Level I trauma centers between January 2015 and December 2019. Data were collected via an electronic patient query tool and cross-referenced with institutional Trauma Registries. Medically trained abstractors determined if PTs were clinically indicated (limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). PTs were further designated as appropriately or inappropriately applied (based on tourniquet location, venous tourniquet, greater than 2-h ischemic time). Descriptive statistics and univariate analyses were performed.

Résultats : 146 patients met inclusion criteria. The incidence of yearly PT placements increased between 2015 and 2019, with an increase in placement by non-EMS personnel (police, firefighter, bystander, and patient). Improvised PTs were frequently utilized by bystanders and patients, whereas first responders had high rates of commercial tourniquet use. A high proportion of tourniquets were placed without indication (72/146, 49%); however, the proportion of PTs placed without a proper indication across applier groups was not statistically different (p = 0.99). Rates of inappropriately applied PTs ranged from 21 to 46% across all groups applying PTs.

Conclusion : PT placement was increasingly performed by non-EMS personnel. Present data indicate that non-EMS persons applied PTs at a similar performance level of those applied by EMS. Study LevelLevel III.

Conclusion (proposition de traduction) : La pose de garrots en préhospitalier est de plus en plus souvent effectuée par le personnel des services médicaux non urgents. Les données actuelles indiquent que les personnes des services médicaux non urgents ont posé des garrots préhospitaliers à un niveau de performance similaire à celui des garrots posés par les services médicaux d'urgence. Niveau de l'étudeNiveau III.

Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls.
Nederpelt CJ, Naar L, Meier K, van Wijck SFM, Krijnen P, Velmahos GC, Kaafarani HMA, Rosenthal MG, Schipper IB. | Eur J Trauma Emerg Surg. 2022 Oct;48(5):4297-4304
DOI: https://doi.org/10.1007/s00068-022-01938-7  | Télécharger l'article au format  
Keywords: Anticoagulant reversal; Direct oral anticoagulants; Geriatric trauma; Neurotrauma; Vitamin K antagonists.

ORIGINAL ARTICLE

Introduction : Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement.

Méthode : We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation.

Résultats : A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15-0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36-7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15-2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06-1.87) compared to controls.

Conclusion : Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

Conclusion (proposition de traduction) : Malgré les taux d'intervention neurochirurgicale plus élevés, les patients qui avaient pris des AOD avant la chute étaient associés à des taux de mortalité et de sortie en réadaptation hospitalière comparables à ceux des patients non anticoagulés. Les recherches futures devraient se concentrer sur l'évaluation et la stratification du risque chez les patients traumatisés exposés aux AOD.

How to improve intubation in the intensive care unit. Update on knowledge and devices.
De Jong A, Myatra SN, Roca O, Jaber S. | Intensive Care Med. 2022 Oct;48(10):1287-1298
DOI: https://doi.org/10.1007/s00134-022-06849-0  | Télécharger l'article au format  
Keywords: Airway; Complications; Intubation; Videolaryngoscope; Videolaryngoscopy.

NARRATIVE REVIEW

Editorial : Tracheal intubation in the critically ill is associated with serious complications, mainly cardiovascular collapse and severe hypoxemia. In this narrative review, we present an update of interventions aiming to decrease these complications. MACOCHA is a simple score that helps to identify patients at risk of difficult intubation in the intensive care unit (ICU). Preoxygenation combining the use of inspiratory support and positive end-expiratory pressure should remain the standard method for preoxygenation of hypoxemic patients. Apneic oxygenation using high-flow nasal oxygen may be supplemented, to prevent further hypoxemia during tracheal intubation. Face mask ventilation after rapid sequence induction may also be used to prevent hypoxemia, in selected patients without high-risk of aspiration. Hemodynamic optimization and management are essential before, during and after the intubation procedure. All these elements can be integrated in a bundle. An airway management algorithm should be adopted in each ICU and adapted to the needs, situation and expertise of each operator. Videolaryngoscopes should be used by experienced operators.

Conclusion : Take‐home message
Preoxygenation differs from apneic oxygenation. While noninvasive ventilation is the preferred method for preoxygenation of critically ill hypoxemic patients, high-flow nasal oxygen may be used for apneic oxygenation to limit the occurrence of desaturation.
In patients at high risk of desaturation, without high risk of aspiration, mask ventilation during apnea should be considered.
Use of videolaryngoscopy in critically ill patients may help to increase first-attempt intubation success, in the hands of trained operators.
Careful hemodynamic management is essential, with the aim to decrease hypotension during the intubation procedure and related cardiac arrest during intubation.

Conclusion (proposition de traduction) : Message à retenir
La préoxygénation diffère de l'oxygénation apnéique. Si la ventilation non invasive est la méthode privilégiée pour la préoxygénation des patients hypoxémiques gravement malades, l'oxygénothérapie nasale à haut débit (Optiflow) peut être utilisé dans l'oxygénation apnéique afin de limiter la survenue d'une désaturation.
Chez les patients présentant un risque élevé de désaturation, sans risque élevé d'inhalation, la ventilation au masque pendant l'apnée doit être envisagée.
L'utilisation de la vidéolaryngoscopie chez les patients gravement malades peut contribuer à augmenter le succès de la première tentative d'intubation, dans les mains d'opérateurs formés.
Une gestion hémodynamique attentive est essentielle, dans le but de réduire l'hypotension pendant la procédure d'intubation et les arrêts cardiaques qui y sont liés.

Commentaire : Algorithme de gestion des voies aériennes La disponibilité de l'équipement pour la gestion d'une voie aérienne difficile est vérifiée. Pendant la procédure, le patient doit être ventilé en cas de désaturation < 90%. Toutes les procédures d'intubation réalisées en réanimation sont compliquées. Pour améliorer la réussite de la première tentative, il est recommandé d'avoir deux opérateurs, d'utiliser une lame métallique et un stylet malléable (sauf pour les vidéolaryngoscopes canalisés). Une induction à séquence rapide est obligatoire. En cas d'intubation difficile prévisible (score de Mallampati III ou IV, SAOS, mobilité réduite du rachis cervical, ouverture buccale limitée, coma, hypoxie sévère, score de non-anesthésiste (MACOCHA) ≥ 3), l'utilisation d'un vidéolaryngoscope est recommandée si l'opérateur est expert dans son utilisation (au moins 15 intubations réalisées avec l'appareil), sauf en cas de sécrétions abondantes. Si le score MACOCHA < 3, le choix du dispositif est laissé à l'appréciation de l'opérateur (laryngoscope direct ou vidéolaryngoscope). En cas d'échec de l'intubation, un vidéolaryngoscope sera utilisé s'il n'a pas été utilisé en premier, et/ou un stylet intubateur (stylet malléable ou stylet angulé long et flexible), suivi successivement de l'utilisation du masque laryngé ou du fastrach, de l'utilisation de la fibroscopie entre des mains expertes et enfin de l'utilisation d'une voie aérienne percutanée ou chirurgicale de secours.

Médicaments utilisés pour la procédure d'intubation : avantages et inconvénients

The physiological underpinnings of life-saving respiratory support.
Telias I, Brochard LJ, Gattarello S, Wunsch H, Junhasavasdikul D, Bosma KJ, Camporota L, Brodie D, Marini JJ, Slutsky AS, Gattinoni L. | Intensive Care Med. 2022 Oct;48(10):1274-1286
DOI: https://doi.org/10.1007/s00134-022-06749-3  | Télécharger l'article au format  
Keywords: Extracorporeal membrane oxygenation; Mechanical ventilation; Myotrauma; Respiratory failure; Ventilator-induced lung injury.

REVIEW

Editorial : Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical ventilation and extracorporeal respiratory support. However, respiratory support is only a supportive therapy, designed to "buy time" while the disease causing respiratory failure abates. It ensures viable gas exchange and prevents cardiorespiratory collapse in the context of excessive loads. Because the use of invasive modalities of respiratory support is also associated with substantial harm, it remains the responsibility of the clinician to minimize such hazards. Direct iatrogenic consequences of mechanical ventilation include the risk to the lung (ventilator-induced lung injury) and the diaphragm (ventilator-induced diaphragm dysfunction and other forms of myotrauma). Adverse consequences on hemodynamics can also be significant. Indirect consequences (e.g., immobilization, sleep disruption) can have devastating long-term effects. Increasing awareness and understanding of these mechanisms of injury has led to a change in the philosophy of care with a shift from aiming to normalize gases toward minimizing harm. Lung (and more recently also diaphragm) protective ventilation strategies include the use of extracorporeal respiratory support when the risk of ventilation becomes excessive. This review provides an overview of the historical background of respiratory support, pathophysiology of respiratory failure and rationale for respiratory support, iatrogenic consequences from mechanical ventilation, specifics of the implementation of mechanical ventilation, and role of extracorporeal respiratory support. It highlights the need for appropriate monitoring to estimate risks and to individualize ventilation and sedation to provide safe respiratory support to each patient.

Conclusion : The treatment of respiratory failure has improved dramatically since the 1950’s polio epidemic. Although there have many been technological advances (better ventilators, improved monitors, more effective and smaller ECMO devices), the major advance has likely been a better physiological and biological understanding that life-saving respiratory support (mechanical ventilation) can also markedly harm patients. This can occur by inflicting injury to the lungs, the diaphragm, impairing hemodynamics and having a potential negative impact on patient’s physical status and mental health. The way specific pathophysiological conditions are interpretated at the bedside and how ventilatory strategies are applied should also be considered. Future research to improve outcomes in patients with respiratory failure will have to address these existential trade-offs of current ventilators and extracorporeal respiratory support systems.

Conclusion (proposition de traduction) : Le traitement de l'insuffisance respiratoire s'est considérablement amélioré depuis l'épidémie de polio des années 1950. Bien qu'il y ait eu de nombreuses avancées technologiques (meilleurs respirateurs, moniteurs améliorés, dispositifs d'ECMO plus efficaces et plus petits), la principale avancée a probablement été une meilleure compréhension physiologique et biologique du fait que l'assistance respiratoire de sauvetage (ventilation mécanique) peut également nuire considérablement aux patients. Cela peut se produire en provoquant des lésions aux poumons et au diaphragme, en altérant l'hémodynamique et en ayant un impact négatif potentiel sur l'état physique et la santé mentale du patient. Il faut également tenir compte de la manière dont les conditions physiopathologiques spécifiques sont interprétées au chevet du patient et dont les stratégies ventilatoires sont appliquées. Les recherches futures visant à améliorer les résultats chez les patients souffrant d'insuffisance respiratoire devront aborder ces compromis existentiels des ventilateurs et des systèmes d'assistance respiratoire extracorporelle actuels.

Immediate coronary angiography and systematic targeted temperature management are associated with improved outcome in comatose survivors of cardiac arrest.
Dall'Ara G, Compagnone M, Spartà D, Carletti R, Grotti S, Guerrieri G, Gaetani S, Cortigiani M, Maitan S, Fabbri A, Ottani F, Caravita L, Tarantino F, Galvani M. | Intern Emerg Med. 2022 Oct;17(7):2083-2092
DOI: https://doi.org/10.1007/s11739-022-03011-y  | Télécharger l'article au format  
Keywords: Cardiac arrest; Coma; Hypothermia; Percutaneous coronary intervention; Targeted temperature management.

EM - ORIGINAL

Introduction : Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC).

Méthode : We evaluated the short- and long-term outcome of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. All consecutive comatose CA survivors without obvious extra-cardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST elevation on electrocardiogram, and good neurological recovery.

Résultats : We enrolled 107 patients with a median age of 64.9 (57.7-73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty-six (61.7%) patients underwent PCI. In-hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in-hospital survival. Long-term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log-rank: p = 0.002).

Conclusion : Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non-shockable) and ST deviation (elevation vs no-elevation), and improved the long-term survival of patients discharged with good neurological recovery. Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST deviation in the post-ROSC electrocardiogram. The benefit was sustained at long-term particularly in those with neurological recovery.

Conclusion (proposition de traduction) : La revascularisation a été associée à de meilleurs résultats, quel que soit le rythme initial (choquable ou non choquable) et la déviation du segment ST (avec ou sans sus-décalage), et a amélioré la survie à long terme des patients sortis de l'hôpital avec une bonne récupération neurologique. La coronarographie systématique et la revascularisation, lorsqu'elles sont indiquées, ont été associées à une survie plus élevée chez les patients comateux soumis à une gestion de la température cible, indépendamment du rythme initial et de la déviation du segment ST sur l'électrocardiogramme post-RACS. Le bénéfice s'est maintenu à long terme, en particulier chez ceux qui ont récupéré sur le plan neurologique.

The impact of cognitive aids on resuscitation performance in in‐hospital cardiac arrest scenarios: a systematic review and meta‐analysis.
Corazza F, Fiorese E, Arpone M, Tardini G, Frigo AC, Cheng A, Da Dalt L, Bressan S. | Intern Emerg Med. 2022 Oct;17(7):2143-2158
DOI: https://doi.org/10.1007/s11739-022-03041-6  | Télécharger l'article au format  
Keywords: Cognitive aid; Heart arrest; Resuscitation; Simulation training; Support tool.

CE-SYSTEMATIC REVIEWS AND META-ANALYSIS

Introduction : Different cognitive aids have been recently developed to support the management of cardiac arrest, however, their effectiveness remains barely investigated. We aimed to assess whether clinicians using any cognitive aids compared to no or alternative cognitive aids for in-hospital cardiac arrest (IHCA) scenarios achieve improved resuscitation performance.

Méthode : PubMed, EMBASE, the Cochrane Library, CINAHL and ClinicalTrials.gov were systematically searched to identify studies comparing the management of adult/paediatric IHCA simulated scenarios by health professionals using different or no cognitive aids. Our primary outcomes were adherence to guideline recommendations (overall team performance) and time to critical resuscitation actions. Random-effects model meta-analyses were performed.

Résultats : Of the 4.830 screened studies, 16 (14 adult, 2 paediatric) met inclusion criteria. Meta-analyses of eight eligible adult studies indicated that the use of electronic/paper-based cognitive aids, in comparison with no aid, was significantly associated with better overall resuscitation performance [standard mean difference (SMD) 1.16; 95% confidence interval (CI) 0.64; 1.69; I² = 79%]. Meta-analyses of the two paediatric studies, showed non-significant improvement of critical actions for resuscitation (adherence to guideline recommended sequence of actions, time to defibrillation, rate of errors in defibrillation, time to start chest compressions), except for significant shorter time to amiodarone administration (SMD - 0.78; 95% CI - 1.39; - 0.18; I² = 0).

Conclusion : To conclude, the use of cognitive aids appears to have benefits in improving the management of simulated adult IHCA scenarios, with potential positive impact on clinical practice. Further paediatric studies are necessary to better assess the impact of cognitive aids on the management of IHCA scenarios.

Conclusion (proposition de traduction) : En conclusion, l'utilisation d'aides cognitives semble avoir des avantages dans l'amélioration de la gestion de scénarios simulés d'arrêt cardiaque à l'hôpital chez l'adulte, avec un impact positif potentiel sur la pratique clinique. D'autres études pédiatriques sont nécessaires pour mieux évaluer l'impact des aides cognitives sur la gestion des scénarios d'arrêt cardiaque en milieu hospitalier.

Association of Intravenous Potassium and Magnesium Administration With Spontaneous Conversion of Atrial Fibrillation and Atrial Flutter in the Emergency Department.
Cacioppo F, Reisenbauer D, Herkner H, Oppenauer J, Schuetz N, Niederdoeckl J, Schnaubelt S, Gupta S, Lutnik M, Simon A, Spiel AO, Buchtele N, Domanovits H, Laggner AN, Schwameis M. | JAMA Netw Open. 2022 Oct 3;5(10):e2237234
DOI: https://doi.org/10.1001/jamanetworkopen.2022.37234
Keywords: Aucun

Original Investigation

Introduction : Whether the simultaneous intravenous administration of potassium and magnesium is associated with the probability of spontaneous conversion to sinus rhythm (SCV) in the acute treatment of atrial fibrillation (AF) and atrial flutter (AFL) is unknown.
Objective: To assess potassium and magnesium administration and SCV probability in AF and AFL in the emergency department.

Méthode : A registry-based cohort study was conducted in the Department of Emergency Medicine of the Medical University of Vienna, Austria. All consecutive patients with AF or AFL were screened between February 6, 2009, and February 16, 2020.
Interventions: Intravenous administration of potassium, 24 mEq, and magnesium, 145.8 mg.
Main outcomes and measures: The primary outcome was the probability of SCV during the patient's stay in the emergency department. Multivariable cluster-adjusted logistic regression was used to estimate the association between potassium and magnesium administration and the probability of SCV.

Résultats : A total of 2546 episodes of nonpermanent AF (median patient age, 68 [IQR, 58-75] years, 1411 [55.4%] men) and 573 episodes of nonpermanent AFL (median patient age, 68 [IQR, 58-75] years; 332 [57.9%] men) were observed. In AF episodes, intravenous potassium and magnesium administration vs no administration was associated with increased odds of SCV (19.2% vs 10.4%; odds ratio [OR], 1.98; 95% CI, 1.53-2.57). In AFL episodes, in contrast, no association was noted for the probability of SCV with potassium and magnesium vs no administration (13.0% vs 12.5%; OR, 1.05; 95% CI, 0.65-1.69).

Conclusion : The findings of this registry-based cohort study on intravenous administration of potassium and magnesium suggest an increased probability of SCV in nonpermanent AF, but not AFL, during a patients' stay in the emergency department.

Conclusion (proposition de traduction) : Les résultats de cette étude de cohorte basée sur un registre concernant l'administration intraveineuse de potassium et de magnésium suggèrent une probabilité accrue de conversion spontanée en un rythme sinusal en cas de fibrillation atriale non permanente, mais pas de flutter atrial, pendant le séjour des patients aux urgences.

2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee.
Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI Jr, Villines TC, Wright LJ. | J Am Coll Cardiol. 2022 Oct 6:S0735-1097(22)06618-9
DOI: https://doi.org/10.1016/j.jacc.2022.08.750  | Télécharger l'article au format  
Keywords: ACC Expert Consensus Decision Pathway; accelerated diagnostic pathway; acute coronary syndrome; biomarkers; cardiac imaging; chest pain; clinical decision pathway; emergency department; myocardial infarction; myocardial injury; myocardial ischemia; stress test; troponins.

EXPERT CONSENSUS DECISION PATHWAY

Editorial : The American College of Cardiology (ACC) has a long history of developing documents (eg, decision pathways, health policy statements, appropriate use criteria) to provide members with guidance on both clinical and nonclinical topics relevant to cardiovascular care. In most circumstances, these documents have been created to complement clinical practice guidelines and to inform clinicians about areas where evidence is new and evolving or where sufficient data is more limited. Despite this, numerous gaps persist, highlighting the need for more streamlined and efficient processes to implement best practices in patient care.

Conclusion : A systematic approach—both at the level of the institution and the individual patient—is essential to achieve optimal outcomes for patients presenting with chest pain to the ED. At the institution level, this Expert Consensus Decision Pathway recommends implementation of hs-cTn assays in conjunction with a CDP to reduce ED “dwell” times and increase the proportion of patients with chest pain who can safely be discharged without additional testing. Successful implementation will decrease ED crowding and limit unnecessary testing. At the individual patient level, this document aims to provide structure for the ED evaluation of chest pain, accelerating the evaluation process and matching the intensity of testing and treatment to patient risk. This evaluation includes careful ECG review and, for appropriate patients, entry into a CDP that combines hs-cTn measurements with risk assessment and selective use of noninvasive testing. The CDP is used to help to guide triage, treatment, and disposition decisions. The CDP should be viewed as a tool to augment rather than replace the clinical judgment of the care team.

Conclusion (proposition de traduction) : Une approche systématique, tant au niveau de l'établissement que du patient, est essentielle pour obtenir des résultats optimaux chez les patients qui se présentent aux urgences avec une douleur thoracique. Au niveau de l'établissement, le présent guide de décision consensuel d'experts recommande la mise en œuvre du dosage de la hs-cTn en conjonction avec un processus de décision clinique afin de réduire le temps d'attente aux urgences et d'augmenter la proportion de patients souffrant de douleurs thoraciques qui peuvent sortir en toute sécurité sans avoir à bénéficier d'autres examens. Une mise en œuvre réussie permettra de réduire l'encombrement des urgences et de limiter les examens inutiles. Au niveau du patient, ce document vise à structurer l'évaluation de la douleur thoracique aux urgences, à accélérer le processus d'évaluation et à adapter l'intensité des examens et du traitement au risque du patient. Cette évaluation comprend un examen minutieux de l'ECG et, pour les patients appropriés, l'entrée dans un circuit de décision clinique qui combine les mesures de hs-cTn avec l'évaluation du risque et l'utilisation sélective de tests non invasifs. Les voies de décision clinique sont utilisées pour aider à guider les décisions de tri, de traitement et d'élimination. Les voies de décision clinique doivent être considérées comme un outil permettant d'augmenter plutôt que de remplacer le jugement clinique de l'équipe de soins.

Commentaire :  Synthèse des décisions cliniques

Signes ECG suggérant une ischémie

Proposition de traduction    

Acute Pulmonary Embolism: A Review.
Freund Y, Cohen-Aubart F, Bloom B. | JAMA. 2022 Oct 4;328(13):1336-1345
DOI: https://doi.org/10.1001/jama.2022.16815
Keywords: Aucun

Review

Introduction : Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US.

Résultats : PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age <50 years, heart rate <100/min, an oxygen saturation level of > 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, >40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%).

Conclusion : In the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.

Conclusion (proposition de traduction) : Aux États-Unis, l'EP touche environ 370 000 patients par an et peut causer environ 60 000 à 100 000 décès par an. Le traitement de première intention consiste en des anticoagulants oraux directs tels que l'apixaban, l'édoxaban, le rivaroxaban ou le dabigatran, la thrombolyse étant réservée aux patients dont la pression artérielle systolique est inférieure à 90 mmHg.

Hypercalcemia: A Review.
Walker MD, Shane E. | JAMA. 2022 Oct 25;328(16):1624-1636
DOI: https://doi.org/10.1001/jama.2022.18331
Keywords: Aucun

Review

Introduction : Hypercalcemia affects approximately 1% of the worldwide population. Mild hypercalcemia, defined as total calcium of less than 12 mg/dL (<3 mmol/L) or ionized calcium of 5.6 to 8.0 mg/dL (1.4-2 mmol/L), is usually asymptomatic but may be associated with constitutional symptoms such as fatigue and constipation in approximately 20% of people. Hypercalcemia that is severe, defined as total calcium of 14 mg/dL or greater (>3.5 mmol/L) or ionized calcium of 10 mg/dL or greater (≥2.5 mmol/L) or that develops rapidly over days to weeks, can cause nausea, vomiting, dehydration, confusion, somnolence, and coma.

Résultats : Approximately 90% of people with hypercalcemia have primary hyperparathyroidism (PHPT) or malignancy. Additional causes of hypercalcemia include granulomatous disease such as sarcoidosis, endocrinopathies such as thyroid disease, immobilization, genetic disorders, and medications such as thiazide diuretics and supplements such as calcium, vitamin D, or vitamin A. Hypercalcemia has been associated with sodium-glucose cotransporter 2 protein inhibitors, immune checkpoint inhibitors, denosumab discontinuation, SARS-CoV-2, ketogenic diets, and extreme exercise, but these account for less than 1% of causes. Serum intact parathyroid hormone (PTH), the most important initial test to evaluate hypercalcemia, distinguishes PTH-dependent from PTH-independent causes. In a patient with hypercalcemia, an elevated or normal PTH concentration is consistent with PHPT, while a suppressed PTH level (<20 pg/mL depending on assay) indicates another cause. Mild hypercalcemia usually does not need acute intervention. If due to PHPT, parathyroidectomy may be considered depending on age, serum calcium level, and kidney or skeletal involvement. In patients older than 50 years with serum calcium levels less than 1 mg above the upper normal limit and no evidence of skeletal or kidney disease, observation may be appropriate. Initial therapy of symptomatic or severe hypercalcemia consists of hydration and intravenous bisphosphonates, such as zoledronic acid or pamidronate. In patients with kidney failure, denosumab and dialysis may be indicated. Glucocorticoids may be used as primary treatment when hypercalcemia is due to excessive intestinal calcium absorption (vitamin D intoxication, granulomatous disorders, some lymphomas). Treatment reduces serum calcium and improves symptoms, at least transiently. The underlying cause of hypercalcemia should be identified and treated. The prognosis for asymptomatic PHPT is excellent with either medical or surgical management. Hypercalcemia of malignancy is associated with poor survival.

Conclusion : Mild hypercalcemia is typically asymptomatic, while severe hypercalcemia is associated with nausea, vomiting, dehydration, confusion, somnolence, and coma. Asymptomatic hypercalcemia due to primary hyperparathyroidism is managed with parathyroidectomy or observation with monitoring, while severe hypercalcemia is typically treated with hydration and intravenous bisphosphonates.

Conclusion (proposition de traduction) : Mild hypercalcemia is typically asymptomatic, while severe hypercalcemia is associated with nausea, vomiting, dehydration, confusion, somnolence, and coma. Asymptomatic hypercalcemia due to primary hyperparathyroidism is managed with parathyroidectomy or observation with monitoring, while severe hypercalcemia is typically treated with hydration and intravenous bisphosphonates.

Characteristics of Pediatric Nasal Foreign Body Cases That Required Multiple Removal Procedures: A Single Tertiary Medical Center Cross-Sectional Study.
Kawaguchi R, Matsui S, Hayashi T, Takei H, Tanizawa N, Ohnishi Y, Sameshima T, Miyawaki K, Yoshii TH, Tanaka R. | Pediatr Emerg Care. 2022 Oct 1;38(10):e1606-e1612
DOI: https://doi.org/10.1097/pec.0000000000002833
Keywords: Aucun

Original article

Introduction : Removal of nasal foreign bodies in children should be completed as few numbers of times as possible to reduce the burden on the child. This study aimed to reveal the characteristics of pediatric nasal foreign body cases that required multiple removal procedure and to investigate the appropriate removal method for each shape of foreign body.

Méthode : We retrospectively reviewed patients who visited a pediatric emergency department because of nasal foreign body from November 1, 2018, to October 31, 2020. We compared the characteristics of patients, foreign bodies, and treatment between the success and failure groups in the first removal procedure. Moreover, we described the detail of patients in the failure group. We also showed final successful removal methods according to the shape of the foreign bodies.

Résultats : We included 104 children in our analysis. Between the success and failure groups in the first removal procedure, there was no statistically significant difference in the characteristics of patients and foreign bodies but a significant difference in the removal method ( P < 0.001). In the failure groups, the most frequent number of times required for removal is 2 and the most common methods in the first removal procedure was the parent's kiss, most of which were performed on spherical foreign bodies in younger children, Finally, only 7 cases (6.7%) failed to remove the foreign body. According to the shape of the foreign bodies, the percentage of forceps and clamps used for successful removal was high in every shape.

Conclusion : There was a significant difference in the removal method between the success and failure groups in the first removal procedure, but finally, most foreign bodies were removed by emergency physicians. Therefore, further research is needed to determine the appropriate removal method for each patient and foreign body.

Conclusion (proposition de traduction) : Il existe une différence significative dans la méthode de retrait entre les groupes de réussite et d'échec de la première procédure de retrait, mais finalement, la plupart des corps étrangers ont été retirés par des médecins urgentistes. Par conséquent, des recherches supplémentaires sont nécessaires pour déterminer la méthode de retrait appropriée pour chaque patient et chaque corps étranger.

Modified DIVA Score: An Improved Clinical Predictive Tool for Detecting Difficult Access in Children.
Rizvi MB, Silver EJ, Khine H, Sellinger C. | Pediatr Emerg Care. 2022 Oct 1;38(10):e1646-e1649
DOI: https://doi.org/10.1097/pec.0000000000002623
Keywords: Aucun

Original Article

Introduction : This study aims to validate the DIVA (Difficult Intravenous Access) score in our population and to identify any additional patient characteristics that may be associated with difficult access in children.

Méthode : This was a cross-sectional study in an urban quaternary pediatric emergency department with patients younger than 21 years and Emergency Severity Index ≥2 who require intravenous (IV) access for their management. In addition to patient characteristics comprising the DIVA score, data were collected on patient "history of difficult access," hydration status, skin shade, history of sickle cell disease or diabetes, technology dependence, and body mass index. The number of IV cannulation attempts and total time taken were recorded for each patient. "Difficult access" was defined as ≥2 or more attempts or time >30 minutes to achieve successful IV cannulation.

Résultats : A convenience sample of 300 pediatric patients was enrolled. The DIVA score had a sensitivity of 51% (95% confidence interval [CI], 40.8%-61.14%) and a specificity of 82.99% (95% CI, 76.95%-87.99%) for predicting "difficult access" in our population. Among all patient characteristics examined in this study, only "history of difficult access" improved the identification of "difficult access" patients. The "history of difficult access" variable had a sensitivity of 61% (95% CI, 50.7%-70.6%) and a specificity of 75.7% (95% 95% CI, 69.12%-81.62%) in predicting "difficult access." With the addition of "history of difficult access" to the original DIVA score, we developed a "modified DIVA score (m-DIVA)." The m-DIVA score had a sensitivity of 78% (95% CI, 68.6%-85.6%) and specificity of 67% (95% CI, 59.9%-73.58%), representing a 52.9% improvement in correctly identifying "difficult access" patients over the original DIVA score.

Conclusion : The m-DIVA score, which incorporates prior history, increases the screening test's sensitivity in identifying "difficult access" patients and should be further investigated as clinical tool.

Conclusion (proposition de traduction) : Le score DIVA modifié, qui intègre les antécédents, augmente la sensibilité du test de dépistage pour identifier les patients à accès veineux difficile et devrait être étudié plus avant en tant qu'outil clinique.

Commentaire :  Score DIVA (Difficult IntraVenous Access) selon Yen K, Riegert A, Gorelick MH. Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access. Pediatr Emerg Care. 2008;24:143–147  .
La prématurité est définie comme une naissance à moins de 38 semaines de grossesse.

Prehospital Airway Management: A Systematic Review.
Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. | Prehosp Emerg Care. 2022 Sep-Oct;26(5):716-727
DOI: https://doi.org/10.1080/10903127.2021.1940400  | Télécharger l'article au format  
Keywords: airway management; comparative effectiveness; prehospital; systematic review.

Original Contribution

Introduction : To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics.

Méthode : We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020.
Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age.

Résultats : We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults.

Conclusion : The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.

Conclusion (proposition de traduction) : Les données probantes actuellement disponibles ne permettent pas de montrer un avantage de l'approches invasive des voies respiratoires en terme de survie, de fonction neurologique, de retour à une activité circulatoire spontanée ou de réussie de l'intubation des voies aériennes supérieures. Le niveau de preuve était faible ou modérée ; la plupart des études incluses étaient observationnelles. Cela confirme la nécessité de mener des essais contrôlés randomisés de haute qualité pour faire progresser la pratique clinique ainsi que la formation et la politique des services médicaux d'urgence, et améliorer les résultats centrés sur le patient.

Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival.
Moore JC, Pepe PE, Scheppke KA, Lick C, Duval S, Holley J, Salverda B, Jacobs M, Nystrom P, Quinn R, Adams PJ, Hutchison M, Mason C, Martinez E, Mason S, Clift A, Antevy PM, Coyle C, Grizzard E, Garay S, Crowe RP, Lurie KG, Debaty GP, Labarère J. | Resuscitation. 2022 Oct;179:9-17
DOI: https://doi.org/10.1016/j.resuscitation.2022.07.039  | Télécharger l'article au format  
Keywords: ACD-CPR; Active compression-decompression CPR; Cardiac arrest; Cardiopulmonary resuscitation; Head up CPR; ITD; Impedance threshold device.

Clinical paper

Introduction : Survival after out-of-hospital cardiac arrest (OHCA) remains poor. A physiologically distinct cardiopulmonary resuscitation (CPR) strategy consisting of (1) active compression-decompression CPR and/or automated CPR, (2) an impedance threshold device, and (3) automated controlled elevation of the head and thorax (ACE) has been shown to improve neurological survival significantly versus conventional (C) CPR in animal models. This resuscitation device combination, termed ACE-CPR, is now used clinically.

Méthode : To assess the probability of OHCA survival to hospital discharge after ACE-CPR versus C-CPR.
Methods : As part of a prospective registry study, 227 ACE-CPR OHCA patients were enrolled 04/2019-07/2020 from 6 pre-hospital systems in the United States. Individual C-CPR patient data (n = 5196) were obtained from three large published OHCA randomized controlled trials from high-performing pre-hospital systems. The primary study outcome was survival to hospital discharge. Secondary endpoints included return of spontaneous circulation (ROSC) and favorable neurological survival. Propensity-score matching with a 1:4 ratio was performed to account for imbalances in baseline characteristics.

Résultats : Irrespective of initial rhythm, ACE-CPR (n = 222) was associated with higher adjusted odds ratios (OR) of survival to hospital discharge relative to C-CPR (n = 860), when initiated in <11 min (3.28, 95 % confidence interval [CI], 1.55-6.92) and < 18 min (1.88, 95 % CI, 1.03-3.44) after the emergency call, respectively. Rapid use of ACE-CPR was also associated with higher probabilities of ROSC and favorable neurological survival.

Conclusion : Compared with C-CPR controls, rapid initiation of ACE-CPR was associated with a higher likelihood of survival to hospital discharge after OHCA.

Conclusion (proposition de traduction) : Comparativement aux contrôles conventionnels de la RCP, le déclenchement rapide de l'élévation contrôlée automatisée de la tête et du thorax lors de la RCP était associé à une probabilité plus élevée de survie jusqu'à la sortie de l'hôpital après un arrêt cardiaque extrahospitalier.

Commentaire : 

Le dispositif d'élévation personnalisé (Controlled Progressive Elevation - CDE) comporte différents niveaux d'appui, un pour la tête et le thorax supérieur, un deuxième pour le thorax moyen et un troisième pour le thorax inférieur, l'abdomen et les extrémités inférieures. (a) 0, (b) 20, (c) 30, (d) 40. In: Moore JC and al. Controlled progressive elevation rather than an optimal angle maximizes cerebral perfusion pressure during head up CPR in a swine model of cardiac arrest. Resuscitation. 2020 May;150:23-28  .

Mechanical chest compression devices under special circumstances.
Gässler H, Kurka L, Rauch S, Seewald S, Kulla M, Fischer M. | Resuscitation. 2022 Oct;179:183-188
DOI: https://doi.org/10.1016/j.resuscitation.2022.06.014
Keywords: Cardiac arrest; Mechanical chest compression device; Outcome; Transport; out-of-hospital CPR.

Clinical paper

Introduction : According to the current resuscitation guidelines, the use of mechanical chest compression devices could be considered under special circumstances like transport with ongoing resuscitation or long-term resuscitation. The aim of this study was to investigate whether survival is improved using mechanical devices under such circumstances.

Méthode : Out-of-hospital cardiac arrests from all high-quality data centres of the German Resuscitation Registry from 2007 to 2020 were investigated. The use of mechanical devices was compared separately for transport with ongoing resuscitation, prolonged resuscitation (>45 min), and resuscitation with fibrinolytic agents applied. Baseline characteristics, 30-day survival/discharged alive, and neurological function at discharge were analysed descriptively; and 30-day survival/discharged alive was additionally analysed using multivariate logistic regression.

Résultats : Overall, patients who were treated with a mechanical device tended to be younger and were significantly more likely to have a witnessed cardiac arrest and a shockable initial rhythm. During the study period, 4,851 patients were transported to hospital with ongoing resuscitation (devices used in 44.2%). The 30-day survival was equal (odds ratio, OR: 1.13, 95%-CI: 0.79-1.60). In 3,920 cases, a resuscitation duration > 45 min was documented (9.5% with device). When a device was used, 30-day survival was significantly increased (OR 2.33, 95%-CI: 1.30-4.15). Fibrinolytic agents were used in 2,106 patients (22.2% with device). Here, 30-day survival was significantly worse with a device (OR: 0.52, 95%-CI: 0.30-0.91).

Conclusion : Mechanical devices are not associated with better survival when used during transport, but rescuer safety could still be an important argument for their use. Devices are associated with better survival in prolonged resuscitation, but worse survival when a fibrinolytic was used.

Conclusion (proposition de traduction) : Les dispositifs mécaniques ne sont pas associés à une meilleure survie lorsqu'ils sont utilisés pendant le transport, mais la sécurité du secouriste pourrait tout de même constituer un argument important en faveur de leur utilisation. Les dispositifs sont associés à une meilleure survie en cas de réanimation prolongée, mais à une survie plus faible lorsqu'un fibrinolytique a été utilisé.

ECPR²: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation.
Schmitzberger FF, Haas NL, Coute RA, Bartos J, Hackmann A, Haft JW, Hsu CH, Hutin A, Lamhaut L, Marinaro J, Nagao K, Nakashima T, Neumar R, Pellegrino V, Shinar Z, Whitmore SP, Yannopoulos D, Peterson WJ. | Resuscitation. 2022 Oct;179:214-220
DOI: https://doi.org/10.1016/j.resuscitation.2022.07.003
Keywords: Cardiac arrest; Delphi; ECPR; OHCA.

Clinical paper

Introduction : Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA.

Méthode : We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale.

Résultats : Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26).

Conclusion : We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Conclusion (proposition de traduction) : Nous présentons une liste d'éléments à prendre en compte pour le déclenchement de la réanimation cardio-pulmonaire extracorporelle après un arrêt cardiaque non traumatique survenu à l'extérieur de l'hôpital chez un adulte. Cette liste a été établie à l'aide d'un processus Delphi modifié par un groupe international d'experts en la matière. Ces résultats peuvent être utiles aux centres qui pratiquent actuellement la réanimation cardio-pulmonaire extra-corporelle en matière d'assurance qualité et servir de modèle pour les nouveaux programmes de réanimation cardio-pulmonaire extra-corporelle.

A Smartphone application to provide real-time cardiopulmonary resuscitation quality feedback.
Stumpf E, Ambati RT, Shekhar R, Staffa SJ, Zurakowski D, Sinha P. | Am J Emerg Med. 2022 Oct;60:34-39
DOI: https://doi.org/10.1016/j.ajem.2022.06.045  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Quality; Technology.

Research article

Introduction : Quality of cardiopulmonary resuscitation (CPR) contributes significantly to outcomes. Key determinants of CPR quality pertaining to chest compressions are compression rate, compression depth, duration of interruptions, and chest recoil. Several studies have demonstrated that real-time audiovisual feedback improves CPR quality. We hypothesize that a mobile application using sensor data from built-in accelerometers in smartphones can provide accurate chest compression quality feedback in real time. This study aims to develop and validate an application for smartphone which can provide real-time audiovisual and haptic feedback on determinants of CPR quality.

Méthode : A mobile application was developed to detect the compression depth and compression rate in real time using data captured from a smartphone's intrinsic accelerometer. The mobile device was placed on an adult manikin's chest at the point of compressions. In a simulated environment, data obtained using the application was compared directly to data obtained from a validated standard CPR quality tool.

Résultats : CPR quality parameters were obtained from the application and industry standard for 60, 30s-long sessions. Bland-Altman plot analysis for compression depth showed agreement between the app measurements and standard within ±4 mm (<10% error). The interclass correlation for agreement in the measurement of compression count was 0.92 (95% CI: 0.88-0.95), indicative of very strong agreement.

Conclusion : Smart device applications using acceleration sensor data derived from smart phones can accurately provide real-time CPR quality feedback. With further development and validation, they can provide a ubiquitously available CPR feedback tool valuable for out-of-hospital arrests and in-hospital arrests in under-privileged areas.

Conclusion (proposition de traduction) : Les applications de systèmes intelligents utilisant les données du capteur d'accélération provenant des téléphones portables peuvent fournir avec précision un retour d'information en temps réel sur la qualité de la réanimation cardio-pulmonaire. Avec un développement et une validation plus poussés, elles peuvent fournir un outil de retour d'information sur la RCP disponible partout et utile pour les arrêts en dehors de l'hôpital et les arrêts à l'hôpital dans les zones défavorisées.

Hyponatremia in the emergency department.
Lindner G, Schwarz C, Haidinger M, Ravioli S. | Am J Emerg Med. 2022 Oct;60:1-8
DOI: https://doi.org/10.1016/j.ajem.2022.07.023  | Télécharger l'article au format  
Keywords: Electrolytes; Emergency; Hyponatremia; Sodium.

Review article

Editorial : Hyponatremia, defined as a serum sodium <135 mmol/L, is frequently encountered in patients presenting to the emergency department. Symptoms are often unspecific and include a recent history of falls, weakness and vertigo. Common causes of hyponatremia include diuretics, heart failure as well as Syndrome of Inappropriate Antidiuresis (SIAD) and correct diagnosis can be challenging. Emergency treatment of hyponatremia should be guided by presence of symptoms and focus on distinguishing between acute and chronic hyponatremia.

Conclusion : Hyponatremia is a common electrolyte disorder in patients presenting to the ED. Common causes include hypovolemia, diuretics, heart failure, cirrhosis of the liver as well as SIAD. Distinguishing symptomatic from asymptomatic hyponatremia is crucial to start adequate therapy and avoid complications. In asymptomatic patients, initiating adequate diagnostic steps should have priority in the ED since treatment should be diagnosis-guided.

Conclusion (proposition de traduction) : L'hyponatrémie est un trouble ionique fréquent chez les patients se présentant aux urgences. Les causes courantes sont l'hypovolémie, les diurétiques, l'insuffisance cardiaque, la cirrhose du foie ainsi que le syndrome de sécrétion inappropriée d'hormone antidiurétique. Il est essentiel de distinguer l'hyponatrémie symptomatique de l'hyponatrémie asymptomatique pour mettre en place un traitement adéquat et éviter les complications. Chez les patients asymptomatiques, la mise en place d'une démarche diagnostique adéquate doit être prioritaire aux urgences, car le traitement doit être guidé par le diagnostic.

Pregnancy in trauma-A Western Trauma Association algorithm.
Rizzo A, Martin M, Inaba K, Schreiber M, Brasel K, Sava J, Ciesla D, Sperry J, Kozar R, Brown C, Moore E. | J Trauma Acute Care Surg. 2022 Oct 1;93(4):e139-e142
DOI: https://doi.org/10.1097/ta.0000000000003740
Keywords: Algorithm, expert opinion, consensus.

2019 WTA ALGORITHM

Introduction : The Western Trauma Association has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations or scarcity of experience. Care of the pregnant trauma patient is one of these clinically complex situations that is based on physiologic data, standard trauma care, trauma care experience, and outcomes.

Méthode : Review of multiple evidence- based guidelines, case reports, and expert opinion were compiled and reviewed.

Résultats : The algorithm is attached with detailed explanation of each step, supported by data if available.

Conclusion : Resuscitative and trauma care of the mother is the utmost priority.

Conclusion (proposition de traduction) : Les soins de réanimation et de traumatologie de la mère sont la priorité absolue.

Commentaire :  Algorithme de prise en charge d'une patiente enceinte ayant subi un traumatisme.

Algorithme de prise en charge d'une détresse foetale chez une mère stable.

Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest.
Kjaergaard J, Møller JE, Schmidt H, Grand J, Mølstrøm S, Borregaard B, Venø S, Sarkisian L, Mamaev D, Jensen LO, Nyholm B, Høfsten DE, Josiassen J, Thomsen JH, Thune JJ, Obling LER, Lindholm MG, Frydland M, Meyer MAS, Winther-Jensen M, Beske RP, Frikke-Schmidt R, Wiberg S, Boesgaard S, Madsen SA, Jørgensen VL, Hassager C. | N Engl J Med. 2022 Oct 20;387(16):1456-1466
DOI: https://doi.org/10.1056/nejmoa2208687
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Evidence to support the choice of blood-pressure targets for the treatment of comatose survivors of out-of-hospital cardiac arrest who are receiving intensive care is limited.

Méthode : In a double-blind, randomized trial with a 2-by-2 factorial design, we evaluated a mean arterial blood-pressure target of 63 mm Hg as compared with 77 mm Hg in comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause; patients were also assigned to one of two oxygen targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category (CPC) of 3 or 4 within 90 days (range, 0 to 5, with higher categories indicating more severe disability; a category of 3 or 4 indicates severe disability or coma). Secondary outcomes included neuron-specific enolase levels at 48 hours, death from any cause, scores on the Montreal Cognitive Assessment (range, 0 to 30, with higher scores indicating better cognitive ability) and the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at 3 months, and the CPC at 3 months.

Résultats : A total of 789 patients were included in the analysis (393 in the high-target group and 396 in the low-target group). A primary-outcome event occurred in 133 patients (34%) in the high-target group and in 127 patients (32%) in the low-target group (hazard ratio, 1.08; 95% confidence interval [CI], 0.84 to 1.37; P = 0.56). At 90 days, 122 patients (31%) in the high-target group and 114 patients (29%) in the low-target group had died (hazard ratio, 1.13; 95% CI, 0.88 to 1.46). The median CPC was 1 (interquartile range, 1 to 5) in both the high-target group and the low-target group; the corresponding median modified Rankin scale scores were 1 (interquartile range, 0 to 6) and 1 (interquartile range, 0 to 6), and the corresponding median Montreal Cognitive Assessment scores were 27 (interquartile range, 24 to 29) and 26 (interquartile range, 24 to 29). The median neuron-specific enolase level at 48 hours was also similar in the two groups. The percentages of patients with adverse events did not differ significantly between the groups.

Conclusion : Targeting a mean arterial blood pressure of 77 mm Hg or 63 mm Hg in patients who had been resuscitated from cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma.

Conclusion (proposition de traduction) : Le fait de cibler une pression artérielle moyenne de 77 mmHg ou de 63 mmHg chez des patients ayant été réanimés après un arrêt cardiaque ne s'est pas traduit par des pourcentages significativement différents de patients décédés ou présentant une invalidité grave ou un coma.

Commentaire : Voir l'analyse de l'article sur le site de la SFAR : Le Masque et la Plume Revue de presse – Janvier Février 2023  .
Conclusion: Parmi les patients comateux après un ACREH, une stratégie ciblant une PAM haute n’a pas permis d’améliorer la survie ou le pronostic neurologique à J90 par rapport à une stratégie ciblant une PAM basse. De même, les stratégies d’oxygénation libérale ou restrictive ne modifiaient pas le pronostic de ces patients.
Commentaire LMLP : Essai randomisé avec méthodologie très stricte, notamment avec le dispositif permettant un double aveugle pour la cible tensionnelle. Risque de biais parait très faible. Population très sélectionnée : grande majorité d’arrêts cardiaque en rythme choquable et survie élevée, pouvant limiter l’extrapolation des résultats. Les cibles recommandées actuellement en post-ressuscitation paraissent adaptées à savoir un objectif de PAM > 65 mmHg et de PaO2 entre 75 et 98 mmHg. Un futur essai thérapeutique pourrait comparer une cible de PAM à 65 mmHg et une cible de PAM plus élevée à 80/85 mmHg comme dans le traumatisme crânien ?

Oxygen Targets in Comatose Survivors of Cardiac Arrest.
Schmidt H, Kjaergaard J, Hassager C, Mølstrøm S, Grand J, Borregaard B, Roelsgaard Obling LE, Venø S, Sarkisian L, Mamaev D, Jensen LO, Nyholm B, Høfsten DE, Josiassen J, Thomsen JH, Thune JJ, Lindholm MG, Stengaard Meyer MA, Winther-Jensen M, Sørensen M, Frydland M, Beske RP, Frikke-Schmidt R, Wiberg S, Boesgaard S, Lind Jørgensen V, Møller JE. | N Engl J Med. 2022 Oct 20;387(16):1467-1476
DOI: https://doi.org/10.1056/nejmoa2208686
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : The appropriate oxygenation target for mechanical ventilation in comatose survivors of out-of-hospital cardiac arrest is unknown.

Méthode : In this randomized trial with a 2-by-2 factorial design, we randomly assigned comatose adults with out-of-hospital cardiac arrest in a 1:1 ratio to either a restrictive oxygen target of a partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa (68 to 75 mm Hg) or a liberal oxygen target of a Pao2 of 13 to 14 kPa (98 to 105 mm Hg); patients were also assigned to one of two blood-pressure targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with severe disability or coma (Cerebral Performance Category [CPC] of 3 or 4; categories range from 1 to 5, with higher values indicating more severe disability), whichever occurred first within 90 days after randomization. Secondary outcomes were neuron-specific enolase levels at 48 hours, death from any cause, the score on the Montreal Cognitive Assessment (ranging from 0 to 30, with higher scores indicating better cognitive ability), the score on the modified Rankin scale (ranging from 0 to 6, with higher scores indicating greater disability), and the CPC at 90 days.

Résultats : A total of 789 patients underwent randomization. A primary-outcome event occurred in 126 of 394 patients (32.0%) in the restrictive-target group and in 134 of 395 patients (33.9%) in the liberal-target group (hazard ratio, 0.95; 95% confidence interval, 0.75 to 1.21; P = 0.69). At 90 days, death had occurred in 113 patients (28.7%) in the restrictive-target group and in 123 (31.1%) in the liberal-target group. On the CPC, the median category was 1 in the two groups; on the modified Rankin scale, the median score was 2 in the restrictive-target group and 1 in the liberal-target group; and on the Montreal Cognitive Assessment, the median score was 27 in the two groups. At 48 hours, the median neuron-specific enolase level was 17 μg per liter in the restrictive-target group and 18 μg per liter in the liberal-target group. The incidence of adverse events was similar in the two groups.

Conclusion : Targeting of a restrictive or liberal oxygenation strategy in comatose patients after resuscitation for cardiac arrest resulted in a similar incidence of death or severe disability or coma.

Conclusion (proposition de traduction) : Le ciblage d'une stratégie d'oxygénation restrictive ou libérale chez les patients comateux après une réanimation pour arrêt cardiaque a entraîné une incidence similaire de décès ou d'invalidité grave ou de coma.

Treatment and Prevention of Heat-Related Illness.
Sorensen C, Hess J. | N Engl J Med. 2022 Oct 13;387(15):1404-1413
DOI: https://doi.org/10.1056/nejmcp2210623  | Télécharger l'article au format  
Keywords: Aucun

Clinical Practice

Editorial : A 71-year-old man with a history of coronary artery disease, congestive heart failure, and schizoaffective disorder presents to the emergency department with confusion. On the day of presentation, he was seen walking near his apartment complex in a busy urban area and was later found collapsed outside his building. The local heat index (accounting for temperature and relative humidity) is 105°F (40.6°C). On arrival in the emergency department, he is conscious but confused. His heart rate is 130 beats per minute, blood pressure 100/70 mm Hg, respiratory rate 28 breaths per minute, rectal temperature 40.5°C, and oxygen saturation 90% while he is receiving oxygen at a rate of 3 liters per minute through a nasal cannula. He opens his eyes to voice and can state his name. He is able to move his arms and legs and has no focal neurologic deficits. His skin is hot and dry to the touch. His medications include furosemide, risperidone, and carvedilol. The patient lives alone in a top-floor apartment without air conditioning. How should this heat-related illness be treated, and how could it have been prevented?

Conclusion : The 71-year-old man described in the vignette presents with confusion and hyperthermia in the context of a high ambient temperature, making heat stroke the likely diagnosis. Risk factors include his living alone on the top floor of a building without air conditioning and his use of medications that can compromise thermoregulation. Treatment should involve rapid cooling followed by diagnostic evaluation and management of complications such as aspiration pneumonia, as well as monitoring in an intensive care unit. Subsequent preventive strategies are needed, and, if instituted earlier, might have averted the current illness. These strategies should include clinical screening before the warm season, tailored recommendations that take into account the patient’s coexisting conditions and medications, and involvement of a multidisciplinary team to aid in improving the safety of his home environment. In addition to broad-based public health measures aimed at reducing risks, rapid action to reduce greenhouse gas emissions is needed to prevent further increases in morbidity and mortality due to heat exposure.

Conclusion (proposition de traduction) : L'homme de 71 ans décrit dans la vignette présente une confusion et une hyperthermie dans le contexte d'une température ambiante élevée, ce qui fait du coup de chaleur le diagnostic probable. Les facteurs de risque comprennent le fait qu'il vit seul au dernier étage d'un immeuble sans climatisation et qu'il prend des médicaments qui peuvent compromettre la thermorégulation. Le traitement doit consister en un refroidissement rapide suivi d'une évaluation diagnostique et d'une prise en charge des complications telles que la pneumonie d'inhalation, ainsi qu'une surveillance dans une unité de soins intensifs. Des stratégies préventives ultérieures sont nécessaires et, si elles avaient été mises en place plus tôt, elles auraient pu éviter la complication actuelle. Ces stratégies devraient inclure un dépistage clinique avant la saison chaude, des recommandations personnalisées tenant compte des pathologies et des médicaments coexistants du patient, et l'implication d'une équipe multidisciplinaire pour aider à améliorer la sécurité de son environnement domestique. Outre les mesures de santé publique à grande échelle visant à réduire les risques, il est nécessaire d'agir rapidement pour réduire les émissions de gaz à effet de serre afin d'éviter une nouvelle augmentation de la morbidité et de la mortalité dues à l'exposition à la chaleur.