Massive blood transfusion following older adult trauma: The effect of blood ratios on mortality.
Hohle RD, Wothe JK, Hillmann BM, Tignanelli CJ, Harmon JV, Vakayil VR. | Acad Emerg Med. 2022 Dec;29(12):1422-1430
DOI: https://doi.org/10.1111/acem.14580  | Télécharger l'article au format  
Keywords: TQIP; blood ratio; massive blood transfusion; older adult; trauma.

ORIGINAL CONTRIBUTION

Introduction : Massive blood transfusion (MBT) following older adult trauma poses unique challenges. Despite extensive evidence on optimal resuscitative strategies in the younger adult patients, there is limited research in the older adult population.

Méthode : We used the Trauma Quality Improvement Program (TQIP) database from 2013 to 2017 to identify all patients over 65 years old who received a MBT. We stratified our population into six fresh-frozen plasma:packed red blood cell (FFP:pRBC) ratio cohorts (1:1, 1:2, 1:3, 1:4, 1:5, 1:6+). Our primary outcomes were 24-h and 30-day mortality. We constructed multivariable regression models with 1:1 group as the baseline and adjusted for confounders to estimate the independent effect of blood ratios on mortality.

Résultats : A total of 3134 patients met our inclusion criteria (median age 73 ± 7.6 years, 65% male). On risk-adjusted multivariable analysis, 1:1 FFP:pRBC ratio was independently associated with lowest 24-h mortality (1:2 odds ratio [OR] 1.60, 95% confidence interval [CI] 1.25-2.06, p < 0.001) and 30-day mortality (1:2 OR 1.44, 95% CI 1.15-1.80, p = 0.002).

Conclusion : Compared to all other ratios, the 1:1 FFP:pRBC ratio had the lowest 24-h and 30-day mortality following older adult trauma consistent with findings in the younger adult population.

Conclusion (proposition de traduction) : Comparé à tous les autres ratios, le ratio 1:1 « plasma frais congelé:concentré de globules rouges » présentait la mortalité la plus faible à 24 heures et à 30 jours après un traumatisme survenu chez une personne âgée, conformément aux résultats obtenus dans la population adulte plus jeune.

A consensus list of ultrasound competencies for graduating emergency medicine residents.
Haidar DA, Peterson WJ, Minges PG, Carnell J, Nomura JT, Bailitz J, Boyd JS, Leo MM, Liu EL, Duanmu Y, Acuña J, Kessler R, Elegante MF, Nelson M, Liu RB, Lewiss RE, Nagdev A, Huang RD. | AEM Educ Train. 2022 Nov 21;6(6):e10817
DOI: https://doi.org/10.1002/aet2.10817  | Télécharger l'article au format  
Keywords: consensus; education; graduate medical education; point‐of‐care ultrasound; resident; ultrasound.

ORIGINAL CONTRIBUTION

Introduction : Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method.

Méthode : We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at >80%.

Résultats : Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus.

Conclusion : Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs.

Conclusion (proposition de traduction) : Notre liste finale représente l'opinion des experts sur les compétences en échographie d'urgence pour les résidents en médecine d'urgence. Nous espérons utiliser cette liste de consensus pour mettre en œuvre un programme d'échographie d'urgence plus cohérent pour les résidents en médecine d'urgence et pour standardiser la formation en échographie d'urgence dans les programmes de résidence en médecine d'urgence.

See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine.
Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand TL, Goldman MP, Prieto MM, Wing R, Breuer RK, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. | AEM Educ Train. 2022 Dec 20;6(6):e10830
DOI: https://doi.org/10.1002/aet2.10830
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees.

Méthode : This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods.

Résultats : There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods.

Conclusion : The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.

Conclusion (proposition de traduction) : La pandémie de COVID-19 a conduit à des changements institutionnels en pédiatrie dans les protocoles de gestion des voies aériennes et a entraîné une diminution des possibilités d'intubation pour les résidents en pédiatrie et les boursiers en médecine d'urgence pédiatrique, sans changement apparent des résultats sur le plan clinique.

Commentaire : See one, do one, teach one ! (regarde une fois, fait une fois puis apprend à quelqu’un d’autre) : principe de l’apprentissage par compagnonnage bienveillant et souvent enrichi émotionnellement avec l'acquisition des compétences techniques requises pour la pratique de la spécialité « sur le terrain raquo;.

Early Vasopressor Utilization Strategies and Outcomes in Critically Ill Patients With Severe Traumatic Brain Injury.
Toro C, Ohnuma T, Komisarow J, Vavilala MS, Laskowitz DT, James ML, Mathew JP, Hernandez AF, Goldstein BA, Sampson JH, Krishnamoorthy V. | Anesth Analg. 2022 Dec 1;135(6):1245-1252
DOI: https://doi.org/10.1213/ane.0000000000005949  | Télécharger l'article au format  
Keywords: Aucun

Original Clinical Research Report

Introduction : Early hypotension after severe traumatic brain injury (sTBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors, commonly norepinephrine and phenylephrine, to support blood pressure after TBI. However, guidelines do not specify vasopressor type, resulting in variation in clinical practice. We describe early vasopressor utilization patterns in critically ill patients with TBI and examine the association between utilization of norepinephrine, compared to phenylephrine, with hospital mortality after sTBI.

Méthode : We conducted a retrospective cohort study of US hospitals participating in the Premier Healthcare Database between 2009 and 2018. We examined adult patients (>17 years of age) with a primary diagnosis of sTBI who were treated in an intensive care unit (ICU) after injury. The primary exposure was vasopressor choice (phenylephrine versus norepinephrine) within the first 2 days of hospital admission. The primary outcome was in-hospital mortality. Secondary outcomes examined included hospital length of stay (LOS) and ICU LOS. We conducted a post hoc subgroup analysis in all patients with intracranial pressure (ICP) monitor placement. Regression analysis was used to assess differences in outcomes between patients exposed to phenylephrine versus norepinephrine, with propensity matching to address selection bias due to the nonrandom allocation of treatment groups.

Résultats : From 2009 to 2018, 24,718 (37.1%) of 66,610 sTBI patients received vasopressors within the first 2 days of hospitalization. Among these patients, 60.6% (n = 14,991) received only phenylephrine, 10.8% (n = 2668) received only norepinephrine, 3.5% (n = 877) received other vasopressors, and 25.0% (n = 6182) received multiple vasopressors. In that time period, the use of all vasopressors after sTBI increased. A moderate degree of variation in vasopressor choice was explained at the individual hospital level (23.1%). In propensity-matched analysis, the use of norepinephrine compared to phenylephrine was associated with an increased risk of in-hospital mortality (OR, 1.65; CI, 1.46-1.86; P < .0001).

Conclusion : Early vasopressor utilization among critically ill patients with sTBI is common, increasing over the last decade, and varies across hospitals caring for TBI patients. Compared to phenylephrine, norepinephrine was associated with increased risk of in-hospital mortality in propensity-matched analysis. Given the wide variation in vasopressor utilization and possible differences in efficacy, our analysis suggests the need for randomized controlled trials to better inform vasopressor choice for patients with sTBI.

Conclusion (proposition de traduction) : L'utilisation précoce de vasopresseurs chez les patients grièvement blessés à la suite d'un traumatisme cérébral sévère est courante, en augmentation au cours de la dernière décennie, et varie d'un hôpital à l'autre pour les patients souffrant d'un traumatisme cérébral sévère. Comparée à la phényléphrine, la noradrénaline a été associée à un risque accru de mortalité hospitalière dans une analyse par appariement de propension. Étant donné la grande variation dans l'utilisation des vasopresseurs et les différences possibles dans l'efficacité, notre analyse suggère la nécessité d'essais contrôlés randomisés pour mieux informer le choix des vasopresseurs pour les patients souffrant d'un traumatisme cranio-cérébral.

Managing Temporomandibular Joint Dislocations.
Gottlieb M, Long B. | Ann Emerg Med. 2022 Dec;80(6):539-547
DOI: https://doi.org/10.1016/j.annemergmed.2022.05.031
Keywords: Aucun

General Medicine

Editorial : Temporomandibular joint (TMJ) dislocation is an important condition to diagnose and manage in the emergency department (ED), with a lifetime prevalence of 5% to 8% and an estimated incidence approaching 25 out of 100,000 people per year. The TMJ is a hinge and gliding joint with a dense fibrocartilaginous disc lying between the condyle and glenoid fossa. Dislocation occurs when the condylar process of the mandible is displaced from its normal location in the glenoid fossa of the temporal bone and becomes locked in an abnormal position, resulting in muscle spasm and preventing mouth closure

Conclusion : After the reduction is complete, assess for adequate reduction and complications. The most common complication of an acute TMJ dislocation is instability with recurrent dislocation. Iatrogenic complications can include fracture or ligamentous injury due to the force required for reduction. Therefore, postreduction imaging (eg, panoramic radiography, maxillofacial CT) is recommended to confirm the reduction and assess for any associated fractures. Clinicians should apply a bandage around the patient’s head and mandible (ie, Barton bandage). A rigid cervical collar may also be used after reduction to provide support along the mandible. If reduction is unsuccessful after several attempts or frequently redislocates, an oral and maxillofacial specialist should be consulted. After reduction and bandage application, the clinician should provide several important instructions to the patient. These instructions can assist with symptom control after reduction and reduce the risk of recurrent dislocation. Patients should follow up with an oral and maxillofacial specialist within 2 to 3 days.

Conclusion (proposition de traduction) : Une fois la réduction terminée, évaluez si la réduction est correcte et s'il y a des complications. La complication la plus fréquente d'une luxation aiguë de l'articulation temporomandibulaire est l'instabilité avec luxation récidivante. Les complications iatrogènes peuvent inclure une fracture ou une lésion ligamentaire due à la force requise pour la réduction. Il est donc recommandé de procéder à une imagerie post-réduction (par exemple, radiographie panoramique, tomographie maxillo-faciale) pour confirmer la réduction et évaluer toute fracture associée. Les cliniciens doivent appliquer un bandage autour de la tête et de la mandibule du patient (c'est-à-dire un bandage de Barton). Un collier cervical rigide peut également être utilisé après la réduction pour fournir un soutien prolongé de la mandibule. Si la réduction échoue après plusieurs tentatives ou si le patient se reluxe fréquemment, il faut consulter un spécialiste ORL et maxillo-faciale. Après la réduction et l'application du bandage, le clinicien doit donner plusieurs instructions importantes au patient. Ces instructions peuvent aider à contrôler les symptômes après la réduction et réduire le risque de luxation récidivante. Les patients doivent être suivis par un spécialiste ORL et maxillo-faciale dans les 2 à 3 jours.

Commentaire :  Technique bimanuelle traditionnelle

Bandage Barton

Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation.
Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. | Ann Emerg Med. 2022 Dec;80(6):485-496
DOI: https://doi.org/10.1016/j.annemergmed.2022.05.002  | Télécharger l'article au format  
Keywords: Aucun

Pediatric

Introduction : Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm.

Méthode : Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities.

Résultats : We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%).

Conclusion : We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.

Conclusion (proposition de traduction) : Nous avons trouvé des associations plus importantes de laryngospasme lors de sédation procédurale en pédiatrie avec de multiples paramètres biologiques, types de procédures et traitements médicamenteux. Cependant, les estimations de ces effets montrent que la prévalence du laryngospasme reste faible, ce qui doit être pris en compte lors de la prise de décision quant à la sédation.

The effect of 20 minutes of cool running water first aid within three hours of thermal burn injury on patient outcomes: A systematic review and meta-analysis.
Griffin B, Cabilan CJ, Ayoub B, Xu HG, Palmieri T, Kimble R, Singer Y. | Australas Emerg Care. 2022 Dec;25(4):367-376
DOI: https://doi.org/10.1016/j.auec.2022.05.004
Keywords: Burns; Cool running water; First aid; First responders; Thermal injury.

Full length article

Introduction : Burn injuries are a leading cause of morbidity that can result in devastating disability and poor quality of life for survivors. This systematic review aimed to synthesise evidence regarding the effect of 20 minutes of cool running water (CRW) within three hours of injury on outcomes of patients with thermal burn injuries.

Méthode : This systematic review was conducted in reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Multiple databases (PubMed, EMBASE, CENTRAL, CINAHL Complete via EBSCO, PROQUEST Dissertations and Theses), and the Australia New Zealand Clinical Trial Registry were searched for eligible studies published in English and Chinese, without date restriction. Meta-analyses were undertaken Methodological quality of studies was assessed by using Downs and Black Checklist.

Résultats : Of 323 records, seven studies were included. The majority (67%) of studies were conducted in Australia and New Zealand. The methodological quality was ranked between 'fair' and 'good'. Twenty minutes of CRW within the first three hours of burn injury significantly decreased the odds of patients requiring skin grafting and surgical intervention for wound management.

Conclusion : There is considerable evidence suggesting the application of 20 min of CRW within the first three hours of injury improves outcomes for patients with burn injury. Consensus between burn organisations and collaborative efforts to translate evidence into practice are needed to optimise burn first aid care which can improve patient outcomes globally.

Conclusion (proposition de traduction) : Il existe de nombreuses preuves suggérant que l'application de 20 minutes d'eau fraîche courante dans les trois premières heures de la blessure améliore les résultats des patients brûlés. Un consensus entre les organisations de brûlés et des efforts de collaboration pour traduire les preuves en pratique sont nécessaires pour optimiser les soins de premiers secours aux brûlés, ce qui peut améliorer les résultats pour les patients dans le monde entier.

Emergency department crowding negatively influences outcomes for adults presenting with asthma: a population-based retrospective cohort study.
Huang Y, Ortiz SS, Rowe BH, Rosychuk RJ. | BMC Emerg Med. 2022 Dec 24;22(1):209
DOI: https://doi.org/10.1186/s12873-022-00766-7  | Télécharger l'article au format  
Keywords: Administrative data; Asthma; Crowding metrics; Emergency department; Length of stay; Time to physician initial assessment.

Research

Introduction : Access to emergency department (ED) services is important for patients with acute asthma; however, ED crowding may impact the quality of care and compromise outcomes. We examine the association between ED crowding metrics and individual patient outcomes for adults presenting with asthma.

Méthode : This population-based retrospective cohort study extracted all ED presentations made by patients aged 18 to 55 years to 18 high-volume EDs in Alberta from April 2014 to March 2019. Physician initial assessment (PIA) time and ED length of stay (LOS) for discharged and admitted patients were calculated. Other metrics and patient outcomes were also obtained. Linear and generalized linear models were fit for continuous and categorical outcomes. Cox proportional hazards models were used for time-to-event outcomes.

Résultats : There were 17,724 ED presentations by 12,569 adults. The median age was 33 years, and females (58.7%) made more presentations. ED crowding affected the PIA time for all triage groups. For the high acuity group (Canadian Triage and Acuity Scale [CTAS] 1/2), 1 h increase in median facility-specific PIA was associated with 26 min (95%CI: 24,28) increase; for the moderate acuity (CTAS 3) and low acuity (CTAS 4/5) groups, the individual-level PIA increased by 54 min (95%CI: 53,55) and 61 min (95%CI: 59,63), respectively adjusted by other predictors. Increases in facility PIA resulted in increase in odds of admissions for the high acuity group and increase odds of left without completion of care for the moderate and low acuity groups.

Conclusion : The care provided for patients from all triage groups was impacted when EDs experienced crowding. Effective interventions are needed to mitigate ED crowding and improve care and outcomes for this important patient group.

Conclusion (proposition de traduction) : Les soins prodigués aux patients de tous les sous-groupes de triage sont influencés par l'encombrement des urgences. Des interventions concrètes sont nécessaires pour atténuer la surcharge des urgences et améliorer les soins et le devenir de cet important groupe de patients.

Shorter laboratory turnaround time is associated with shorter emergency department length of stay: a retrospective cohort study.
Vrijsen BEL, Haitjema S, Westerink J, Hulsbergen-Veelken CAR, van Solinge WW, Ten Berg MJ. | BMC Emerg Med. 2022 Dec 21;22(1):207
DOI: https://doi.org/10.1186/s12873-022-00763-w  | Télécharger l'article au format  
Keywords: Clinical laboratory techniques; Hospital emergency services.; Length of stay.

Research article

Introduction : A longer emergency department length of stay (EDLOS) is associated with poor outcomes. Shortening EDLOS is difficult, due to its multifactorial nature. A potential way to improve EDLOS is through shorter turnaround times for diagnostic testing. This study aimed to investigate whether a shorter laboratory turnaround time (TAT) and time to testing (TTT) were associated with a shorter EDLOS.

Méthode : A retrospective cohort study was performed, including all visits to the emergency department (ED) of an academic teaching hospital from 2017 to 2020 during which a standardized panel of laboratory tests had been ordered. TTT was calculated as the time from arrival in the ED to the ordering of laboratory testing. TAT was calculated as the time from test ordering to the reporting of the results, and was divided into a clinical and a laboratory stage. The outcome was EDLOS in minutes. The effect of TTT and TAT on EDLOS was estimated through a linear regression model.

Résultats : In total, 23,718 ED visits were included in the analysis. Median EDLOS was 199.0 minutes (interquartile range [IQR] 146.0-268.0). Median TTT was 7.0 minutes (IQR 2.0-12.0) and median TAT was 51.1 minutes (IQR 41.1-65.0). Both TTT and TAT were positively associated with EDLOS. The laboratory stage comprised a median of 69% (IQR 59-78%) of total TAT.

Conclusion : Longer TTT and TAT are independently associated with longer EDLOS. As the laboratory stage predominantly determines TAT, it provides a promising target for interventions to reduce EDLOS and ED crowding.

Conclusion (proposition de traduction) : L'allongement du délai de réalisation des analyses et du délai d'exécution sont indépendamment associés à une durée de séjour plus longue aux urgences. Comme les délais d'exécution sont principalement déterminés par l'étape du laboratoire, celle-ci constitue une cible potentielle pour les interventions visant à réduire la durée du séjour aux urgences et l'encombrement de celles-ci.

FRENCH versus ESI: comparison between two nurse triage emergency scales with referent scenarios.
Aubrion A, Clanet R, Jourdan JP, Creveuil C, Roupie E, Macrez R. | BMC Emerg Med. 2022 Dec 12;22(1):201
DOI: https://doi.org/10.1186/s12873-022-00752-z  | Télécharger l'article au format  
Keywords: ESI; Emergency medicine classification; Emergency nursing; FRENCH scale; Triage.

Research article

Introduction : Acute triage is needed to prioritize care and achieve optimal resource allocation in busy emergency departments. The main objective is to compare the FRench Emergency Nurse Classification in Hospital scale (FRENCH) to the American scale Emergency Severity Index (ESI). Secondary objectives are to compare for each scale the over and under-triage, the triage matching to the gold standard and the inter-individual sorting reproducibility between the nurses.

Méthode : This is a prospective observational study conducting among the nursing staffs and nursing students, selected from Caen University College Hospital and Lisieux Hospital Center emergency departments between two months. Each group individually rank 60 referent clinical cases composed by scales designers. An assessment of scale practicality is collected after for each tool. The collected parameters are analyzed by a Cohen kappa concordance test (κ).

Résultats : With 8151 triage results of gold standard scenarios sorting in two scales by the same nurses, the FRENCH scale seems to give better triage results than the US ESI scale (nurse: FRENCH 60% and ESI 53%, p = 0.003 ; nursing students: FRENCH 49% and ESI 42%, p < 0.001). In the two groups ESI has also a big tendency to under-sort (p = 0.01), particularly for the most severe patients (p < 0.01). The interobserver sorting concordance for any experience gives good results for the FRENCH and the ESI without any difference (nurses : FRENCH K_PQ=0.72 ESI K_PQ=0.78; p = 0.32 ; students K_PQ=0.44 K_PQ=0.55; p = 0.22).

Conclusion : The ESI and FRENCH scales comparison on 8151 sorting results shows direct validity in favor of FRENCH one and similar interobserver agreement for both scales.

Conclusion (proposition de traduction) : La comparaison des échelles ESI et FRENCH sur 8151 résultats de triage montre une validité directe en faveur de l'échelle FRENCH et un accord inter-observateur similaire pour les deux échelles.

Factors associated with unfavorable outcomes in patients with acute abdominal pain visiting the emergency department.
Dadeh AA | BMC Emerg Med. 2022 Dec 6;22(1):195
DOI: https://doi.org/10.1186/s12873-022-00761-y  | Télécharger l'article au format  
Keywords: Acute abdominal pain; Emergency department; Invasive procedure; Unfavorable outcome.

Research

Introduction : Unfavorable outcomes occur in patients with acute abdominal pain who visit the emergency department (ED). We aimed to determine the factors associated with unfavorable outcomes in patients with acute abdominal pain visiting the ED.

Méthode : This retrospective cohort study was conducted from July 1, 2015 to June 30, 2016. The inclusion criterion was patients aged older than 18 years who presented to the ED with acute abdominal pain. Significant factors associated with unfavorable outcomes were examined using univariate and multivariate logistic regression analyses.

Résultats : A total of 951 patients were included in the study. Multivariate logistic regression analysis showed that the ED length of stay (EDLOS) > 4 h (adjusted odds ratio (AOR) 2.62, 95% confidence interval [CI]: 1.33-5.14; p = 0.005), diastolic blood pressure (DBP) < 80 mmHg (AOR 3.31, 95% CI: 1.71-6.4; p ≤ 0.001), respiratory rate ≥ 24 breaths/min (AOR 2.03, 95% CI: 1.07-3.86; p ≤ 0.031), right lower quadrant (RLQ) tenderness (AOR 3.72, 95% CI: 1.89-7.32; p ≤ 0.001), abdominal distension (AOR 2.91, 95% CI: 1.29-6.57; p = 0.010), hypoactive bowel sounds (AOR 2.89, 95% CI: 1.09-7.67; p = 0.033), presence of specific abdominal signs (AOR 2.07, 95% CI: 1.1-3.88; p = 0.024), white blood cell count ≥ 12,000 cells/mm³ (AOR 2.37, 95% CI: 1.22-4.6; p = 0.011), and absolute neutrophil count (ANC) > 75% (AOR 2.83, 95% CI: 1.39-5.75; p = 0.004) were revealed as significant factors associated with unfavorable outcomes.

Conclusion : The present study revealed that the significant clinical signs associated with the occurrence of unfavorable outcomes were DBP < 80 mmHg, tachypnea (≥ 24 breaths/min), RLQ tenderness, abdominal distension, hypoactive bowel sounds, and presence of specific abdominal signs. Moreover, the associated laboratory results identified in this study were leukocytosis and ANC > 75%. Additionally, patients with abdominal pain visiting the ED who had an EDLOS longer than 4 h were associated with unfavorable outcomes.

Conclusion (proposition de traduction) : La présente étude a révélé que les signes cliniques significatifs associés à la survenue d'issues défavorables étaient une pression artérielle diastolique < 80 mmHg, une tachypnée (≥ 24 respirations/min), une sensibilité de la fosse iliaque droit, une distension abdominale, des bruits intestinaux atténués et la présence de signes abdominaux spécifiques. En outre, les résultats de laboratoire associés identifiés dans cette étude étaient une hyperleucocytose et une numération absolue des neutrophiles > 75 %. En outre, les patients souffrant de douleurs abdominales se rendant aux urgences et dont la durée de séjour aux urgences était supérieure à 4 heures étaient associés à des résultats défavorables.

Is prehospital intubation of severely injured children in accordance with guidelines?.
Maek T, Fochtmann U, von Loewenich A, Jungbluth P, Zimmermann W, Lefering R, Lendemans S, Hussmann B. | BMC Emerg Med. 2022 Dec 6;22(1):194
DOI: https://doi.org/10.1186/s12873-022-00750-1  | Télécharger l'article au format  
Keywords: Multivariate regression analysis; Outcome; Prehospital intubation severely injured children; Trauma registry.

Research

Introduction : The current German S3 guideline for polytrauma lists five criteria for prehospital intubation: apnea, severe traumatic brain injury (GCS ≤8), severe chest trauma with respiratory failure, hypoxia, and persistent hemodynamic instability. These guideline criteria, used in adults in daily practice, have not been previously studied in a collection of severely injured children. The aim of this study was to assess the extent to which the criteria are implemented in clinical practice using a multivariate risk analysis of severely injured children.

Méthode : Data of 289,698 patients from the TraumaRegister DGU® were analyzed. Children meeting the following criteria were included: Maximum Abbreviated Injury Scale 3+, primary admission, German-speaking countries, years 2008-2017, and declaration of intubation. Since children show age-dependent deviating physiology, four age groups were defined (years old: 0-2; 3-6; 7-11; 12-15). An adult collective served as a control group (age: 20-50). After a descriptive analysis in the first step, factors leading to prehospital intubation in severely injured children were analyzed with a multivariate regression analysis.

Résultats : A total of 4489 children met the inclusion criteria. In this cohort, young children up to 2 years old had the significantly highest injury severity (Injury Severity Score: 21; p ≤ 0.001). Falls from both high (> 3 m) and low heights (< 3 m) were more common in children than in adults. The same finding applied to the occurrence of severe traumatic brain injury. When at least one intubation criterion was formally present, the group up to 6 years old was least likely to actually be intubated (61.4%; p ≤ 0.001). Multivariate regression analysis showed that Glasgow Coma Scale score ≤ 8 in particular had the greatest influence on intubation (odds ratio: 26.9; p ≤ 0.001).

Conclusion : The data presented here show for the first time that the existing criteria in the guideline for prehospital intubation are applied in clinical practice (approximately 70% of cases), compared to adults, in the vast majority of injured children. Although severely injured children still represent a minority of all injured patients, future guidelines should focus more on them and address them in a specialized manner.

Conclusion (proposition de traduction) : Les données présentées ici montrent pour la première fois que les directives actuelles d'intubation préhospitalière sont appliquées dans la pratique clinique (environ 70 % des cas), par rapport aux adultes, dans la grande majorité des enfants blessés. Bien que les enfants gravement blessés représentent encore une minorité de tous les patients blessés, les futures lignes directrices devraient se concentrer davantage sur eux et les traiter de manière spécialisée.

Modified chair method: an easy and efficient reduction method without medication for anterior shoulder dislocation.
Ge Y, Yang M, Gao F, Peng W, Wu X. | BMC Emerg Med. 2022 Dec 5;22(1):19
DOI: https://doi.org/10.1186/s12873-022-00757-8  | Télécharger l'article au format  
Keywords: Anterior shoulder dislocation; Chair method; Closed reduction.

Research

Introduction : Various maneuvers have been introduced to address anterior shoulder dislocations. Chair method allows the patient to sit comfortably and feel less pain during the reduction procedure. However, the rarity of comparative studies led to a lack of evidence to popularize. The present study aimed to introduce a modified chair (MOC) reduction method for anterior shoulder dislocation and explore its effectiveness compared with the traditional Hippocratic approach.

Méthode : This is a single-center retrospective study of 257 patients with anterior shoulder dislocation from September 2020 and July 2021. Patients were divided into two groups according to the reduction method they received (either the Hippocratic method or the MOC method). Success rate, reduction time, visual analog scale (VAS) pain score, satisfaction level, and a new indicator, pain index (reduction time (s)* VAS/ 10), were compared.

Résultats : One hundred sixteen patients (43 females, 73 males) underwent the Hippocratic method, and 141 (65 females, 76 males) MOC method. A significantly higher success rate was seen in the MOC group (96.5%(136/141) vs. 84.5%(98/116) in the Hippocratic group; OR 5, 95%CI 1.79 ~ 13.91; p = 0.002). Pain index of the patients in the MOC group was much lower than that in the Hippocratic group (3.20 (2.10, 4.53) vs. 36.70 (22.40, 47.25), p < 0.001). The reduction time, VAS pain score, and satisfaction level also favored the MOC method.

Conclusion : The MOC method is an easy and efficient reduction method with minimum assistance for anterior shoulder dislocations. Physicians can skillfully perform this procedure with the help of their body weight. The MOC method could be attempted for shoulder dislocations in the emergency department.

Conclusion (proposition de traduction) : La méthode de la chaise modifiée est une méthode de réduction facile et efficace avec une intervention minimale dans les luxations antérieures de l'épaule. Les médecins peuvent exécuter facilement cette procédure en s'appuyant sur le poids de leur corps. La méthode du fauteuil modifié peut être utilisée pour les luxations de l'épaule dans les services d'urgence.

Commentaire :  Méthode de réduction de la luxation de l'épaule par la technique de la chaise modifiée.

Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis.
Sithamparapillai A, Grewal K, Thompson C, Walsh C, McLeod S. | CJEM. 2022 Dec;24(8):809-819
DOI: https://doi.org/10.1007/s43678-022-00368-z  | Télécharger l'article au format  
Keywords: Emergency department; Lidocaine; Sedation; Shoulder dislocation.

Original Research

Introduction : Anterior shoulder dislocations are commonly treated in the emergency department (ED). Analgesia for reduction is provided by intra-articular lidocaine (IAL) injection or intravenous sedation (IV sedation). The objective of this systematic review and meta-analysis was to compare IAL versus IV sedation for closed reduction of acute anterior shoulder dislocation in the ED.

Méthode : Electronic searches of MEDLINE and EMBASE (1946-September 2021) were completed and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing IAL and IV sedation for reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED were included. Outcomes of interest included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost. Two reviewers independently screened abstracts, assessed study quality and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) with 95% confidence intervals (CIs).

Résultats : 12 RCTs were included with a total of 630 patients (IAL = 327; IV sedation = 303). There was no difference in reduction success between IAL and IV sedation (RR 0.93; 95% CI 0.86-1.01, I₂ = 69%), significantly lower adverse events with IAL (RR 0.16; 95% CI 0.07-0.33, I₂ = 0%), shorter ED length of stay with IAL (mean difference - 1.48; 95% CI - 2.48 to - 0.47, I₂ = 93%), no difference in pain scores post-analgesia and no difference in ease of reduction.

Conclusion : ntra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction. Intra-articular lidocaine may be an effective alternative to IV sedation for reducing anterior shoulder dislocations, particularly when IV sedation is contraindicated or not feasible.

Conclusion (proposition de traduction) : La lidocaïne intra-articulaire peut être aussi efficace que la sédation intraveineuse pour réduire avec succès les luxations antérieures de l'épaule aux urgences, avec moins d'effets indésirables, une durée de séjour aux urgences plus courte et aucune différence dans les scores de douleur ou la facilité de réduction. La lidocaïne intra-articulaire peut être une alternative efficace à la sédation IV pour réduire les luxations antérieures de l'épaule, en particulier lorsque la sédation IV est contre-indiquée ou non réalisable.

Commentaire : Anesthésie intra-articulaire - luxation antérieure de l’épaule.
Xylocaïne 1 % injection sous-acromiale (20 ml) 15 minutes avant le geste (+/_ morphine titrée 2 à 3 mg toutes les 5 min) :
• Le site d'insertion de l'aiguille est environ 2 cm en dessous du bord latéral du processus acromial (dans la dépression créée par l'absence de la tête humérale).
• Frotter la zone avec une solution antiseptique et laisser la solution antiseptique sécher pendant au moins 1 minute.
•  Insérer l'aiguille intra-articulaire perpendiculairement à la peau, appliquer une contre-pression sur le piston de la seringue et faire avancer l'aiguille médialement et légèrement en bas d'environ 2 cm.

Si du sang est aspiré de l'articulation, maintenir l'embase de l'aiguille immobile, passer à une seringue vide, aspirer tout le sang et ré-attacher la seringue anesthésique.
• Injecter 10 à 20 mL de solution anesthésique (lidocaïne à 1%).
• Attendre que l'analgésie se produise (jusqu'à 15 à 20 minutes) avant de poursuivre.

Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department.
Liu S, McLeod SL, Atzema CL, Austin PC, de Wit K, Sharma S, Mittmann N, Borgundvaag B, Grewal K. | CJEM. 2022 Dec;24(8):853-861
DOI: https://doi.org/10.1007/s43678-022-00392-z
Keywords: Anticoagulation; Delayed intracranial hemorrhage; Emergency medicine; Head injury.

Original Research

Introduction : Elderly patients on oral anticoagulation are commonly seen in emergency departments (EDs). Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. Data on delayed bleeds in anticoagulated patients are limited. The objective of this study was to examine risk of delayed intracranial hemorrhage in patients presenting to the ED with a head injury anticoagulated with warfarin or a direct oral anticoagulant, compared to patients not anticoagulated.

Méthode : Cohort study using administrative data from Ontario of patients ≥ 65 years presenting to the ED with a complaint of head injury between 2016 and 2018. The primary outcome was delayed intracranial hemorrhage, defined as a new ICD-10 code for intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed. The main exposure variable was oral anticoagulation use, which was a three-level variable (warfarin, direct oral anticoagulants, or no oral anticoagulation). We used multivariable logistic regression to determine the odds of delayed intracranial hemorrhage based on anticoagulation status.

Résultats : 69,321 patients were included: 58,233 (84.0%) had not been prescribed oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant prescription. Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients not anticoagulated, 586 (1.0%) had a delayed intracranial hemorrhage, 54 (1.8%) patients on warfarin, and 78 (1.0%) patients on a direct oral anticoagulant had a delayed intracranial hemorrhage. There was an increased odds of delayed intracranial hemorrhage with warfarin use compared with no anticoagulation (OR 1.5, 95% CI 1.1-2.1). There was no association between delayed intracranial hemorrhage and direct oral anticoagulant use compared to no anticoagulation (OR 0.9, 95% CI 0.6-1.1).

Conclusion : There was an increased odds of delayed intracranial hemorrhage within 90 days in older ED head injured patients prescribed warfarin compared to patients not on anticoagulation. direct oral anticoagulant use was not associated with increased risk of delayed intracranial hemorrhage.

Conclusion (proposition de traduction) : e risque d'hémorragie intracrânienne tardive dans les 90 jours était plus élevé chez les patients âgés victimes d'un traumatisme crânien vus aux urgences et à qui l'on avait prescrit de la warfarine que chez ceux qui n'étaient pas sous anticoagulation. L'utilisation d'anticoagulants oraux directs (AOD) n'était pas associée à un risque accru d'hémorragie intracrânienne tardive.

Isselbacher EM, Preventza O, Hamilton Black J 3rd, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A Jr, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. | Circulation. 2022 Dec 13;146(24):e334-e482
DOI: https://doi.org/10.1161/cir.0000000000001106  | Télécharger l'article au format  
Keywords: AHA Scientific Statements; Loeys-Dietz syndrome; Marfan syndrome; abdominal aortic aneurysm; aortic dissection; aortitis; aortopathy; bicuspid aortic valve; blunt traumatic aortic injury; cardiac surgery; endovascular aortic repair; guidelines; heritable thoracic aortic disease; intramural hematoma; malperfusion syndrome; penetrating atherosclerotic ulcer; thoracic aortic aneurysm; thoracic endovascular aortic repair; thoracoabdominal aortic aneurysm; vascular surgery.

Practice Guidelines

Introduction : he "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

Méthode : A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Conclusion : TOP 10 TAKE-HOME MESSAGES FOR THE DIAGNOSIS AND MANAGEMENT OF AORTIC DISEASE
1. Because outcomes for patients with aortic disease are enhanced at programs with higher volumes, experienced practitioners, and extensive management capabilities, Multidisciplinary Aortic Team care is considered in determining the appropriate timing of intervention.
2. Shared decision-making involving the patient and a multidisciplinary team is highly encouraged to determine the optimal medical, endovascular, and open surgical therapies. In patients with aortic disease who are contemplating pregnancy or who are pregnant, shared decision-making is especially important when considering the cardiovascular risks of pregnancy, the diameter thresholds for prophylactic aortic surgery, and the mode of delivery.
3. Computed tomography, magnetic resonance imaging, and echocardiographic imaging of patients with aortic disease should follow recommended approaches for image acquisition, measurement and reporting of relevant aortic dimensions, and the frequency of surveillance before and after intervention.
4. At centers with Multidisciplinary Aortic Teams and experienced surgeons, the threshold for surgical intervention for sporadic aortic root and ascending aortic aneurysms has been lowered from 5.5 cm to 5.0 cm in selected patients, and even lower in specific scenarios among patients with heritable thoracic aortic aneurysms.
5. In patients who are significantly smaller or taller than average, surgical thresholds may incorporate indexing of the aortic root or ascending aortic diameter to either patient body surface area or height, or aortic cross-sectional area to patient height.
6. Rapid aortic root growth or ascending aortic aneurysm growth, an indication for intervention, is defined as ≥0.5 cm in 1 year or ≥0.3 cm per year in 2 consecutive years for those with sporadic aneurysms and ≥0.3 cm in 1 year for those with heritable thoracic aortic disease or bicuspid aortic valve.
7. In patients undergoing aortic root replacement surgery, valve-sparing aortic root replacement is reasonable if the valve is suitable for repair and when performed by experienced surgeons in a Multidisciplinary Aortic Team.
8. Patients with acute type A aortic dissection, if clinically stable, should be considered for transfer to a high-volume aortic center to improve survival. The operative repair of type A aortic dissection should entail at least an open distal anastomosis r

Conclusion (proposition de traduction) : LES 10 PRINCIPAUX MESSAGES À RETENIR POUR LE DIAGNOSTIC ET LA PRISE EN CHARGE DE LA MALADIE AORTIQUE
1. Étant donné que les résultats pour les patients présentant un syndrome aortique sont meilleurs dans les programmes ayant des volumes plus importants, des praticiens expérimentés et des capacités de gestion étendues, les soins de l'équipe multidisciplinaire de l'aorte sont pris en compte pour déterminer le moment approprié de l'intervention.
2. La prise de décision partagée impliquant le patient et une équipe multidisciplinaire est fortement encouragée pour déterminer les traitements médicaux, endovasculaires et chirurgicales à ciel ouvert optimaux. Chez les patientes présentant un syndrome aortique qui envisagent une grossesse ou qui sont enceintes, la prise de décision partagée est particulièrement importante lorsqu'il s'agit de prendre en compte les risques cardiovasculaires de la grossesse, les seuils de diamètre pour la chirurgie aortique prophylactique et le mode d'accouchement.
3. La tomodensitométrie, l'imagerie par résonance magnétique et l'échocardiographie des patients présentant un syndrom aortique doivent suivre les approches recommandées pour l'acquisition des images, la mesure et le compte rendu des dimensions aortiques pertinentes et la fréquence de la surveillance avant et après l'intervention.
4. Dans les centres dotés d'équipes multidisciplinaires sur l'aorte et de chirurgiens expérimentés, le seuil d'intervention chirurgicale pour les anévrismes sporadiques de la racine de l'aorte et de l'aorte ascendante a été abaissé de 5,5 cm à 5,0 cm chez certains patients, et même plus bas dans des scénarios spécifiques chez les patients atteints d'anévrismes thoraciques héréditaires.
5. Chez les patients nettement plus petits ou plus grands que la moyenne, les seuils chirurgicaux peuvent intégrer l'indexation du diamètre de la racine aortique ou de l'aorte ascendante sur la surface corporelle ou la taille du patient, ou de la surface de la section aortique sur la taille du patient.
6. Une croissance rapide de la racine aortique ou de l'anévrisme de l'aorte ascendante, une indication d'intervention, est définie comme ≥ 0,5 cm en 1 an ou ≥ 0,3 cm par an pendant 2 années consécutives pour ceux qui ont des anévrismes sporadiques et ≥ 0,3 cm en 1 an pour ceux qui ont une maladie thoracique héréditaire de l'aorte ou une valve aortique bicuspide.
7. Chez les patients subissant une chirurgie de remplacement de la racine

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.
Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Cae. | Circulation. 2022 Dec 20;146(25):e483-e557
DOI: https://doi.org/10.1161/cir.0000000000001095  | Télécharger l'article au format  
Keywords: AHA Scientific Statements; advanced life support; basic life support; cardiac arrest; first aid; infant, newborn; pediatrics; resuscitation.

ILCOR SUMMARY STATEMENT

Editorial : This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Evidence-based work up and management of non-specific neck pain in the emergency department.
Siu V, Lin S, Milan Sivakumar M, Varkey TC. | Emerg Care J. 2022 Dec;18:10929
DOI: https://doi.org/10.4081/ecj.2022.10929  | Télécharger l'article au format  
Keywords: Neck pain; management; evidence based imaging; therapeutics; review article.

REVIEWS

Editorial : Neck pain has become a commonly encountered complaint inthe emergency department and primary care office. A large proportionof the population, ranging from a fifth (⅕) to a third (⅓) ofthe total, will experience non-specific neck pain in their lifetime.Because of the difficulty to quickly parse out the differential andthe severity of several of these diagnoses, it is imperative forphysicians in the emergency department to establish a systematicand effective approach for evaluating nonspecific neck pain. Thisarticle will present a standardized case of a patient presenting withnonspecific neck pain, critically analyze current evidence andguidelines from major ruling bodies in internal medicine, neurology,neurosurgery, and radiology, examine major statementsreleased by the Choosing Wisely Campaign and the AmericanCollege of Radiology, and propose a new diagnostic decision treefor the management of nonspecific neck pain.

Conclusion : Neck pain can quickly progress into a debilitating presence for many individuals and management of nonspecific neck pain in theemergency setting can often be challenging because of the widerange of potential diagnosis and their significance in becoming alife-threatening outcome for patients. Concerns for meningitis andencephalitis require immediate imaging workup and LP. Otherwise, symptom and pain control remain the best line of management.

Conclusion (proposition de traduction) : Les douleurs cervicales peuvent rapidement devenir invalidantes pour de nombreuses personnes. La prise en charge des douleurs cervicales non spécifiques aux urgences est souvent difficile en raison de l'éventail des diagnostics potentiels et de leur importance dans la mise en jeu de la vie des patients. Les craintes de méningite et d'encéphalite nécessitent un bilan d'imagerie et une PL immédiats. Sinon, le contrôle des symptômes et de la douleur reste la meilleure ligne de conduite.

Review article: Peripheral intravenous catheter insertion in adult patients with difficult intravenous access: A systematic review of assessment instruments, clinical practice guidelines and escalation pathways.
Paterson RS, Schults JA, Slaughter E, Cooke M, Ullman A, Kleidon TM, Keijzers G, Marsh N, Rickard CM. | Emerg Med Australas. 2022 Dec;34(6):862-870
DOI: https://doi.org/10.1111/1742-6723.14069  | Télécharger l'article au format  
Keywords: adults; clinical decision-making; inpatients; peripheral catheterization.

Review Article

Editorial : The optimal approach for peripheral intravenous catheter (PIVC) insertion in adult hospitalised patients with difficult intravenous access (DIVA) is unknown. The present study aimed to critically appraise the quality of (i) assessment instruments and (ii) clinical practice guidelines (CPGs) or escalation pathways for identifying and managing patients with DIVA. Cochrane Central Register of Controlled Trials, EBSCO MEDLINE, EMBASE (OVID) and EBSCO CINAHL databases were searched on 22 March 2021. Studies describing a DIVA assessment measure, CPG or escalation pathway for PIVC insertion in adults (≥18 years of age) were included. Data were extracted using a standardised data extraction form including study design, type of resource and reported clinical outcomes. Quality of DIVA assessment instruments were reviewed using the COnsensus-based Standards for the selection of health Measurement Instruments checklist. Methodological quality of CPGs and escalation pathways was assessed using the Appraisal of Guidelines for Research and Evaluation-II (AGREE-II) instrument. Overall, 24 DIVA resources comprising 16 DIVA assessment instruments and nine CPGs or escalation pathways (including one combined assessment instrument and escalation pathway) were identified. Instruments commonly focused on vein visibility and palpability as indicators of DIVA. CPGs and escalation pathways unanimously recommended use of vessel visualisation technology for patients with or suspected of DIVA. Methodological quality of the resources was mixed. Consensus and standardisation of resources to identify DIVA and recommendations for managing patients with DIVA is limited. Adopting consistent, evidence-based CPGs, escalation pathways or DIVA assessment instruments may significantly improve clinical outcomes.

Conclusion : There is limited international consensus and standardisation of resources to identify and manage patients with or at-risk of difficult PIVC insertion, however, the adoption of CPGs, escalation pathways or DIVA assessment instruments for patients with DIVA may improve clinical outcomes. Combined, the included resources demonstrated consensus of recommended use of USG PIVC insertion in patients with DIVA. Future research should evaluate the impact of implementing DIVA resources in clinical practice to improve patient care.

Conclusion (proposition de traduction) : Le consensus international et la standardisation des méthodes permettant d'identifier et de prendre en charge les patients présentant ou risquant de présenter des difficultés de pose de cathéter intraveineux périphérique sont limités. Toutefois, l'adoption de guides de pratique clinique, de procédures de recours ou d'instruments d'évaluation de l'accès intraveineux difficile pour les patients présentant des difficultés d'accès intraveineux peut améliorer les résultats cliniques. Dans l'ensemble, les documents inclus ont montré un consensus sur l'utilisation recommandée de la pose de cathéters intraveineux périphériques guidée par ultrasons chez les patients présentant des difficultés d'accès intraveineux. Les recherches futures devraient évaluer l'impact de la mise en œuvre des outils d'accès intraveineux difficile dans la pratique clinique afin d'améliorer les soins aux patients.

Keeping it simple: the value of mortality prediction after trauma with basic indices like the Reverse Shock Index multiplied by Glasgow Coma Scale.
Frieler S, Lefering R, Gerstmeyer J, Drotleff N, Schildhauer TA, Waydhas C, Hamsen U; TraumaRegister DGU. | Emerg Med J. 2022 Dec;39(12):912-917
DOI: https://doi.org/10.1136/emermed-2020-211091
Keywords: emergency ambulance systems; emergency care systems; major trauma management; pre-hospital; risk management.

PREDICTION

Introduction : Identification of trauma patients at significant risk of death in the prehospital setting is challenging. The prediction probability of basic indices like vital signs, Shock Index (SI), SI multiplied by age (SIA) or the GCS is limited and more complex scores are not feasible on-scene. The Reverse SI multiplied by GCS score (rSIG) has been proposed as a triage tool to identify trauma patients with an increased risk of dying at EDs. Age adjustment (rSIG/A) displayed no advantage.We aim to (1) validate the accuracy of the rSIG in predicting death or early transfusion in a large trauma registry population, and (2) determine if the rSIG is valid for evaluation of trauma patients in the prehospital setting.

Méthode : 70 829 trauma patients were retrieved from the TraumaRegister DGU database (time period between 2008 and 2017). The area under the receiver operating characteristic curve (AUROC) was calculated to measure the ability of SI, SIA, rSIG and rSIG divided by age (rSIG/A) to predict in-hospital mortality from data at the time of hospital arrival and solely from prehospital data.

Résultats : The rSIG at time of hospital admission was not sufficiently predictive for clinical decision-making. However, rSIG calculated solely from prehospital data accurately predicted risk of death. Using prehospital data, the AUROC for mortality of rSIG/A was the highest (0.85; CI: 0.85 to 0.86), followed by rSIG (0.76; CI: 0.75 to 0.77), SIA (0.71; CI: 0.70 to 0.71) and SI (0.48; CI: 0.47 to 0.49).

Conclusion : The prehospital rSIG/A can be a useful adjunct for the prehospital evaluation of trauma patients and their allocation to trauma centres or trauma team activation. However, we could not confirm that the rSIG at hospital admission is a reliable tool for risk stratification.

Conclusion (proposition de traduction) : Le score Shock Index inversé, pondéré du score de Glasgow rapporté à l'âge peut être un complément utile pour l'évaluation préhospitalière des patients victimes de traumatismes et leur transfert vers des centres de traumatologie ou l'activation de l'équipe de traumatologie. Cependant, nous n'avons pas pu confirmer que le score shock index inversé, pondéré du score de Glasgow à l'admission à l'hôpital est un outil fiable pour la stratification du risque.

Commentaire : • Shock Index (SI) = Fréquence cardiaque ÷ Pression Artérielle Systolique (FC/PAS) : le Shock Index ≥ 1, à une valeur pronostique en terme de mortalité chez les traumatisés graves, indique généralement un état de choc non compensé et la possible nécessité d'une réanimation.
• Shock Index ajusté sur l'âge (SIA) = Fréquence cardiaque ÷ Pression Artérielle Systolique : les valeurs seuils identifiés sont : SIA > 1,22 entre 4 et 6 ans, > 1,0 entre 7 et 12 ans et > 0,9 entre 13 et 16 ans (valeur adulte).
• Shock Index modifié par le score de Glasgow (SIA/G) = (Fréquence cardiaque ÷ Pression Artérielle Systolique)/score de Glasgow.

• Reverse Shock Index (rSI) = Pression Artérielle Systolique ÷ Fréquence cardiaque (PAS/FC) : le rSI <1 est associé à un mauvais résultat chez les patients traumatisés et permet d'identifier les patients présentant un risque élevé de mortalité, même en l'absence d'hypotension notable.
• Reverse SI multiplied by GCS score (rSIG) = (Pression Artérielle Systolique ÷ Fréquence cardiaque) x score de Glasgow.
• Age adjustment Reverse SI multiplied by GCS score (rSIG/A) = ((Pression Artérielle Systolique ÷ Fréquence cardiaque) x score de Glasgow) ÷ par l'âge.

Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly.
Ma Y, Mandell JC, Rocha T, Mendicuti MA, Weaver MJ, Khurana B. | Emerg Radiol. 2022 Dec;29(6):1009-1018
DOI: https://doi.org/10.1007/s10140-022-02090-w
Keywords: Diagnostic accuracy; Emergency radiology; Pelvic fractures; Pelvic radiographs.

Original Article

Introduction : Prompt identification of traumatic pelvic fractures in the elderly is critical to guide clinical management; however, the accuracy of pelvic radiographs is often compromised by multiple factors. The purpose of this study is to examine the diagnostic accuracy of radiographs for the detection of pelvic fractures, with CT as the standard of reference.

Méthode : A retrospective review was performed of patients ≥ 65 years with traumatic pelvic fractures evaluated with both pelvic radiography and computed tomography (CT) from May 2016 to October 2019. Pelvic fractures were classified into fractures of the pubis, ilium, ischium, sacrum, and acetabulum. All pelvic radiographs were independently reviewed by two emergency radiologists. Original CT reports were utilized for the reference standard.

Résultats : 177 patients were included, with a total of 555 fractures. The mean age was 81 years and 68% were female. The most common mechanism of injury was fall (62%), followed by motor vehicle accidents (18%). The most fractured bone was the pubis (314/555 fractures). Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity for the detection of pelvic fractures is classified by the following types: pubis 61%, acetabulum 60%, ilium 41%, sacrum 20%, and ischium 17%. Eighteen patients (10%) required surgical fixation. Mortality was 8%.

Conclusion : Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.

Conclusion (proposition de traduction) : Les radiographies pelviennes sont peu sensibles à la détection des fractures pelviennes traumatiques. Ces fractures radiographiquement occultes peuvent être cliniquement significatives en tant que cause de douleurs à long terme et peuvent nécessiter une consultation orthopédique et une éventuelle prise en charge chirurgicale.

Association between troponin and outcome in patients with chest pain and rapid atrial fibrillation: a retrospective study of a single-center 10-year cohort.
García A, Miota N, Miró Ò, López-Ayala P, López-Barbeito B, Strebel I, Xipell C, Fuenzalida C, Martínez-Nadal G, Boeddinghaus J, Nestelberger T, Twerenbold R, Mueller C, Coll-Vinent B. | Eur J Emerg Med. 2022 Dec 1;29(6):404-412
DOI: https://doi.org/10.1097/mej.0000000000000945
Keywords: Aucun

Original Article

Introduction : The prognosis of myocardial infarction in patients with rapid atrial fibrillation (RAF) is poorly known. We sought to ascertain if troponin concentrations are associated with a higher risk of major adverse cardiovascular events (MACE) in patients with RAF and chest discomfort suggestive of coronary origin.

Méthode : We retrospectively reviewed all consecutive patients attending an emergency department of a single-center (2008-2017) with chest pain suggestive of coronary origin who had RAF and at least one troponin determination. Patients were classified as having normal/increased troponin. They were followed until December 2019 to detect MACE (primary outcome), which included acute coronary syndrome (ACS), revascularization, stroke, or all-cause death. In addition to cardiovascular death and type I myocardial infarction, these were considered secondary outcomes. The adjusted risk was determined by Cox regression, and sensitivity analysis were run. Relationship between troponin as a continuous variable and outcomes was also evaluated, as well as interaction by sex.

Résultats : We included 574 patients (median = 76.5 years, IQR = 14, women 56.8%, increased troponin 34.1%) followed by a median of 3.8 years (IQR = 4.8). MACE occurred in 200 patients (34.8%). Increased troponin was independently associated with MACE (adjusted hazard ratio, 1.502, 95% CI, 1.130-1.998), ACS (adjusted hazard ratio, 2.488, 95% CI, 1.256-4.928), type I myocardial infarction (adjusted hazard ratio, 2.771, 95% CI, 1.212-6.333) and stroke (adjusted hazard ratio, 3.580, 95% CI, 1.888-6.787) but not with death, cardiovascular death or revascularization. Sensitivity analyses were consistent with these results. There was no interaction by sex. When assessed continuously, an increase in troponin concentrations was lineally associated with a steady increase in the risk of MACE.

Conclusion : In patients with RAF who complain of chest pain, increased troponin levels are related to adverse cardiovascular outcomes.

Conclusion (proposition de traduction) : Chez les patients présentant une fibrillation atriale rapide et se plaignant de douleurs thoraciques, l'augmentation des taux de troponine est liée à des résultats cardiovasculaires défavorables.

Early chest CT-scan in emergency patients affected by community-acquired pneumonia is associated with improved diagnosis consistency.
Claessens YE, Berthier F, Baqué-Juston M, Perrin C, Faraggi M, Keita-Perse O, Duval X. | Eur J Emerg Med. 2022 Dec 1;29(6):417-420
DOI: https://doi.org/10.1097/mej.0000000000000955  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Chest CT-scan (CT) exceeds chest X-ray (CXR) to diagnose community-acquired pneumonia (CAP) but actual use and results remain unclear. We examine whether CT performed at ED visit improved ED diagnosis of CAP as compared to a final diagnosis of CAP at hospital discharge (gold standard diagnosis for the study), and how it impacts relevant clinical outcomes.

Méthode : This retrospective monocenter observational study was based on the analysis of the hospital database. Patients with a diagnosis of CAP in the ED (ICD-10 codes: J110, J111, from J12- to J18-, J440, J690, U0710, and U0711) were included. We compared ED patients who were diagnosed with CAP using CXR and CT. We measured diagnostic consistency, duration of ED visit, percentage of CXR and CT during hospital stay, hospital length-of-stay, ICU admission, and in-hospital mortality. Multivariate analysis was adjusted for CRB65 score by multiple logistic regression analysis for binary outcomes and by multivariate analysis of variance for continuous outcomes.

Résultats : We included 994 ED patients with an initial diagnosis of CAP (751 receiving CXR, 243 receiving CT). CT prescription in the ED increased over time ( P < 0.001). In patients admitted after ED, CT improved diagnosis consistency for CAP [88.2% vs. 80.9%; difference 7.3% (95% confidence interval 1.2-13.3%)] with a trend for lower hospital length-of-stay [10.2 vs. 12.2 days; difference -2.0 (95% confidence interval -3.9 to -0.1)], but not ICU admission ( P = 0.09) and in-hospital mortality ( P = 0.056).

Conclusion : Diagnosis of patients admitted with CAP improved when CT was obtained at ED visit. These results should be reproduced at a larger scale to test whether early CT conserves healthcare resources.

Conclusion (proposition de traduction) : Le diagnostic des patients admis pour une pneumonie acquise en communauté s'est amélioré lorsque le CT a été obtenu lors de la consultation aux urgences. Ces résultats devraient être reproduits à plus grande échelle afin de vérifier si la tomodensitométrie précoce préserve les ressources de santé.

The impact of delayed time to first CT head on functional outcomes after blunt head trauma with moderately depressed GCS.
Schellenberg M, Benjamin E, Cowan S, Owattanapanich N, Wong MD, Inaba K, Demetriades D. | Eur J Trauma Emerg Surg. 2022 Dec;48(6):4445-4450
DOI: https://doi.org/10.1007/s00068-021-01677-1  | Télécharger l'article au format  
Keywords: Computed tomography of the head; Glasgow Coma Scale score; Time to intervention; Traumatic brain injury; Undertriage.

ORIGINAL ARTICLE

Introduction : Recent work suggests patients with moderately depressed Glasgow Coma Scale (GCS) score in the Emergency Department (ED) who do not undergo immediate head CT (CTH) have delayed neurosurgical intervention and longer ED stay. The present study objective was to determine the impact of time to first CTH on functional neurologic outcomes in this patient population.

Méthode : Blunt trauma patients presenting to our Level I trauma center (11/2015-10/2019) with first ED GCS 9-12 were retrospectively identified and included. Transfers and those with extracranial AIS ≥ 3 were excluded. The study population was stratified into Immediate (≤ 1 h) and Delayed (1-6 h) CTH groups based on time from ED arrival to first CTH. Outcomes included functional outcomes at hospital discharge based on the Modified Rankin Scale (mRS).

Résultats : After exclusions, 564 patients were included: 414 (73%) with Immediate CTH and 150 (27%) Delayed CTH. Both groups arrived with median GCS 11 and alcohol/drug intoxication did not differ (p > 0.05). AIS Head/Neck was comparable (3[3-4] vs. 3[3-3], p = 0.349). Time to ED disposition decision and ED exit were significantly shorter after Immediate CTH (2.8[1.5-5.3] vs. 5.2[3.6-7.5]h, p < 0.001 and 5.5[3.3-8.9] vs. 8.1[5.2-11.7]h, p < 0.001). Functional outcomes were slightly worse after Immediate CTH (mRS 2[1-4] vs. 2[1-3], p = 0.002). Subgroup analysis of patients requiring neurosurgical intervention demonstrated a greater proportion of moderately disabled patients with a lower proportion of severely disabled or dead patients after Immediate CTH as compared to Delayed CTH (51 vs. 20%, p = 0.063 and 35 vs. 60%, p = 0.122).

Conclusion : Immediate CTH shortened time to disposition decision out of the ED and ED exit. Patients requiring neurosurgical intervention after Immediate CTH had improved functional outcomes when compared to those undergoing Delayed CTH. These differences did not reach statistical significance in this single-center study and, therefore, a large, multicenter study is the next step in demonstrating the potential functional outcomes benefit of Immediate CTH after blunt head trauma.

Conclusion (proposition de traduction) : Le scanner crânien immédiat a permis de réduire le délai de décision de sortie des urgences et la sortie des urgences. Les patients nécessitant une intervention neurochirurgicale après un scanner crânien immédiat ont eu de meilleurs résultats fonctionnels que ceux ayant subi un scanner crânien différé. Ces différences n'étaient pas statistiquement significatives dans cette étude monocentrique et, par conséquent, une étude multicentrique de grande envergure est la prochaine étape pour démontrer les avantages potentiels en termes de résultats fonctionnels d'un scanner crânien immédiat après un traumatisme crânien contondant.

Characteristics, image findings and clinical outcome of moderate and severe traumatic brain injury among severely injured children: a population-based cohort study.
Weber C, Andreassen JS, Behbahani M, Thorsen K, Søreide K. | Eur J Trauma Emerg Surg. 2022 Dec;48(6):4473-4480
DOI: https://doi.org/10.1007/s00068-021-01820-y
Keywords: Glasgow Coma Scale; Glasgow Outcome Scale; Mortality; Paediatric trauma; Traumatic brain injury.

Original Article

Introduction : The aim of this study was to explore patient and injury characteristics, image findings, short-term clinical outcome and time trends of moderate and severe traumatic brain injury in severely injured children.

Méthode : This study is an observational cohort study based on prospectively collected data from an institutional trauma registry database covering all trauma patients in South West Norway. All paediatric patients registered in the database between 01.01.2004 and 31.12.2019 were included.

Résultats : During the 16 years-study periods, 82 paediatric patients with moderate (n = 42) and severe (n = 40) traumatic brain injury were identified. Median age was 13.0 years, 45% were female and median Glasgow Coma Scale score at admission was 9.0. Cranial fractures were common image findings in both groups. Cerebral contusions (32%) and epidural hematomas (29%) were more commonly found in moderate traumatic brain injury; cerebral contusions (49%), diffuse axonal injury (31%) and cerebral oedema (46%) were more prominent in severe traumatic brain injury. All children with moderate traumatic brain injury survived and favourable outcome was registered in 98%. Overall mortality in the severe traumatic brain injury cohort was 38% (thereof 25% due to TBI) and only 38% had a favourable short-term outcome.

Conclusion : In this population-based study on paediatric trauma patients over a period of 16 years severe traumatic brain injury in children still had a considerably high mortality and a higher proportion of patients experienced an unfavourable clinical short-term outcome. Moderate traumatic brain injury resulted in favourable clinical outcome.

Conclusion (proposition de traduction) : Dans cette étude de population portant sur des patients ayant subi un traumatisme en pédiatrie sur une période de 16 ans, les lésions cérébrales traumatiques graves chez les enfants ont toujours un taux de mortalité considérablement élevé et une plus grande proportion de patients ont connu un résultat clinique défavorable à court terme. Les lésions cérébrales traumatiques modérées ont donné lieu à des résultats cliniques favorables.

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index.
Forssten MP, Bass GA, Scheufler KM, Mohammad Ismail A, Cao Y, Martin ND, Sarani B, Mohseni S. | Eur J Trauma Emerg Surg. 2022 Dec;48(6):4481-4488
DOI: https://doi.org/10.1007/s00068-021-01841-7  | Télécharger l'article au format  
Keywords: Mortality; Revised Cardiac Risk Index; Risk stratification; Traumatic brain injury.

ORIGINAL ARTICLE

Introduction : Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients.

Méthode : All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference.

Résultats : 259,399 patients met the study's inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05-1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11-1.90), p = 0.006], compared to RCRI 0.

Conclusion : An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.

Conclusion (proposition de traduction) : Un Revised Cardiac Risk Index (RCRI) élevé ≥ 2 est significativement associé à un risque accru de mortalité à l'hôpital chez les patients présentant une lésion cérébrale traumatique grave isolée. La simplicité et l'applicabilité au chevet du patient de cet indice en font un choix intéressant pour la stratification du risque dans cette population de patients.

Commentaire : Référence originale :
Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O'Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50  .

Calculateur en ligne :
Revised Cardiac Risk Index for Pre-Operative Risk - MDCalc  .

Score :


1. Risque de chirurgie vasculaire sus-inguinale, intrapéritonéale ou intrathoracique. 2. Antécédents de cardiopathie ischémique. 3. Antécédents d'insuffisance cardiaque congestive. 4. Antécédents de maladie cérébrovasculaire (accident vasculaire cérébral ou accident ischémique transitoire). 5. Antécédents de diabète nécessitant une prise d'insuline préopératoire 6. Maladie rénale chronique [créatinine > 2 mg/dL (176,8 μmol/L)].

Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed.
Stausberg T, Ahnert T, Thouet B, Lefering R, Böhmer A, Brockamp T, Wafaisade A, Fröhlich M; TraumaRegister DGU. | Eur J Trauma Emerg Surg. 2022 Dec;48(6):4623-4630
DOI: https://doi.org/10.1007/s00068-022-01988-x  | Télécharger l'article au format  
Keywords: Airway management; Hemorrhagic shock; Multiple trauma; Preclinical treatment.

ORIGINAL ARTICLE

Introduction : The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI.

Méthode : The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information.

Résultats : In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently.

Conclusion : Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.

Conclusion (proposition de traduction) : La prise de décision concernant l'intubation pré-hospitalière chez les patients traumatisés est difficile en raison de divers facteurs. Malgré la présence d'une ligne directrice, la recommandation d'intubation endotrachéale n'est pas toujours appliquée. Les patients présentant un état de choc comme indication supplémentaire et une intubation consécutive ont montré un résultat inférieur. Ainsi, le état de choc isolé ne semble pas être une indication appropriée pour l'intubation endotrachéale pré-hospitalière, mais reste clairement un indicateur important de la gravité du traumatisme et de la nécessité d'activer l'équipe de traumatologie.

The conundrum of the definition of haemorrhagic shock: a pragmatic exploration based on a scoping review, experts’ survey and a cohort analysis.
James A, Abback PS, Pasquier P, Ausset S, Duranteau J, Hoffmann C, Gauss T, Hamada SR; Traumabase Group. | Eur J Trauma Emerg Surg. 2022 Dec;48(6):4639-4649
DOI: https://doi.org/10.1007/s00068-022-01998-9  | Télécharger l'article au format  
Keywords: Experts’ survey; Hemorrhagic shock; Methodology; Outcome; Scoping review; Severe trauma.

ORIGINAL ARTICLE

Introduction : Traumatic hemorrhagic shock (THS) is a complex, dynamic process and, no consensual definition of THS is available. This study aims (1) to explore existing definitions of traumatic hemorrhagic shock (THS), (2) to identify essential components of these definitions and (3) to illustrate in a pragmatic way the consequences of applying five of these definitions to a trauma registry.

Méthode : We conducted (1) a scoping review to identify the definitions used for traumatic hemorrhagic shock (THS); (2) an international experts survey to rank by relevance a selection of components extracted from these definitions and (3) a registry-based analysis where several candidate definitions were tested in a large trauma registry to evaluate how the use of different definitions affected baseline characteristics, resources use and patient outcome.

Résultats : Sixty-eight studies were included revealing 52 distinct definitions. The most frequently used was "a systolic blood pressure (SBP) less than or equal to 70 mmHg or between 71 and 90 mmHg if the heart rate is greater than or equal to 108 beats per min". The expert panel identified base excess, blood lactate concentration, SBP and shock index as the most relevant physiological components to define THS. Five definitions of THS were tested and highlighted significant differences across groups on important outcomes such as the proportion of massive transfusion, the need for surgery, in-hospital length of stay or in-hospital mortality.

Conclusion : This study demonstrates a large heterogeneity in the definitions of THS suggesting a need for standardization. Five candidate definitions were identified in a three-step process to illustrate how each shapes study cohort composition and impacts outcome. The results inform research stakeholders in the choice of a consensual definition.

Conclusion (proposition de traduction) : Cette étude démontre une grande hétérogénéité dans les définitions du choc hémorragique traumatique, suggérant un besoin de standardisation. Cinq définitions potentielles ont été identifiées dans un processus en trois étapes afin d'illustrer comment chacune d'entre elles détermine la composition de la cohorte d'étude et influe sur les résultats. Les résultats éclairent les acteurs du monde de la recherche sur le choix d'une définition consensuelle.

High arterial oxygen levels and supplemental oxygen administration in traumatic brain injury: insights from CENTER-TBI and OzENTER-TBI.
Rezoagli E, Petrosino M, Rebora P, Menon DK, Mondello S, Cooper DJ, Maas AIR, Wiegers EJA, Galimberti S, Citerio G; CENTER-TBI, OzENTER-TBI Participants and Investigators. | Intensive Care Med. 2022 Dec;48(12):1709-1725
DOI: https://doi.org/10.1007/s00134-022-06884-x  | Télécharger l'article au format  
Keywords: PaO2, FiO2, Traumatic brain injury, GOSE, Mortality, GFAP

Original

Introduction : The effect of high arterial oxygen levels and supplemental oxygen administration on outcomes in trau- matic brain injury (TBI) is debated, and data from large cohorts of TBI patients are limited. We investigated whether exposure to high blood oxygen levels and high oxygen supplementation is independently associated with outcomes in TBI patients admitted to the intensive care unit (ICU) and undergoing mechanical ventilation.

Méthode : This is a secondary analysis of two multicenter, prospective, observational, cohort studies performed in Europe and Australia. In TBI patients admitted to ICU, we describe the arterial partial pressure of oxygen (PaO2) and the oxygen inspired fraction (FiO2). We explored the association between high PaO2 and FiO2 levels within the first week with clinical outcomes. Furthermore, in the CENTER-TBI cohort, we investigate whether PaO2 and FiO2 levels may have differential relationships with outcome in the presence of varying levels of brain injury severity (as quantified by levels of glial fibrillary acidic protein (GFAP) in blood samples obtained within 24 h of injury).

Résultats : The analysis included 1084 patients (11,577 measurements) in the CENTER-TBI cohort, of whom 55% had an unfavorable outcome, and 26% died at a 6-month follow-up. Median PaO2 ranged from 93 to 166 mmHg. Exposure to higher PaO2 and FiO2 in the first seven days after ICU admission was independently associated with a higher mortality rate. A trend of a higher mortality rate was partially confirmed in the OzENTER-TBI cohort (n = 159). GFAP was inde- pendently associated with mortality and functional neurologic outcome at follow-up, but it did not modulate the outcome impact of high PaO2 and FiO2 levels, which remained independently associated with 6-month mortality.

Conclusion : In two large prospective multicenter cohorts of critically ill patients with TBI, levels of PaO2 and FiO2 varied widely across centers during the first seven days after ICU admission. Exposure to high arterial blood oxygen or high supplemental oxygen was independently associated with 6-month mortality in the CENTER-TBI cohort, and the severity of brain injury did not modulate this relationship. Due to the limited sample size, the findings were not wholly validated in the external OzENTER-TBI cohort. We cannot exclude the possibility that the worse outcomes associated with higher PaO2 were due to use of higher FiO2 in patients with more severe injury or physiological compromise. Further, these findings may not apply to patients in whom FiO2 and PaO2 are titrated to brain tissue oxygen monitor- ing (PbtO2) levels. However, at minimum, these findings support the need for caution with oxygen therapy in TBI, particularly since titration of supplemental oxygen is immediately applicable at the bedside.

Conclusion (proposition de traduction) : Dans deux grandes cohortes prospectives multicentriques de patients gravement malades souffrant de traumatisme crânien, les niveaux de PaO2 et de FiO2 variaient considérablement d'un centre à l'autre au cours des sept premiers jours suivant l'admission aux soins intensifs. L'exposition à un taux élevé d'oxygène dans le sang artériel ou à un taux élevé d'oxygène supplémentaire était indépendamment associée à la mortalité à 6 mois dans la cohorte CENTER-TBI, et la gravité des lésions cérébrales ne modulait pas cette relation. En raison de la taille limitée de l'échantillon, les résultats n'ont pas été entièrement validés dans la cohorte externe OzENTER-TBI. Nous ne pouvons pas exclure la possibilité que les moins bons résultats associés à une PaO2 plus élevée soient dus à l'utilisation d'une FiO2 plus élevée chez les patients présentant des lésions plus graves ou un compromis physiologique. En outre, ces résultats peuvent ne pas s'appliquer aux patients chez qui la FiO2 et la PaO2 sont ajustées aux niveaux de surveillance de l'oxygène du tissu cérébral (PbtO2). Cependant, ces résultats soulignent au moins la nécessité de faire preuve de prudence dans l'oxygénothérapie en cas de traumatisme crânien, d'autant plus que la titration de l'oxygène supplémentaire est immédiatement applicable au chevet du patient.

Commentaire : Message à retenir
Dans deux grandes cohortes prospectives multicentriques de patients victimes de lésions cérébrales traumatiques, les niveaux d'oxygène artériel et supplémentaire variaient considérablement d'un centre à l'autre au cours des sept premiers jours suivant l'admission en unité de soins intensifs.
L'exposition à un taux élevé d'oxygène dans le sang artériel ou à un taux élevé d'oxygène supplémentaire - un gaz thérapeutique immédiatement titrable au chevet du patient - était indépendamment associée à la mortalité à 6 mois, indépendamment de la gravité de la lésion cérébrale.

Vialla F | Med Droit. 2022 Dec;177:95–107
DOI: https://doi.org/10.1016/j.meddro.2022.09.002
Keywords: Dignity; Freedom; Autonomy; Consent; Refusal of treatment; Blood transfusion; Jehovah’s Witness

Droit civil

Editorial : Après une vingtaine d’années de répit, l’ordonnance rendue le 20 mai 2022 par le juge des référés du Conseil d’État remet sous les feux de l’actualité la question du refus transfusionnel émis par les témoins de Jéhovah. Entre les décisions de 2001 et 2002 et celle de 2022 le corpus législatif et réglementaire a considérablement renforcé les droits des patients, consolidant toujours l’autonomie de la personne. Bien que le refus de traitement soit clairement affirmé, la Haute juridiction administrative n’en maintient pas moins sa position.

Conclusion (proposition de traduction) : Dans son avis 87 le Comité Consultatif National d’Éthique (CCNE) relevait que « Le respect du consentement se trouve renforcé si le refus se fonde sur les convictions religieuses de l’intéressé. Or la liberté de religion est garantie par notre Constitution et par la Convention européenne des droits de l’homme ».
CCNE « refus de traitement et autonomie de la personne », avis n^o 87,14 avril 2005, p. 21 ; Martinez Éric, Vialla Franc¸ ois Dir., Les grands avis du Comité consultatif doctrinenational d’éthique, LGDJ 2013 ; Fortier Vincente, Vialla Franc¸ ois Dir., La religion dans les établissements de santé, LEH 2013, coll. À la croisée de regards, spécialement p. 319 et s.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.
Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Phil Chung S, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de. | Resuscitation. 2022 Dec;181:208-288
DOI: https://doi.org/10.1016/j.resuscitation.2022.10.005  | Télécharger l'article au format  
Keywords: AHA Scientific Statements; advanced life support; basic life support; cardiac arrest; first aid; infant, newborn; pediatrics; resuscitation.

ILCOR Summary Statement

Editorial : This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest.

Conclusion : Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Conclusion (proposition de traduction) : Les membres de six groupes de travail ont évalué, discuté et débattu de la qualité des données probantes en utilisant les critères d'évaluation, d'élaboration et d'évaluation de la gradation des recommandations et ont formulé des recommandations de traitement consensuelles. Les sections Justification et Points forts du cadre des données probantes à la décision donnent un aperçu des délibérations des groupes de travail et énumèrent les lacunes prioritaires en matière de connaissances pour la recherche future.

Drug routes in out-of-hospital cardiac arrest: A summary of current evidence.
Hooper A, Nolan JP, Rees N, Walker A, Perkins GD, Couper K. | Resuscitation. 2022 Dec;181:70-78
DOI: https://doi.org/10.1016/j.resuscitation.2022.10.015  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Drug administration; Epinephrine; Intraosseous; Intravenous; Out-of-Hospital Cardiac Arrest.

Review

Editorial : Recent evidence showing the clinical effectiveness of drug therapy in cardiac arrest has led to renewed interest in the optimal route for drug administration in adult out-of-hospital cardiac arrest. Current resuscitation guidelines support use of the intravenous route for intra-arrest drug delivery, with the intraosseous route reserved for patients in whom intravenous access cannot be established. We sought to evaluate current evidence on drug route for administration of cardiac arrest drugs, with a specific focus on the intravenous and intraosseous route. We identified relevant animal, manikin, and human studies through targeted searches of MEDLINE in June 2022. Across pre-hospital systems, there is wide variation in use of the intraosseous route. Early administration of cardiac arrest drugs is associated with improved patient outcomes. Challenges in obtaining intravenous access mean that the intraosseous access may facilitate earlier drug administration. However, time from administration to the central circulation is unclear with pharmacokinetic data limited mainly to animal studies. Observational studies comparing the effect of intravenous and intraosseous drug administration on patient outcomes are challenging to interpret because of resuscitation time bias and other confounders. To date, no randomised controlled trial has directly compared the effect on patient outcomes of intraosseous compared with intravenous drug administration in cardiac arrest. The International Liaison Committee on Resuscitation has described the urgent need for randomised controlled trials comparing the intravenous and intraosseous route in adult out-of-hospital cardiac arrest. Ongoing clinical trials will directly address this knowledge gap.

Conclusion : The optimum route for drug administration in OHCA is uncertain. The most effective drug route will facilitate rapid access, drug delivery and transport to the central circulation accompanied by improved clinical outcome. There are potential advantages to the IO route, including speed and success of insertion, although this may be influ- enced by anatomical site. Similarly, there are potential advantages to the IV route, such as a low risk of dislodgement and a potentially more favourable pharmacokinetic profile. Ongoing clinical trials will inform clinical practice regarding the role of intraosseous access in adult out-of-hospital cardiac arrest.

Conclusion (proposition de traduction) : La voie optimale d'administration des médicaments en cas d'arrêt cardiaque extrahospitalier est incertaine. La voie d'administration la plus efficace facilitera l'accès rapide, l'administration et le passage du médicament dans la circulation centrale, tout en améliorant les résultats cliniques. La voie intra-osseuse présente des avantages potentiels, notamment la rapidité et la réussite de la pose, bien qu'elle puisse être affectée par le site anatomique. De même, la voie intraveineuse présente des avantages potentiels, tels qu'un faible risque de déperfusion et un profil pharmacocinétique potentiellement plus favorable. Les essais cliniques en cours éclaireront la pratique clinique concernant le rôle de l'accès intra-osseux dans l'arrêt cardiaque extrahospitalier chez l'adulte.

Symptoms reported in calls to emergency medical services within 24 hours prior to out-of-hospital cardiac arrest.
Gnesin F, Mills EHA, Jensen B, Møller AL, Zylyftari N, Bøggild H, Ringgren KB, Kragholm K, Blomberg SNF, Christensen HC, Lippert F, Køber L, Folke F, Torp-Pedersen C. | Resuscitation. 2022 Dec;181:86-96
DOI: https://doi.org/10.1016/j.resuscitation.2022.10.021  | Télécharger l'article au format  
Keywords: Emergency medical services; Epidemiology; Out-of-hospital cardiac arrest; Public health.

Rapid response systems

Introduction : There is limited evidence regarding prodromal symptoms of out-of-hospital cardiac arrest (OHCA). We aimed to describe patient characteristics, prodromal symptoms, and prognosis of patients contacting emergency medical services (EMS) within 24 hours before OHCA.

Méthode : We identified all OHCA treated by Copenhagen EMS from 2016 through 2018 using the Danish Cardiac Arrest Registry and linked them to emergency calls. We included all pre-arrest calls by patients or bystanders if they were performed 1) within 24 hours before the OHCA call or 2) during the OHCA event for EMS-witnessed OHCA. Calls were reviewed by healthcare professionals using a survey guide.

Résultats : Among 4,071 patients, 481 patients (12 %) had 539 calls within 24 hours prior to OHCA (60 % male, median age 74 years of age). The patient spoke on the phone in 25 % of calls. The most common symptoms were breathing problems (59 %), confusion (23 %), unconsciousness (20 %), chest pain (20 %), and paleness (19 %). Patients with breathing problems compared to chest pain were more likely to be ≤ 75 years of age (55 % versus 35 %), less likely to be male (52 % versus 73 %), have shockable rhythm (10 % versus 38 %), receive bystander defibrillation (6 % versus 19 %) or EMS defibrillation (15 % versus 65 %), achieve return of spontaneous circulation (37 % versus 68 %) and survive 30 days following OHCA (10 % versus 50 %).

Conclusion : More than 10% of patients with OHCA had a call to EMS within 24 hours before OHCA. The most common symptom was breathing problems which compared to chest pain had lower 30-day survival.

Conclusion (proposition de traduction) : Plus de 10 % des patients ayant présenté un arrêt cardiaque extrahospitalier ont appelé les services médicaux d'urgence dans les 24 heures précédant l'arrêt cardiaque extrahospitalier. Le symptôme le plus courant était les problèmes respiratoires qui, comparés à la douleur thoracique, avaient un taux de survie à 30 jours plus faible.

Association of prehospital post-resuscitation peripheral oxygen saturation with survival following out-of-hospital cardiac arrest.
Smida T, Menegazzi JJ, Crowe RP, Bardes J, Scheidler JF, Salcido DD. | Resuscitation. 2022 Dec;181:28-36
DOI: https://doi.org/10.1016/j.resuscitation.2022.10.011  | Télécharger l'article au format  
Keywords: Airway; Extraglottic; Hypoxemia; Hypoxia; Out of hospital cardiac arrest; Post resuscitation; Post rosc; Prehospital; Supraglottic.

Clinical paper

Introduction : Hypoxia and hyperoxia following resuscitation from out-of-hospital cardiac arrest (OHCA)may cause harm by exacerbating secondary brain injury. Our objective was to retrospectively examine theassociationof prehospital post-ROSC hypoxia and hyperoxia with the primary outcome of survival to discharge home.

Méthode : We utilized the 2019-2021 ESO Data Collaborative public use research datasets for this study (ESO, Austin, TX). Average prehospital SpO₂, lowest recorded prehospital SpO₂, and hypoxia dose were calculated for each patient. Theassociationof these measures with survival was explored using multivariable logistic regression. We also evaluated theassociationof American Heart Association (AHA) and European Resuscitation Council (ERC) recommended post-ROSC SpO₂ target ranges with outcome.

Résultats : After application of exclusion criteria, 19,023 patients were included in this study. Of these, 52.3% experienced at least one episode of post-ROSC hypoxia (lowest SpO₂ < 90%) and 19.6% experienced hyperoxia (average SpO₂ > 98%). In comparison to normoxic patients, patients who were hypoxic on average (AHA aOR: 0.31 [0.25, 0.38]; ERC aOR: 0.34 [0.28, 0.42]) and patients who had a hypoxic lowest recorded SpO₂ (AHA aOR: 0.48 [0.39, 0.59]; ERC aOR: 0.52 [0.42, 0.64]) had lower adjusted odds of survival. Patients who had a hyperoxic average SpO₂ (AHA aOR: 0.75 [0.59, 0.96]; ERC aOR: 0.68 [0.53, 0.88]) and patients who had a hyperoxic lowest recorded SpO₂ (AHA aOR: 0.66 [0.48, 0.92]; ERC aOR: 0.65 [0.46, 0.92]) also had lower adjusted odds of survival.

Conclusion : Prehospital post-ROSC hypoxia and hyperoxia were associated with worse outcomes in this dataset.

Conclusion (proposition de traduction) : L'hypoxie et l'hyperoxie préhospitalières après le retour de la circulation spontanée ont été associées à des résultats plus défavorables dans cet ensemble de données.

Development of a clinical decision rule for the early prediction of Shock-Refractory Out-of-Hospital cardiac arrest.
Lupton JR, Jui J, Neth MR, Sahni R, Daya MR, Newgard CD. | Resuscitation. 2022 Dec;181:60-67
DOI: https://doi.org/10.1016/j.resuscitation.2022.10.010  | Télécharger l'article au format  
Keywords: Defibrillation; Out-of-hospital cardiac arrest; Refractory Ventricular Fibrillation; Shock-Refractory Cardiac Arrest.

Clinical paper

Introduction : Nearly half of ventricular fibrillation or ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA) patients receive three or more shocks, often referred to as refractory VF/VT. Our objective was to derive a clinical decision rule (CDR) for the early stratification of patients into risk categories for refractory VF/VT.

Méthode : We included adults with non-traumatic OHCA in the Resuscitation Outcomes Consortium Epistry (2011-2015) with ≥ 1 EMS shock. We used Classification and Regression Tree analysis for CDR building using variables known at initial EMS rhythm analysis including age, sex, witness, location, bystander interventions, initial EMS rhythm, obvious non-cardiac etiology, and dispatch to arrival times. The outcome was refractory VF/VT (≥3 shocks). We calculated sensitivity, specificity, area under the receiver operating curve (AUROC), and odds ratios (OR). The rule was validated using the Portland Cardiac Arrest Epidemiologic Registry (2018-2020).

Résultats : There were 17,140 eligible patients and 8,146 (47.5%) had refractory VF/VT. The optimal CDR (AUROC = 0.671) defined three groups: high-risk were any patients requiring an EMS shock after a bystander AED shock; moderate-risk were any non-EMS witnessed arrests with shockable initial EMS rhythms; and the remainder were low-risk. Refractory VF/VT increased across the low (30.7%), moderate (58.5%) and high-risk (84.8%) groups. Compared to low-risk, being moderate-risk or higher (OR [95% CI]:3.37 [3.16-3.59]; sensitivity 72.7%; specificity 55.9%) or high-risk (OR:12.63 [9.89-16.13]; sensitivity 5.4%; specificity 99.1%) had higher odds of refractory VF/VT. Results was similar in the validation cohort (n = 765, AUROC = 0.672).

Conclusion : Patients at higher risk for refractory VF/VT can be identified early in EMS care.

Conclusion (proposition de traduction) : Les patients présentant un risque élevé de FV/TV réfractaire peuvent être identifiés dès le début de la prise en charge par les services médicaux d'urgence.

Anteroposterior pacer pad position is better than anterolateral for transcutaneous cardiac pacing.
Moayedi S, Patel P, Brady N, Witting M, Dickfeld TL. | Resuscitation. 2022 Dec;181:140-146
DOI: https://doi.org/10.1016/j.resuscitation.2022.11.009  | Télécharger l'article au format  
Keywords: Bradycardia; Cardiac pacing; Transcutaneous pacing.

Clinical paper

Introduction : Transcutaneous cardiac pacing (TCP) is a lifesaving procedure for patients with certain types of unstable bradycardia. We aimed to assess the difference in the pacing thresholds between the anteroposterior (AP) and anterolateral (AL) pacer pad positions. The second aim was to characterize the severity of chest wall muscle contractions during TCP.

Méthode : In this prospective crossover trial, we enrolled patients presenting to the electrophysiology laboratory for elective cardioversion. After successful cardioversion, sedated participants were sequentially paced in both positions. The study procedure concluded after successful capture or inability to achieve capture by 140 mA (the pacer's maximum output) in both positions. Pacing thresholds were compared between positions, using a student's paired t-test, assigning a value of 141 mA to any trials with non-capture.

Résultats : Forty-one patients were screened; 20 were enrolled in the study. Seven participants were excluded from the paired analysis (three were prevented from pacing in the second position at the anesthesiologist's discretion, and 4 did not capture in either position). The study population consisted of 14 men and 6 women with a median age of 65 years. The mean pacing threshold was 33 mA lower (P = 0.001, 95% CI 20-45) in the AP (93 mA) versus the AL (126 mA) position. The median contraction severity score was 3 in the AL position versus 4 in the AP position (P = 0.005).

Conclusion : Placing pacer pads in the AP position requires less energy to capture. Major resuscitation guidelines may favor the AP position for TCP.

Conclusion (proposition de traduction) : Le placement des électrodes de stimulation en position antéropostérieure nécessite moins d'énergie pour la capture. Les principales directives de réanimation peuvent favoriser la position antéropostérieure pour la stimulation cardiaque transcutanée.

Effect of calcium in patients with pulseless electrical activity and electrocardiographic characteristics potentially associated with hyperkalemia and ischemia-sub-study of the Calcium for Out-of-hospital Cardiac Arrest (COCA) trial.
Vallentin MF, Povlsen AL, Granfeldt A, Terkelsen CJ, Andersen LW. | Resuscitation. 2022 Dec;181:150-157
DOI: https://doi.org/10.1016/j.resuscitation.2022.11.006  | Télécharger l'article au format  
Keywords: Advanced Life Support; Calcium; Cardiac arrest; Electrocardiography; Out-of-hospital.

Clinical paper

Introduction : The Calcium for Out-of-hospital Cardiac Arrest (COCA) trial was recently conducted and published. This pre-planned sub-study evaluated the effect of calcium in patients with pulseless electrical activity (PEA) including subgroup analyses based on electrocardiographic characteristics potentially associated with hyperkalemia and ischemia.

Méthode : Patients aged ≥ 18 years were included if they had a non-traumatic out-of-hospital cardiac arrest and received adrenaline. The trial drug consisted of calcium chloride (5 mmol) or saline placebo given after the first, and again after the second, dose of adrenaline for a maximum of two doses. This sub-study analyzed patients with PEA as their last known rhythm prior to receiving the trial drug. Outcomes were return of spontaneous circulation and survival at 30 days.

Résultats : 104 patients were analyzed. In the calcium group, 9 patients (20 %) achieved return of spontaneous circulation vs 23 patients (39 %) in the placebo group (risk ratio 0.51; 95 %CI 0.26, 1.00). Subgroup analyses based on electrocardiographic characteristics potentially associated with hyperkalemia and ischemia showed similar results. At 30 days, 1 patient (2.2 %) was alive in the calcium group while 8 patients (13.6 %) were alive in the placebo group (risk ratio 0.16; 95 %CI 0.02, 1.26).

Conclusion : In adults with out-of-hospital cardiac arrest presenting with PEA, effect estimates suggested harm of calcium administration as compared to placebo but with wide confidence intervals. Results were consistent for patients with electrocardiographic characteristics potentially associated with hyperkalemia and ischemia. The results do not support calcium administration based strictly on electrocardiographic findings seen during out-of-hospital cardiac arrest.

Conclusion (proposition de traduction) : Chez les adultes ayant fait un arrêt cardiaque en dehors de l'hôpital et présentant une activité électrique sans pouls, les estimations de l'effet suggèrent que l'administration de calcium est préjudiciable par rapport au placebo, mais avec de larges intervalles de confiance. Les résultats étaient cohérents pour les patients présentant des caractéristiques électrocardiographiques potentiellement associées à une hyperkaliémie et à une ischémie. Les résultats ne plaident pas en faveur de l'administration de calcium en se basant strictement sur les résultats électrocardiographiques enregistrés lors d'un arrêt cardiaque extrahospitalier.

Outcomes associated with intra-arrest hyperoxaemia in out-of-hospital cardiac arrest: A registry-based cohort study.
Izawa J, Komukai S, Nishioka N, Kiguchi T, Kitamura T, Iwami T. | Resuscitation. 2022 Dec;181:173-181
DOI: https://doi.org/10.1016/j.resuscitation.2022.11.008  | Télécharger l'article au format  
Keywords: Blood gas analysis; Emergency medical services; Heart arrest; Partial pressure; Resuscitation.

Clinical paper

Introduction : An association between post-arrest hyperoxaemia and worse outcomes has been reported for out-of-hospital cardiac arrest (OHCA) patients, but little is known about the relationship between intra-arrest hyperoxaemia and clinically relevant outcomes. This study aimed to investigate the association between intra-arrest hyperoxaemia and outcomes for OHCA patients.

Méthode : This was an observational study using a registry database of OHCA cases that occurred between 2014 and 2017 in Japan. We included adult, non-traumatic OHCA patients who were in cardiac arrest at the time of hospital arrival and for whom partial pressure of arterial oxygen (PaO₂) levels was measured during resuscitation. Main exposure was intra-arrest PaO₂ level, which was divided into three categories: hypoxaemia, PaO₂ < 60 mmHg; normoxaemia, 60-300; or hyperoxaemia, ≥300. Primary outcome was favourable functional survival at one month or at hospital discharge. Multivariable logistic regression was performed to adjust for clinically relevant variables.

Résultats : Among 16,013 patients who met the eligibility criteria, the proportion of favourable functional survival increased as the PaO₂ categories became higher: 0.5 % (57/11,484) in hypoxaemia, 1.1 % (48/4243) in normoxaemia, and 5.2 % (15/286) in hyperoxaemia (p-value for trend < 0.001). Higher PaO₂ categories were associated with favourable functional survival and the adjusted odds ratios increased as the PaO₂ categories became higher: 2.09 (95 % CI: 1.39-3.14) in normoxaemia and 5.04 (95 % CI: 2.62-9.70) in hyperoxaemia when compared to hypoxaemia as a reference.

Conclusion : In this observational study of adult OHCA patients, intra-arrest normoxaemia and hyperoxaemia were associated with better functional survival, compared to hypoxaemia.

Conclusion (proposition de traduction) : Dans cette étude d'observation de patients adultes victimes d'un arrêt cardiaque extrahospitalier, la normoxémie et l'hyperoxémie pendant l'arrêt ont été associées à une meilleure survie fonctionnelle, par rapport à l'hypoxémie.

End-tidal carbon dioxide (ETCO₂) at intubation and its increase after 10 minutes resuscitation predicts survival with good neurological outcome in out-of-hospital cardiac arrest patients.
Baldi E, Caputo ML, Klersy C, Benvenuti C, Contri E, Palo A, Primi R, Cresta R, Compagnoni S, Cianella R, Burkart R, De Ferrari GM, Auricchio A, Savastano S. | Resuscitation. 2022 Dec;181:197-207
DOI: https://doi.org/10.1016/j.resuscitation.2022.09.015  | Télécharger l'article au format  
Keywords: ETCO₂; Good neurological outcome; Out-of-hospital cardiac arrest; Survival.

Clinical paper

Introduction : To evaluate whether end-tidal carbon dioxide (ETCO₂) value at intubation and its early increase (10 min) after intubation predict both the survival to hospital admission and the survival at hospital discharge, including good neurological outcome (CPC 1-2), in patients with out-of-hospital cardiac arrest (OHCA).

Méthode : All consecutive OHCA patients of any etiology between 2015 and 2018 in Pavia Province (Italy) and Ticino Region (Switzerland) were considered. Patients died before ambulance arrival, with a "do-not-resuscitate" order, without ETCO₂ value or with incomplete data were excluded.

Résultats : The study population consisted of 668 patients. An ETCO₂ value at intubation > 20 mmHg and its increase 10 min after intubation were independent predictors (after correction for known predictors of OHCA outcome) of survival to hospital admission and survival at hospital discharge. Relative to hospital discharge with good neurological outcome, ETCO₂ at intubation and its 10-min change were confirmed predictors both individually and in a bivariable analysis (OR 1.83, 95 %CI 1.02-3.3; p = 0.04 and OR 3.9, 95 %CI 1.97-7.74; p < 0.001, respectively). This was confirmed also when accounting for gender, age, etiology and location. After further adjustment for bystander and CPR status, presenting rhythm and EMS arrival time, the ETCO₂ change remained an independent predictor.

Conclusion : ETCO₂ value > 20 mmHg at intubation and its increase during resuscitation improve the prediction of survival at hospital discharge with good neurological outcome of OHCA patients. ETCO₂ increase during resuscitation is a more powerful predictor than ETCO₂ at intubation. A larger prospective study to confirm this finding appears warranted.

Conclusion (proposition de traduction) : La valeur de l'ETCO₂ > 20 mmHg à l'intubation et son augmentation pendant la réanimation améliorent la prédiction de la survie à la sortie de l'hôpital avec un bon résultat neurologique chez les patients victimes d'un arrêt cardiaque extrahospitalier. L'augmentation de l'ETCO₂ pendant la réanimation est un facteur prédictif plus puissant que l'ETCO₂ à l'intubation. Une étude prospective de plus grande envergure pour confirmer ce résultat semble justifiée.

Prehospital misdiagnosis of acute cerebral disease for acute coronary syndrome: a retrospective study.
Grabert J, Heister U, Mayr A, Kirfel A, Staerk C, Fleckenstein T, Velten M. | Scand J Trauma Resusc Emerg Med. 2022 Dec 23;30(1):75
DOI: https://doi.org/10.1186/s13049-022-01063-9  | Télécharger l'article au format  
Keywords: Aucun

Original research

Introduction : In cerebrovascular accidents symptoms, laboratory results and electrocardiogram (ECG) changes can mimic acute coronary syndrome (ACS) and is subsumed as neurogenic stunned myocardium. So far, data regarding the frequency of cerebrovascular accidents misdiagnosed for ACS in a prehospital setting are missing. This study aims to quantify misdiagnoses and discover discriminating features.

Méthode : In a retrospective cohort study, prehospital and hospital medical records of all patients treated by physician-staffed emergency medical teams in the city of Bonn (Germany) with suspected ACS in 2018 were evaluated regarding medical history, prehospital symptoms and findings as well as hospital diagnoses.

Résultats : From 758 patients admitted for presumed ACS, 9 patients (1.2%, 95% CI: 0.5-2.2%) suffered from acute cerebral disease (ACD group). Mainly, diagnoses were cerebrovascular accidents and one case of neuroborreliosis. A history of intracranial haemorrhage was found more often in the ACD group compared to the remaining cohort (OR 19, p = 0.01), while a history of arterial hypertension was less frequent (OR 0.22, p = 0.03). Presentation with headaches (OR 10.1, p = 0.03) or neurological symptoms (OR 16.9, p = 0.01) occurred more frequent in the ACD group. ECG changes were similar between groups.

Conclusion : Acute cerebral disease misdiagnosed for ACS seems more common than assumed. Out of 758 patients with presumed ACS, 9 patients (1.2%) suffered from ACD, which were cerebrovascular accidents mainly. This is highly relevant, since prehospital treatment with heparin and acetylsalicylic acid is indicated in ACS but contraindicated in cerebrovascular accidents without further diagnostics. Thus, discriminating these patients is crucial. An attentive patient history and examination may be the key to differentiating ACD. Due to small ACD group size, further studies are needed.

Conclusion (proposition de traduction) : Les maladies cérébrales aiguës diagnostiquées à tort pour un SCA semblent plus fréquentes que prévu. Sur 758 patients présentant un SCA présumé, 9 patients (1,2 %) souffraient d'une maladie cérébrale aiguë, principalement des accidents vasculaires cérébraux. Ce constat est très pertinent, car le traitement préhospitalier à l'héparine et à l'acide acétylsalicylique est indiqué en cas de SCA, mais contre-indiqué en cas d'accident vasculaire cérébral sans autre diagnostic. Il est donc crucial de distinguer ces patients. Une anamnèse et un examen attentifs du patient peuvent être la clé pour différencier une maladie cérébrale aiguë. En raison de la petite taille du groupe de patients souffrant d'une maladie cérébrale aiguë, des études supplémentaires sont nécessaires.

Thoracic injuries in trauma patients: epidemiology and its influence on mortality.
Lundin A, Akram SK, Berg L, Göransson KE, Enocson A. | Scand J Trauma Resusc Emerg Med. 2022 Dec 12;30(1):69
DOI: https://doi.org/10.1186/s13049-022-01058-6  | Télécharger l'article au format  
Keywords: Chest injury; Mortality; Poly trauma; Thoracic trauma; Trauma

Original research

Introduction : Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality.

Méthode : Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality.

Résultats : A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3).

Conclusion : Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

Conclusion (proposition de traduction) : Les lésions thoraciques étaient un facteur prédictif indépendant de la mortalité à 30 jours après ajustement des variables clés pertinentes. Nous avons également constaté une différence dans les types de blessures, les patients plus âgés présentant une proportion plus élevée de fractures des côtes, tandis que les patients plus jeunes souffraient davantage de blessures des organes thoraciques internes.

Intravenous metoprolol versus diltiazem for atrial fibrillation with concomitant heart failure.
Compagner CT, Wysocki CR, Reich EK, Zimmerman LH, Holzhausen JM. | Am J Emerg Med. 2022 Dec;62:49-54
DOI: https://doi.org/10.1016/j.ajem.2022.10.001
Keywords: Atrial fibrillation; Beta-blocker; Calcium-channel blocker; Diltiazem; Heart failure; Metoprolol.

Research article

Introduction : Atrial fibrillation (Afib) with rapid ventricular response (RVR) is acutely treated with intravenous push (IVP) metoprolol (MET) or diltiazem (DIL). In heart failure (HF) patients, diltiazem is not recommended due to negative inotropic effects. Studies comparing the treatment of atrial fibrillation often exclude HF. Hirschy et al. evaluated HF patients with concomitant Afib with RVR who received IVP metoprolol or diltiazem to determine their effectiveness and safety. They found similar safety and effectiveness outcomes between the two groups.

Méthode : This retrospective, IRB-approved study evaluated patients presenting to the emergency center (EC) with Afib with RVR and HF from January 1, 2018 to July 31, 2021. Included patients were 18 years of age or older, received IVP metoprolol or diltiazem in the EC, and had a recorded baseline ejection fraction (EF). The primary effectiveness outcome was successful heart rate (HR) control 30 min after treatment with either IVP metoprolol or diltiazem, which was defined as HR <100 beats per minute (bpm). Secondary effectiveness outcomes included HR control 60 min post-IVP and at EC discharge or transfer and HR reduction >20% at 30 min after IVP, 60 min after IVP, and at time of discharge or transfer. Other secondary outcomes included the time to adequate HR control, the total dose of IVP metoprolol or diltiazem given, any additional rate-controlling agents given, and crossover between metoprolol and diltiazem. Safety outcomes included bradycardia, hypotension, shortness of breath, increased oxygen requirements, change in EF, acute kidney injury or renal replacement therapy.

Résultats : Of 2580 evaluated, 193 patients were included (134 DIL vs. 59 MET) with age 73.3 ± 12.2 years, 63% female. The average EF was 48.2 ± 14.2% and 30% of patients had heart failure with reduced ejection fraction (HFrEF) while 64% had heart failure with preserved ejection fraction (HFpEF). Effective heart rate control 30 min post-IVP was not different between the two groups (55% DIL vs. 41% MET, p = 0.063). DIL effectively controlled HR quicker than MET (13 [9, 125] DIL vs. 27 [5, 50] MET, min, p = 0.009). DIL resulted in greater HR reductions at 30 min (33.2 ± 25.4 DIL vs. 19.7 ± 19.7 MET, bpm, p < 0.001) and at 60 min (31 ± 23.5 DIL vs. 19.6 ± 19.1 MET, bpm, p = 0.002). DIL also more frequently resulted in a HR reduction of 20% or greater at 30 min (63% DIL vs. 27% MET, p < 0.001), 60 min post-IVP (59% DIL vs. 41% MET, p = 0.019), and at time of patient discharge or transfer from the EC (70% DIL vs. 49% MET, p = 0.005). No differences in safety outcomes were identified.

Conclusion : Acute management of patients with Afib with RVR and HF is challenging. While successful rate control at 30 min was not significantly different between diltiazem and metoprolol, IVP diltiazem reduced HR more quickly and reduced HR by 20% or greater more frequently than IVP metoprolol with no safety outcome differences. Further studies are needed to evaluate diltiazem's safety in patients with Afib and HF.

Conclusion (proposition de traduction) : La prise en charge aiguë des patients souffrant de fibrillation auriculaire avec réponse ventriculaire rapide et insuffisance cardiaque est un défi. Alors que la réussite du contrôle de la fréquence cardiaque à 30 minutes n'était pas significativement différente entre le diltiazem et le métoprolol, le diltiazem administré par voie intraveineuse a réduit la fréquence cardiaque plus rapidement et a réduit la fréquence cardiaque de 20 % ou plus plus fréquemment que le métoprolol administré par voie intraveineuse, sans qu'il y ait de différences en termes de sécurité. D'autres études sont nécessaires pour évaluer la sécurité du diltiazem chez les patients atteints de fibrillation auriculaire et d'insuffisance cardiaque.

A Narrative Review of the Uses of Ultrasound in the Evaluation, Analgesia, and Treatment of Distal Forearm Fractures.
Ottenhoff J, Kongkatong M, Hewitt M, Phillips J, Thom C. | J Emerg Med. 2022 Dec;63(6):755-765
DOI: https://doi.org/10.1016/j.jemermed.2022.09.012
Keywords: POCUS; distal radius fracture; forearm fracture; fraction reduction; fracture; hematoma block; ultrasound.

Clinical Review

Introduction : Distal forearm fractures are a commonly encountered injury in the emergency department (ED), accounting for 500,000 to 1.5 million visits and 17% of ED fractures. The evaluation and management of these fractures frequently employs x-ray studies, conscious sedation, closed reduction, and splinting. Point-of-care ultrasound (POCUS) can offer significant benefit in the diagnosis and management of these common injuries.

Méthode : To review the clinical utility of POCUS in the diagnosis of distal forearm fractures, as well as to demonstrate the performance of ultrasound-guided analgesia delivery and ultrasound-guided reduction technique.

Résultats : The initial evaluation of forearm injuries frequently includes x-ray studies. However, multiple studies have shown ultrasound to be sensitive and specific for distal radius fractures, with the added value of detecting soft tissue injuries missed by conventional radiography. POCUS may also facilitate analgesia through the use of ultrasound-guided hematoma blocks, which removes the need for conscious sedation prior to manipulation. Finally, POCUS can be used after manipulation to assess cortical realignment of the bone fragments and spare the patient multiple reduction attempts and repeat radiographs.

Conclusion : Distal forearm fractures are common, and the emergency physician should be adept with the evaluation and management of these injuries. POCUS can be a reliable modality in the detection of these fractures and can be used to facilitate analgesia and augment success of reduction attempts. These techniques may decrease length of stay, improve patient pain, and decrease reduction attempts.

Conclusion (proposition de traduction) : Les fractures distales de l'avant-bras sont fréquentes et le médecin urgentiste doit savoir évaluer et prendre en charge ces traumatismes. L'échographie au point d'intervention peut être une modalité fiable de détection de ces fractures et peut être utilisée pour faciliter l'analgésie et augmenter le succès des tentatives de réduction. Ces techniques peuvent réduire la durée du séjour, améliorer la douleur du patient et diminuer les tentatives de réduction.