Diagnosis and Management of Monkeypox: A Review for the Emergency Clinician.
van Nispen C, Reffett T, Long B, Gottlieb M, Frawley TC. | Ann Emerg Med. 2023 Jan;81(1):20-30
DOI: https://doi.org/10.1016/j.annemergmed.2022.07.014  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Editorial : The outbreak of monkeypox in May and June 2022 is the largest outside of central and western Africa since the 2003 outbreak in the United States. Monkeypox, like smallpox, is caused by an orthopoxvirus, though its clinical manifestations tend to be less severe. It is characterized by a prodromal flu-like illness with lymphadenopathy followed by a centrifugally spreading rash, sometimes involving the face, palms, soles, and oral mucosa. Although the vast majority of cases resolve with symptomatic management, a small number of patients can suffer severe outcomes including, but not limited to, secondary bacterial skin infections, pneumonitis, ocular sequelae, encephalitis, hypovolemia, and death. Local, state, and federal health authorities should be involved in the care of people under investigation for this illness. With confirmed cases worldwide and the possibility of community spread, emergency clinicians need to be aware of the manifestations and management of this disease, both to treat those with the disease as well as to provide education to those exposed and at risk of infection.

Conclusion : The monkeypox outbreak in May and June 2022 occurred outside the typical endemic regions of central and western Africa and has spread largely in the absence of travel or exposure to known sick contacts. This provides the impetus for emergency clinicians to gather expertise in diagnosing and managing monkeypox. Additionally, they must educate monkeypox patients and the worried well about the disease, given their role as frontline and safety net providers. Finally, although this review summarizes current knowledge about the diagnosis and management of the virus, clinicians must continue to stay apprised of updates to recommendations from local, state, and federal health authorities as more is learned about this outbreak.

Conclusion (proposition de traduction) : L'épidémie de variole du singe survenue en mai et juin 2022 s'est produite en dehors des régions endémiques typiques d'Afrique centrale et occidentale et s'est largement propagée en l'absence de voyages ou d'exposition à des contacts malades connus. Cette situation incite les cliniciens d'urgence à acquérir une expertise dans le diagnostic et la prise en charge de la variole du singe. De plus, ils doivent informer les patients atteints de la variole du singe et les personnes inquiètes sur la maladie, étant donné leur rôle de prestataires de services de première ligne et de filets de sécurité. Enfin, bien que cette revue résume les connaissances actuelles sur le diagnostic et la prise en charge du virus, les médecins doivent continuer à se tenir informés des mises à jour des recommandations des autorités sanitaires locales, étatiques et fédérales au fur et à mesure qu'ils en apprennent davantage sur cette épidémie.

Commentaire :  Lésions caractéristiques de la variole du singe

A Clinical Score for Predicting the Paroxysmal Supraventricular Tachycardia's Recurrence Risk; a Retrospective Cross-sectional Study.
Yuksen C, Tienpratarn W, Promkul R, Jenpanitpong C, Watcharakitpaisan S, Yaithet J, Phonphom V. | Arch Acad Emerg Med. 2023 Jan 1;11(1):e2
DOI: https://doi.org/10.22037/aaem.v11i1.1825  | Télécharger l'article au format  
Keywords: Adenosine; Clinical Decision Rules; Emergency Service; Hospital; Recurrence; Supraventricular; Tachycardia.

Original/Research Article

Introduction : Identifying prognostic variables associated with the probability of recurrent paroxysmal supraventricular tachycardia (PSVT) would aid decision-making regarding disposition of the patients. This study aims to develop a clinical scoring system to predict PSVT recurrence after adenosine administration in the emergency department (ED).

Méthode : This retrospective cross-sectional study was conducted on patients who were referred to the emergency department of Ramathibodi Hospital, a university-affiliated super-tertiary care hospital in Bangkok, Thailand, with diagnosis of PSVT during a 10-year period from 01 January 2010 until 31 December 2020. The cases were divided into recurrent and non-recurrent PSVT based on the response to standard treatment and the independent predictors of recurrence were studied using multivariable logistic regression analysis.

Résultats : 264 patients were diagnosed with PSVT and successfully converted by adenosine. 24 (9.1%) had recurrent PSVT, and 240 (90.9%) had no recurrent PSVT in the same ED visit. The risk of PSVT recurrence in ED corresponded with the history of hypertension (p = 0.059), valvular heart disease (p = 0.052), heart rate ≥ 100 (p = 0.012), and systolic blood pressure < 100 after electrocardiogram (ECG) converted to sinus rhythm (p = 0.022) and total dose of adenosine (p = 0.002). We developed a clinical prediction score of PSVT recurrence with an accuracy of 79.5%. A score of 0 (low risk), 1-2 (moderate risk), and > 2 (high risk) had a positive likelihood ratio (LR+) of 0.31, 0.56 and 2.33, respectively.

Conclusion : It seems that, using the PSVT recurrence score we could screen the high-risk patients for PSVT recurrence (score>2) who need to be observed for at least 6-12 hours and receive cardiologist consultation in ED. In addition, the moderate and low-risk group (score 0-2) need to be observed for 1 hour and can be discharged from ED.

Conclusion (proposition de traduction) : Il semble qu'en utilisant le score de récidive de la tachycardie supraventriculaire paroxystique, nous puissions dépister les patients à haut risque de récidive de la tachycardie supraventriculaire paroxystique (score > 2) qui doivent être surveillés pendant au moins 6-12 heures et bénéficier d'une consultation avec un cardiologue aux urgences. Par ailleurs, les patients à risque modéré ou faible (score 0-2) doivent être gardés en observation pendant une heure et peuvent quitter les urgences.

Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis.
Vazirizadeh-Mahabadi M, Yarahmadi M. | Arch Acad Emerg Med. 2023 Jan 1;11(1):e5
DOI: https://doi.org/10.22037/aaem.v11i1.1833  | Télécharger l'article au format  
Keywords: Spinal cord injuries; cervical cord; clinical decision rules; diagnosis; sensitivity and specificity; wounds and injuries.

REVIEW ARTICLE

Introduction : The Canadian C-spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) are two criteria designed to rule-out clinically important traumatic cervical Spinal Cord Injury (SCI). In this systematic review and meta-analysis, we reviewed the articles comparing the performance of these two models.

Méthode : Search was done in Medline, Embase, Scopus and Web of Science until June 2022. Observational studies with direct comparison of CCR and NEXUS criteria in detection of clinically important cervical SCI were included. Two independent reviewers screened the relevant articles and summarized the data. Certainty of evidence was assessed based on QUADAS-2. Data were recorded as true positive, true negative, false positive, and false negative. Then, using "diagma" package and applying weighted random effect model, area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, negative likelihood ratio, positive likelihood ratio, and diagnostic odds ratio (DOR) were calculated with 95% confidence interval (95% CI).

Résultats : We included 5 studies with direct comparison. Area under the ROC curve of NEXUS in screening of patients with clinically important cervical SCI was 0.708 (95% CI: 0.647 to 0.762). Pooled sensitivity and specificity of NEXUS criteria in screening of patients with clinically important cervical SCI were 0.899 (95% CI: 0.845 to 0.936) and 0.398 (95% CI: 0.315 to 0.488). The positive and negative likelihood ratios of NEXUS were 1.494 (95% CI: 1.146 to 1.949) and 0.254 (95% CI: 1.155 to 1.414), respectively. Diagnostic odds ratio of NEXUS was 5.894 (95% CI: 3.372 to 10.305). Furthermore, area under the ROC curve of CCR in screening of clinically important cervical SCI was 0.793 (95% CI: 0.657 to 0.884). Meta-analysis results showed that pooled sensitivity of CCR criteria in screening of patients with clinically important cervical SCI was 0.987 (95% CI: 0.957 to 0.996) and specificity was 0.167 (95% CI: 0.073 to 0.336). The positive and negative likelihood ratios of CCR were 1.184 (95% CI: 0.837 to 1.675) and 0.081 (95% CI: 0.021 to 0.308), respectively. Diagnostic odds ratio of CCR was 14.647 (95% CI: 3.678 to 58.336).

Conclusion : Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.

Conclusion (proposition de traduction) : D'après les études, la Canadian C-spine Rule et NEXUS sont des règles sensibles qui ont le potentiel de réduire l'imagerie inutile chez les patients présentant un traumatisme du rachis cervical. Cependant, la faible spécificité et les résultats faussement positifs de ces deux outils laissent penser que de nombreuses personnes continueront à subir une imagerie inutile après le dépistage d'un traumatisme cervical à l'aide de ces outils. Dans cette méta-analyse, la règle canadienne du rachis cervical semble avoir une meilleure précision de dépistage.

Commentaire : Voir la Canadian C-spine Rule   (onglet Traumatologie).

Prediction of pre-hospital blood transfusion in trauma patients based on scoring systems.
Plodr M, Berková J, Hyšpler R, Truhlář A, Páral J, Kočí J. | BMC Emerg Med. 2023 Jan 12;23(1):2. 2023 Jan 12;23(1):2
DOI: https://doi.org/10.1186/s12873-022-00770-x  | Télécharger l'article au format  
Keywords: Pre-hospital; Pulse pressure; Scoring systems; Shock index; Transfusion; Trauma.

Research

Introduction : Pre-hospital blood transfusion (PHBT) is a safe and gradually expanding procedure applied to trauma patients. A proper decision to activate PHBT with the presently limited diagnostic options at the site of an incident poses a challenge for pre-hospital crews. The purpose of this study was to compare the selected scoring systems and to determine whether they can be used as valid tools in identifying patients with PHBT requirements.

Méthode : A retrospective single-center study was conducted between June 2018 and December 2020. Overall, 385 patients (aged [median; IQR]: 44; 24-60; 73% males) were included in this study. The values of five selected scoring systems were calculated in all patients. To determine the accuracy of each score for the prediction of PHBT, the Receiver Operating Characteristic (ROC) analysis was used and to measure the association, the odds ratio with 95% confidence intervals was counted (Fig. 1).

Résultats : Regarding the proper indication of PHBT, shock index (SI) and pulse pressure (PP) revealed the highest value of AUC and sensitivity/specificity ratio (SI: AUC 0.88; 95% CI 0.82-0.93; PP: AUC 0.85 with 95% CI 0.79-0.91).

Conclusion : Shock index and pulse pressure are suitable tools for predicting PHBT in trauma patients.

Conclusion (proposition de traduction) : L'indice de choc et la pression artérielle sont des outils appropriés pour prédire la transfusion sanguine pré-hospitalière chez les patients traumatisés.

Aspirin Versus Clopidogrel for Long-Term Maintenance Monotherapy After Percutaneous Coronary Intervention: The HOST-EXAM Extended Study.
Kang J, Park KW, Lee H, Hwang D, Yang HM, Rha SW, Bae JW, Lee NH, Hur SH, Han JK, Shin ES, Koo BK, Kim HS. | Circulation. 2023 Jan 10;147(2):108-117
DOI: https://doi.org/10.1161/circulationaha.122.062770  | Télécharger l'article au format  
Keywords: percutaneous coronary intervention; platelet aggregation inhibitors; treatment outcome.

ORIGINAL RESEARCH ARTICLE

Introduction : Long-term outcomes of antiplatelet monotherapy in patients who receive percutaneous coronary intervention are unknown. The HOST-EXAM (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis-Extended Antiplatelet Monotherapy) Extended study reports the posttrial follow-up results of the original HOST-EXAM trial.

Méthode : From March 2014 through May 2018, 5438 patients who maintained dual antiplatelet therapy without clinical events for 12±6 months after percutaneous coronary intervention with drug-eluting stents were randomly assigned in a 1:1 ratio to receive clopidogrel (75 mg once daily) or aspirin (100 mg once daily). The primary end point (a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission attributable to acute coronary syndrome, and Bleeding Academic Research Consortium type 3 or greater bleeding), secondary thrombotic end point (cardiac death, nonfatal myocardial infarction, ischemic stroke, readmission attributable to acute coronary syndrome, and definite or probable stent thrombosis), and bleeding end point (Bleeding Academic Research Consortium type 2 or greater bleeding) were analyzed during the extended follow-up period. Analysis was performed on the per-protocol population (2431 patients in the clopidogrel group and 2286 patients in the aspirin group).

Résultats : During a median follow-up of 5.8 years (interquartile range, 4.8-6.2 years), the primary end point occurred in 12.8% and 16.9% in the clopidogrel and aspirin groups, respectively (hazard ratio, 0.74 [95% CI, 0.63-0.86]; P<0.001). The clopidogrel group had a lower risk for the secondary thrombotic end point (7.9% versus 11.9%; hazard ratio, 0.66 [95% CI, 0.55-0.79]; P<0.001) and secondary bleeding end point (4.5% versus 6.1%; hazard ratio, 0.74 [95% CI, 0.57-0.94]; P=0.016). There was no significant difference in the incidence of all-cause death between the 2 groups (6.2% versus 6.0%; hazard ratio, 1.04 [95% CI, 0.82-1.31]; P=0.742). Landmark analysis at 2 years showed that the beneficial effect of clopidogrel was consistent throughout the follow-up period.

Conclusion : During an extended follow-up of >5 years after randomization, clopidogrel monotherapy compared with aspirin monotherapy was associated with lower rates of the composite net clinical outcome in patients without clinical events for 12±6 months after percutaneous coronary intervention with drug-eluting stents.

Conclusion (proposition de traduction) : Au cours d'un suivi prolongé de plus de 5 ans après la randomisation, le clopidogrel en monothérapie par rapport à l'aspirine en monothérapie a été associé à des taux plus faibles de résultats cliniques nets composites chez les patients sans événements cliniques pendant 12±6 mois après une intervention coronarienne percutanée avec des stents actifs.

Commentaire : Dans le cadre du suivi prolongé des patients n'ayant pas connu d'événement pendant 6 à 18 mois après l'ICP et ayant reçu avec succès la durée prévue de la bithérapie antiplaquettaire, la monothérapie par le clopidogrel, comparée à la monothérapie par l'aspirine, a réduit de manière significative le risque du critère composite de décès toutes causes confondues, d'infarctus du myocarde non fatal, d'accident vasculaire cérébral, de réadmission pour cause de SCA et d'hémorragie de type 3 ou plus (BARC).

Incidence of traumatic lumbar punctures in adults: the impact of a patient's first procedure.
Sievänen H, Kari J, Eskola V, Huurre A, Soukka H, Palmu S. | Clin Med (Lond). 2023 Jan;23(1):31-37
DOI: https://doi.org/10.7861/clinmed.2022-0169
Keywords: diagnosis; erythrocyte count; lumbar puncture; spinal tap; traumatic puncture.

ORIGINAL RESEARCH

Introduction : Lumbar puncture (LP) is a widely used diagnostic method in patients of all ages. Blood-contaminated cerebrospinal fluid samples are frequent and may compromise diagnostic accuracy.
titre_en_Objectivesplus: We determined age-specific incidences of traumatic LPs (TLPs) in adults and examined factors that accounted for the incidence of TLPs.

Méthode : Erythrocyte count data from 15,812 LP procedures (2,404 were performed twice) were collected from hospital records of patients aged from 18 to 104 years. The incidence of TLPs in a patient's second LP procedure was evaluated with logistic regression analysis using the first LP, the time between the procedures and age as predictors.

Résultats : The incidence of TLP in the second procedure was at least double that in the first procedure. If the first procedure was traumatic, the odds ratio of a TLP in the second procedure was 7-40-fold. One day between the successive procedures was associated with an over 10-fold odds ratio increase of TLP, and a week was still 4-8-fold odds ratio increase. Age was also associated with the incidence of TLP.

Conclusion : Two factors (a week or less between a patient's two LP procedures or a traumatic first LP) multiply the odds of the second procedure being traumatic and contribute to whether a patient's following LP procedure is successful.

Conclusion (proposition de traduction) : Deux critères (une semaine ou moins entre les deux ponctions lombaires d'un patient ou une première ponction lombaire traumatisante) multiplient les risques de traumatisme lors de la deuxième intervention et contribuent à la réussite de la ponction lombaire suivante.

Prehospital ABC (Age, Bystander and Cardiogram) scoring system to predict neurological outcomes of cardiopulmonary arrest on arrival: post hoc analysis of a multicentre prospective observational study.
Uehara K, Tagami T, Hyodo H, Ohara T, Sakurai A, Kitamura N, Nakada TA, Takeda M, Yokota H, Yasutake M. | Emerg Med J. 2023 Jan;40(1):42-47
DOI: https://doi.org/10.1136/emermed-2020-210864
Keywords: clinical management; management; resuscitation.

PREHOSPITAL CARE

Introduction : There is currently limited evidence to guide prehospital identification of patients with cardiopulmonary arrest on arrival (CPAOA) to hospital who have potentially favourable neurological function. This study aimed to develop a simple scoring system that can be determined at the contact point with emergency medical services to predict neurological outcomes.

Méthode : We analysed data from patients with CPAOA using a regional Japanese database (SOS-KANTO), from January 2012 to March 2013. Patients were randomly assigned into derivation and validation cohorts. Favourable neurological outcomes were defined as cerebral performance category 1 or 2. We developed a new scoring system using logistic regression analysis with the following predictors: age, no-flow time, initial cardiac rhythm and arrest place. The model was internally validated by assessing discrimination and calibration.

Résultats : Among 4907 patients in the derivation cohort and 4908 patients in the validation cohort, the probabilities of favourable outcome were 0.9% and 0.8%, respectively. In the derivation cohort, age ≤70 years (OR 5.11; 95% CI 2.35 to 11.14), no-flow time ≤5 min (OR 4.06; 95% CI 2.06 to 8.01) and ventricular tachycardia or fibrillation as initial cardiac rhythm (OR 6.66; 95% CI 3.45 to 12.88) were identified as predictors of favourable outcome. The ABC score consisting of Age, information from Bystander and Cardiogram was created. The areas under the receiver operating characteristic curves of this score were 0.863 in the derivation and 0.885 in the validation cohorts. Positive likelihood ratios were 6.15 and 6.39 in patients with scores >2 points and were 11.06 and 17.75 in those with 3 points.

Conclusion : The ABC score showed good accuracy for predicting favourable neurological outcomes in patients with CPAOA. This simple scoring system could potentially be used to select patients for extracorporeal cardiopulmonary resuscitation and minimise low-flow time.

Conclusion (proposition de traduction) : Le score ABC a fait preuve d'une bonne précision pour prédire le pronostic neurologique favorable chez les patients victimes d'un arrêt cardio-respiratoire à notre arrivée. Ce système de scoring simple pourrait potentiellement être utilisé pour sélectionner les patients en vue d'une réanimation cardio-pulmonaire extracorporelle et minimiser le temps de low-flow.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit.
Milési C, Baudin F, Durand P, Emeriaud G, Essouri S, Pouyau R, Baleine J, Beldjilali S, Bordessoule A, Breinig S, Demaret P, Desprez P, Gaillard-Leroux B, Guichoux J, Guilbert AS, Guillot C, Jean S, Levy M, Noizet-Yverneau O, Rambaud J, Recher M, Reynaud S, Valla F, Radoui K, Faure MA, Ferraro G, Mortamet G; French Speaking Group for Pediatric Intensive and Emergency Care. | Intensive Care Med. 2023 Jan;49(1):5-25
DOI: https://doi.org/10.1007/s00134-022-06918-4
Keywords: Bronchiolitis; Guidelines; High-flow nasal cannula; Noninvasive ventilation; Pediatric intensive care; Recommendation.

GUIDELINES

Introduction : We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

Méthode : Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

Résultats : This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

Conclusion : These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Conclusion (proposition de traduction) : Ces recommandations couvrent les différents aspects de la prise en charge de la bronchiolite sévère chez les nourrissons admis dans une unité de soins intensifs pédiatriques. Par rapport aux différentes manières de prendre en charge les patients atteints de bronchiolite sévère décrites dans la littérature, notre travail original propose une approche globalement moins invasive en termes de surveillance et de traitement.

The prediction of fluid responsiveness.
Monnet X, Malbrain MLNG, Pinsky MR. | Intensive Care Med. 2023 Jan;49(1):83-86
DOI: https://doi.org/10.1007/s00134-022-06900-0
Keywords: Aucun

Lasting Legacy in Intensive Care Medicine

Editorial : During the cholera epidemics in the nineteenth century, intravenous fluid infusion was observed “to restore the blood to its natural specific gravity and to restore its deficient saline matters” in the blue stage of spasmodic cholera. It then became clear that fluid therapy during shock is aimed at increasing cardiac output (CO), ultimately improving tissue oxygenation. However, during the 1980s, authors measuring the effects of fluid boluses on CO, found that it remained unchanged in roughly 50% of the patients. In fact, they observed at the bedside a physiological reality: the relationship between CO and preload has a variable slope, depending on the preload level and, for a given preload, on ventricular contractility. In the 1980s, the concept of predicting fluid responsiveness before infusing fluids arose. For years, the central venous pressure (CVP) and other markers of cardiac preload have been used to guide the decision of administering a fluid bolus. Regrettably, many studies then and afterward showed that, on average, these static markers of preload do not indicate the slope of the Frank-Starling curve.

Conclusion : Predicting fluid responsiveness was born from a double observation, namely that fluids are both harmful and inconstantly effective. Assessing fluid responsiveness allows one to avoid the administration of a deleterious treatment to patients who do not need it, and give it when needed. Using these dynamic measures in the most severely ill patients walks the tightrope between aggressive restoration of cardiac output and fluid overload, allowing for truly personalized treatment.

Conclusion (proposition de traduction) : La capacité de prédire la réponse aux remplissage vasculaire est née d'un double constat, à savoir que le remplissage vasculaire est à la fois nocif et d'une efficacité inconstante. L'évaluation de la réponse au remplissage vasculaire permet d'éviter l'administration d'un traitement délétère à des patients qui n'en ont pas besoin, et de le donner quand il est nécessaire. L'utilisation de ces mesures dynamiques chez les patients les plus gravement malades permet de trouver le juste milieu entre la restauration intensive du débit cardiaque et la surcharge liquidienne, ce qui permet un traitement véritablement personnalisé.

Management of diabetic ketoacidosis.
Besen BAMP, Ranzani OT, Singer M. | Intensive Care Med. 2023 Jan;49(1):95-98
DOI: https://doi.org/10.1007/s00134-022-06894-9
Keywords: Aucun

Understanding the Disease

Editorial : Diabetic ketoacidosis (DKA) commonly requires critical care admission. Guidelines, however, provide differing recommendations. We propose a pathophysiology- based approach to management. DKA diagnosis and resolution criteria are described in the Supplemental File.

Conclusion : Knowledge of DKA pathophysiology allied to current evidence may better guide DKA management. We present seven myths of DKA pathophysiology that the clinician should be aware of. Although a rigid prescriptive approach may prove adequate in many situations, pathophysiological reasoning is necessary for the increasingly more common atypical situations and for managing patients with underlying comorbidities.

Conclusion (proposition de traduction) : La connaissance de la physiopathologie de l'acidocétose diabétique alliée aux données probantes actuelles peut mieux guider la gestion de l'acidocétose diabétique. Nous présentons sept mythes de la physiopathologie de l'acidocétose diabétique que le clinicien doit connaître. Bien qu'une approche de prescription rigoureuse puisse s'avérer adéquate dans de nombreuses situations, le raisonnement physiopathologique est nécessaire pour les situations atypiques de plus en plus courantes et pour la prise en charge des patients présentant des comorbidités sous-jacentes.

Management of oliguria.
Ostermann M, Shaw AD, Joannidis M. | Intensive Care Med. 2023 Jan;49(1):103-106
DOI: https://doi.org/10.1007/s00134-022-06909-5
Keywords: Aucun

Understanding the Disease

Editorial : Oliguria is common in critically ill patients. It may be a physiological response to hypovolemia (representing intact glomerular and tubular function) or could be due to decreased glomerular filtration or tubular injury and be a sign of acute kidney injury (AKI). The skill is to dis- tinguish between both scenarios and to manage patients accordingly.

Conclusion : Oliguria is relatively frequent in patients in the ICU and in the perioperative setting and most episodes are not followed by a serum creatinine rise consistent with AKI.
While clinically important, isolated oliguria should be interpreted with caution and within the clinical context. The FST and new AKI biomarkers have potential to help differentiating between physiological oliguria and pathophysiological conditions.

Conclusion (proposition de traduction) : L'oligurie est relativement fréquente chez les patients en soins intensifs et dans le cadre périopératoire et la plupart des épisodes ne sont pas suivis d'une élévation de la créatinine sérique correspondant à une insuffisance rénale aiguë.
Bien que cliniquement importante, l'oligurie isolée doit être interprétée avec prudence et dans le contexte clinique. L'épreuve d'effort au furosémide et les nouveaux biomarqueurs de l'insuffisance rénale aiguë pourraient aider à différencier l'oligurie physiologique des conditions pathophysiologiques.

Commentaire : 

Tranexamic acid in emergency medicine. An overview of reviews.
Dhingra P, Yeung M, Lang E. | Intern Emerg Med. 2023 Jan;18(1):211-218
DOI: https://doi.org/10.1007/s11739-022-03155-x  | Télécharger l'article au format  
Keywords: Evidence-based medicine; Quality improvement; Tranexamic acid.

Em - Review

Introduction : Tranexamic acid (TXA) is a common haemorrhage control agent in both emergency department (ED) settings and intra-operatively. While efficacy and potential harms are well-studied, there are no overviews of reviews completed on TXA efficacy in the ED setting.

Méthode : We set out to provide an overview of systematic reviews on TXA efficacy in trauma, gastrointestinal bleeding, and subarachnoid haemorrhage in the ED setting, with outcomes including short and long-term mortality, thromboembolic (TE) events, and whether bleeding continued. Our review is guided by the PRIOR statement. We searched Pubmed, Medline, and EMBASE using broad search terms for systematic reviews, and calculated pooled relative-risk ratios using random and fixed-effects modelling from these studies. A risk-of-bias assessment was also completed for each review.

Résultats : We identified 13 systematic reviews for inclusion, with a variety of different outcomes. We identified improvements in 24-h mortality for trauma (RR 0.88, 95% CI 0.84-0.92) and gastrointestinal bleeds (RR 0.30, 95% CI 0.23-0.39), and decreased long-term gastrointestinal bleed mortality (RR 0.57, 95% CI 0.48-0.69). We also identified an increase in TE risk in gastrointestinal bleeding scenarios (RR 1.45, 95% CI 1.09-1.94), but no other clinical scenarios.

Conclusion : TXA is effective in reducing mortality following trauma and gastrointestinal bleeds, however, there is limited evidence at this time to support TXA administration in the context of subarachnoid haemorrhage. TE risk is elevated when used in gastrointestinal bleeds. Selective use in high-risk patients may be warranted. TXA should strongly be considered in management in ED and prehospital settings.

Conclusion (proposition de traduction) : L'acide tranexamique est efficace pour réduire la mortalité à la suite d'un traumatisme et d'une hémorragie gastro-intestinale. Cependant, les preuves sont limitées à l'heure actuelle pour confirmer l'administration d'acide tranexamique dans le contexte d'une hémorragie sous-arachnoïdienne. Le risque thromboembolique est élevé lorsqu'il est utilisé dans les saignements gastro-intestinaux. Une utilisation ciblée chez les patients à haut risque peut être justifiée. L'acide tranexamique doit être fortement envisagé dans la prise en charge aux urgences et en milieu préhospitalier.

Risk factors for failed first intubation attempt in an out-of-hospital setting: a multicenter prospective study.
Galinski M, Wrobel M, Boyer R, Reuter PG, Ruscev M, Debaty G, Bagou G, Dehours E, Bosc J, Lorendeau JP, Goddet S, Marouf K, Catoire P, Combes X, Simonnet B, Gil-Jardiné C. | Intern Emerg Med. 2023 Jan;18(1):265-272
DOI: https://doi.org/10.1007/s11739-022-03120-8  | Télécharger l'article au format  
Keywords: First intubation attempt; Prehospital emergency setting; Risk factors for failure.

EM - ORIGINAL

Introduction : This study was performed to identify variables potentially associated with failure of the first intubation attempt in an out-of-hospital emergency setting, considering all aspects of tracheal intubation. This observational prospective multicenter study was performed over 17 months and involved 10 prehospital emergency medical units.

Méthode : After each tracheal intubation, the operator was required to provide information concerning operator and patient characteristics, as well as the environmental conditions during intubation, by completing a data collection form. The primary endpoint was failure of the first intubation attempt.

Résultats : During the study period, 1546 patients were analyzed, of whom 59% were in cardiac arrest; 486 intubations failed on the first attempt (31.4% [95% confidence interval = 30.2-32.6]). Multivariate analysis revealed that the following 7 of 28 factors were associated with an increased risk of a failed first intubation attempt: operator with fewer than 50 prior intubations (odds ratio [OR] = 1.8 [1.4-2.4]), small inter-incisor space (OR = 2.3 [1.7-3.2]), limited extension of the head (OR = 1.6 [1.1-2.1]), macroglossia (OR = 2.3 [1.6-3.2]), ear/nose/throat (ENT) tumor (OR = 4.4 [1.4-13.4]), cardiac arrest (OR = 1.8 [1.3-2.6]), and vomiting (OR = 1.7 [1.3-2.3]).

Conclusion : The frequency of adverse events among non-cardiac arrest patients was 17.6%; it increased with each additional intubation attempt. The first intubation attempt failed in more than 30% of cases, and seven variables were associated with increased risk of failure. Most of these factors could not be predicted.

Conclusion (proposition de traduction) : La fréquence des événements indésirables chez les patients victimes d'un arrêt cardiaque était de 17,6 % ; elle augmentait avec chaque tentative d'intubation supplémentaire. La première tentative d'intubation a échoué dans plus de 30 % des cas, et sept variables ont été associées à un risque accru d'échec. La plupart de ces facteurs ne pouvaient pas être prédits.

Commentaire : Le risque d'échec de la première tentative est plus élevé pour les opérateurs ayant une expérience de moins de 50 intubations. Une revue de la littérature a conclu qu'une expérience préalable d'au moins 50 intubations avec pas plus de deux tentatives d'intubation est nécessaire pour obtenir un taux de réussite de 90%. Le taux de survie est plus élevé chez les patients victimes d'un arrêt cardiaque intubés par des secouristes ayant plus de 50 intubations antérieures, et chez les patients victimes d'un arrêt cardiaque non intubés par des secouristes ayant plus de 26 intubations antérieures. Les médecins ont un taux plus élevé d'extension limitée de la tête, de macroglossie, de vomissements et de tumeur ORL.

ROX index versus HACOR scale in predicting success and failure of high-flow nasal cannula in the emergency department for patients with acute hypoxemic respiratory failure: a prospective observational study.
Praphruetkit N, Boonchana N, Monsomboon A, Ruangsomboon O. | Int J Emerg Med. 2023 Jan 10;16(1):3
DOI: https://doi.org/10.1186/s12245-023-00477-1  | Télécharger l'article au format  
Keywords: HACOR scale; High-flow nasal cannula; Nasal high flow; ROX index.

Research

Introduction : High-flow nasal cannula has been a promising initial respiratory support measure for patients with acute hypoxemic respiratory failure (AHRF) in the emergency department (ED). However, delayed detection of HFNC failure is associated with increased mortality. The ROX index is a tool that can help predict HFNC success. Nonetheless, its utility in ED patients is limited, and no studies have compared it with the HACOR scale, another tool that may be as accurate in predicting HFNC failure. Therefore, we aimed to compare the prognostic utility of the ROX index and the HACOR scale in emergency AHRF patients.

Méthode : This prospective observational study was conducted at the ED of Siriraj Hospital, Thailand, between August 2018 and February 2020. Adult patients with AHRF requiring HFNC in the ED were included. The ROX index and the HACOR scale were measured at 1, 2, and 6 h after HFNC initiation. The primary outcome was HFNC success, defined as no intolerance or escalation towards mechanical ventilation or non-invasive ventilation within 48 h.

Résultats : A total of 75 patients were enrolled; 52 (69.3%) had a successful treatment. The ROX index was higher in the success group, while the HACOR scale was lower at all timepoints. The ROX index yielded generally higher discrimination capacity based on the area under the receiver operating characteristic curve (AUROC) than the HACOR scale [AUROC at 1, 2, and 6 h = 0.815, 0.784, 0.853 for ROX in predicting HFNC success and 0.733, 0.690, and 0.764 for HACOR in predicting HFNC failure]. The ROX index measured at 6 h at the cut-point of 4.88 had 92.98% sensitivity, 61.11% specificity, 88.33% positive predictive value, and 73.33% negative predictive value with a diagnostic accuracy of 85.33%.

Conclusion : The ROX index had superior prognostic utility in predicting HFNC outcome (success/failure) compared to the HACOR scale in patients with AHRF in the ED setting. Moreover, it is less complex and more efficient to be employed at bedside. Therefore, the ROX index is a more appropriate tool to guide further management and potential escalation therapy for AHRF patients with HFNC therapy initiated in the ED.

Conclusion (proposition de traduction) : L'indice ROX a une meilleure valeur pronostique pour prédire le résultat (succès/échec) de la canule nasale à haut débit que l'échelle HACOR chez les patients souffrant d'insuffisance respiratoire aiguë hypoxémique aux urgences. De plus, il est moins complexe et plus efficace pour être utilisé au chevet du patient. Par conséquent, l'indice ROX est un outil plus approprié pour guider la prise en charge et l'éventuelle escalade thérapeutique chez les patients souffrant d'insuffisance respiratoire hypoxémique aiguë dont le traitement par oxygénothérapie nasale à haut débit est initié aux urgences.

Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial.
Grillot N, Lebuffe G, Huet O, Lasocki S, Pichon X, Oudot M, Bruneau N, David JS, Bouzat P, Jobert A, Tching-Sin M, Feuillet F, Cinotti R, Asehnoune K, Roquilly A; Atlanrea Study GroupSociété Française d’Anesthésie Réanimation (SFAR) Research Network. | JAMA. 2023 Jan 3;329(1):28-38
DOI: https://doi.org/10.1001/jama.2022.23550  | Télécharger l'article au format  
Keywords: Aucun

Randomized Controlled Trial

Editorial : It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent.

Introduction : To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation.
Design, setting, and participants: Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021.
Interventions: Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 μg/kg; n = 575) immediately after injection of a hypnotic.

Méthode : The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%.

Résultats : Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%).

Conclusion : Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference.

Conclusion (proposition de traduction) : Chez les adultes présentant un risque d'inhalation lors d'une intubation en séquence rapide en salle d'opération, le rémifentanil, comparé aux curares, n'a pas satisfait au critère de non-infériorité en ce qui concerne la réussite de l'intubation à la première tentative sans complications majeures. Bien que le rémifentanil soit statistiquement inférieur aux curares, le large intervalle de confiance autour de l'estimation de l'effet reste compatible avec la non-infériorité et limite les conclusions sur la pertinence clinique de la différence.

Commentaire : Cet essai de non-infériorité sur 15 centres français n’a pas montré de bénéfices à utiliser le rémifentanil, donc nous continuerons à faire de la séquence rapide sur des patients &aquo; estomac plein » avec un curare d’action rapide.

Effect of Early High-Flow Nasal Oxygen vs Standard Oxygen Therapy on Length of Hospital Stay in Hospitalized Children With Acute Hypoxemic Respiratory Failure: The PARIS-2 Randomized Clinical Trial.
Franklin D, Babl FE, George S, Oakley E, Borland ML, Neutze J, Acworth J, Craig S, Jones M, Gannon B, Shellshear D, McCay H, Wallace A, Hoeppner T, Wildman M, Mattes J, Pham TMT, Miller L, Williams A, O'Brien S, Lawrence S, Bonisch M, Gibbons K, Moloney S, Waugh J, Hobbins S, Grew S, Fahy R, Dalziel SR, Schibler A. | JAMA. 2023 Jan 17;329(3):224-234
DOI: https://doi.org/10.1001/jama.2022.21805
Keywords: Aucun

Original Investigation

Introduction : Nasal high-flow oxygen therapy in infants with bronchiolitis and hypoxia has been shown to reduce the requirement to escalate care. The efficacy of high-flow oxygen therapy in children aged 1 to 4 years with acute hypoxemic respiratory failure without bronchiolitis is unknown.
Objective: To determine the effect of early high-flow oxygen therapy vs standard oxygen therapy in children with acute hypoxemic respiratory failure.

Méthode : A multicenter, randomized clinical trial was conducted at 14 metropolitan and tertiary hospitals in Australia and New Zealand, including 1567 children aged 1 to 4 years (randomized between December 18, 2017, and March 18, 2020) requiring hospital admission for acute hypoxemic respiratory failure. The last participant follow-up was completed on March 22, 2020.
Interventions: Enrolled children were randomly allocated 1:1 to high-flow oxygen therapy (n = 753) or standard oxygen therapy (n = 764). The type of oxygen therapy could not be masked, but the investigators remained blinded until the outcome data were locked.
Main outcomes and measures: The primary outcome was length of hospital stay with the hypothesis that high-flow oxygen therapy reduces length of stay. There were 9 secondary outcomes, including length of oxygen therapy and admission to the intensive care unit. Children were analyzed according to their randomization group.

Résultats : Of the 1567 children who were randomized, 1517 (97%) were included in the primary analysis (median age, 1.9 years [IQR, 1.4-3.0 years]; 732 [46.7%] were female) and all children completed the trial. The length of hospital stay was significantly longer in the high-flow oxygen group with a median of 1.77 days (IQR, 1.03-2.80 days) vs 1.50 days (IQR, 0.85-2.44 days) in the standard oxygen group (adjusted hazard ratio, 0.83 [95% CI, 0.75-0.92]; P < .001). Of the 9 prespecified secondary outcomes, 4 showed no significant difference. The median length of oxygen therapy was 1.07 days (IQR, 0.50-2.06 days) in the high-flow oxygen group vs 0.75 days (IQR, 0.35-1.61 days) in the standard oxygen therapy group (adjusted hazard ratio, 0.78 [95% CI, 0.70-0.86]). In the high-flow oxygen group, there were 94 admissions (12.5%) to the intensive care unit compared with 53 admissions (6.9%) in the standard oxygen group (adjusted odds ratio, 1.93 [95% CI, 1.35-2.75]). There was only 1 death and it occurred in the high-flow oxygen group.

Conclusion : Nasal high-flow oxygen used as the initial primary therapy in children aged 1 to 4 years with acute hypoxemic respiratory failure did not significantly reduce the length of hospital stay compared with standard oxygen therapy.

Conclusion (proposition de traduction) : L'oxygène nasal à haut débit utilisé comme traitement initial de première intention chez les enfants âgés de 1 à 4 ans souffrant d'insuffisance respiratoire hypoxémique aiguë n'a pas réduit de manière significative la durée du séjour à l'hôpital par rapport à l'oxygénothérapie standard.

Are Pelvic Binders an Effective Prehospital Intervention?.
Bangura A, Burke CE, Enobun B, O'Hara NN, Gary JL, Floccare D, Chizmar T, Pollak AN, Slobogean GP. | Prehosp Emerg Care. 2023;27(1):24-30
DOI: https://doi.org/10.1080/10903127.2021.2015024
Keywords: Aucun

Article

Introduction : Widespread adoption of prehospital pelvic circumferential compression devices (PCCDs) by emergency medical services (EMS) systems has been slow and variable across the United States. We sought to determine the frequency of prehospital PCCD use by EMS providers. Secondarily, we hypothesized that prehospital PCCD use would improve early hemorrhagic shock outcomes.

Méthode : We conducted a single-center retrospective cohort study of 162 unstable pelvic ring injuries transported directly to our center by EMS from 2011 to 2020. Included patients received a PCCD during their resuscitation (prehospital or emergency department). Prehospital treatment details were obtained from the EMS medical record. The primary outcome was the proportion of patients who received a PCCD by EMS before hospital arrival. Secondarily, we explored factors associated with receiving a prehospital PCCD, and its association with changes in vital signs, blood transfusion, and mortality.

Résultats : EMS providers documented suspicion of a pelvic ring fracture in 85 (52.8%) patients and 52 patients in the cohort (32.2%) received a prehospital PCCD. Wide variation in prehospital PCCD use was observed based on patient characteristics, geographic location, and EMS provider level. Helicopter flight paramedics applied a prehospital PCCD in 46% of the patients they transported (38/83); in contrast, the EMS organizations geographically closest to our hospital applied a PCCD in ≤5% of cases (2/47). Other predictors associated with receiving a prehospital PCCD included lower body mass index (p = 0.005), longer prehospital duration (p = 0.001) and lower Injury Severity Score (p < 0.05). We were unable to identify any improvements in clinical outcomes associated with prehospital PCCD, including early vital signs, number of blood transfusions within 24 hours, or mortality during admission (p > 0.05).

Conclusion : Our results demonstrate wide practice variation in the application of prehospital PCCDs. Although disparate PCCD application across the state is likely explained by differences across EMS organizations and provider levels, our study was unable to identify any clinical benefits to the prehospital use of PCCDs. It is possible that the benefits of a prehospital PCCD can only be observed in the most displaced fracture patterns with the greatest early hemodynamic instability.

Conclusion (proposition de traduction) : Nos résultats démontrent une grande variation de pratique dans l'application des ceinture pelvienne préhospitalière. Bien que l'application disparate de ceinture pelvienne à travers l'état s'explique probablement par les différences entre les organisations de services médicaux d'urgence et les niveaux de prestataires, notre étude n'a pas pu identifier de bénéfices cliniques à l'utilisation préhospitalière de ceinture pelvienne. Il est possible que les avantages d'un dispositif de ceinture pelvienne préhospitalière ne puissent être observés que dans les modèles de fractures les plus déplacées avec la plus grande instabilité hémodynamique précoce.

Characteristics and Outcomes of Prehospital Tourniquet Use for Trauma in the United States.
Hashmi ZG, Hu PJ, Jansen JO, Butler FK, Kerby JD, Holcomb JB. | Prehosp Emerg Care. 2023;27(1):31-37
DOI: https://doi.org/10.1080/10903127.2021.2025283
Keywords: Aucun

Article

Introduction : The use of the extremity tourniquet in military environments has reduced preventable deaths due to exsanguinating hemorrhage, leading to increased use in civilian settings. However, the outcomes of contemporary prehospital tourniquet use in civilian settings are not well-described nationally. The objective of this study was to describe the characteristics and outcomes following prehospital tourniquet use by emergency medical services (EMS) in the United States.

Méthode : All trauma activations reported to the National EMS Information System 2019 (NEMSIS) were included. Patients who had ≥1 tourniquet applied were identified. Descriptive analyses were used to compare characteristics between tourniquet and no-tourniquet cohorts. Coarsened exact matching was performed to generate a k2k match (on age, sex, lowest-systolic blood pressure, initial patient acuity, provider's initial impression, injury mechanism, and presence of upper/lower extremity injuries) and used to compare outcomes. Trauma patients who may have potentially benefited from tourniquet application (extremity injury, shock index ≥1 and no documented tourniquet application) were identified.

Résultats : A total of 7,161 tourniquets were applied among 4,571,379 trauma activations (1.6/1000 activations). Patients in the tourniquet cohort were younger (40 ± 18 vs 52 ± 26 mean ± SD years), more hypotensive (16.1% vs. 2.5%) and had higher initial acuity (65.0% critical/emergent vs. 20.6%) [p < 0.01 for all]. A total of 7,074 patients in the tourniquet cohort were matched with 7,074 patients in the non-tourniquet cohort. Post-match analysis revealed that the patients in tourniquet cohort had a higher final acuity (80.8% vs. 75.0%, p < 0.01), lower scene-time (15.4 ± 13.6 vs. 17.0 ± 14.2 mean ± SD minutes, p < 0.01), and higher survival-to-hospital (83.6% vs. 75.1%, p < 0.01). A total of 141,471 trauma patients who may have potentially benefited from tourniquet application were identified.

Conclusion : Prehospital tourniquet use by EMS in the United States is associated with lower scene-time and improved survivability to hospital. Results indicate that patients might benefit from wider tourniquet use in the civilian prehospital setting.

Conclusion (proposition de traduction) : L'utilisation préhospitalière du garrot par les services médicaux d'urgence aux États-Unis est associée à une réduction du temps passé sur les lieux et à une amélioration des chances de survie à l'hôpital. Les résultats indiquent que les patients pourraient bénéficier d'une utilisation plus large du garrot dans le cadre préhospitalier civil.

Extracorporeal cardiopulmonary resuscitation for cardiac arrest: An updated systematic review.
Holmberg MJ, Granfeldt A, Guerguerian AM, Sandroni C, Hsu CH, Gardner RM, Lind PC, Eggertsen MA, Johannsen CM, Andersen LW. | Resuscitation. 2023 Jan;182:109665
DOI: https://doi.org/10.1016/j.resuscitation.2022.12.003  | Télécharger l'article au format  
Keywords: Cardiac Arrest; Cardiopulmonary Bypass; Cardiopulmonary Resuscitation; Extracorporeal Cardiopulmonary Resuscitation; Extracorporeal Membrane Oxygenation.

Review

Introduction : To provide an updated systematic review on the use of extracorporeal cardiopulmonary resuscitation (ECPR) compared with manual or mechanical cardiopulmonary resuscitation during cardiac arrest.

Méthode : This was an update of a systematic review published in 2018. OVID Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for randomized trials and observational studies between January 1, 2018, and June 21, 2022. The population included adults and children with out-of-hospital or in-hospital cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed bias. The certainty of evidence was evaluated using GRADE.

Résultats : The search identified 3 trials, 27 observational studies, and 6 cost-effectiveness studies. All trials included adults with out-of-hospital cardiac arrest and were terminated before enrolling the intended number of subjects. One trial found a benefit of ECPR in survival and favorable neurological status, whereas two trials found no statistically significant differences in outcomes. There were 23 observational studies in adults with out-of-hospital cardiac arrest or in combination with in-hospital cardiac arrest, and 4 observational studies in children with in-hospital cardiac arrest. Results of individual studies were inconsistent, although many studies favored ECPR. The risk of bias was intermediate for trials and critical for observational studies. The certainty of evidence was very low to low. Study heterogeneity precluded meta-analyses. The cost-effectiveness varied depending on the setting and the analysis assumptions.

Conclusion : Recent randomized trials suggest potential benefit of ECPR, but the certainty of evidence remains low. It is unclear which patients might benefit from ECPR.

Conclusion (proposition de traduction) : Des essais randomisés récents suggèrent un bénéfice potentiel de la réanimation cardio-pulmonaire extracorporelle, mais la certitude des preuves reste faible. On ne sait pas exactement quels patients pourraient bénéficier d'une réanimation cardiopulmonaire extracorporelle.

Sodium bicarbonate administration is associated with improved survival in asystolic and PEA Out-of-Hospital cardiac arrest.
Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ. | Resuscitation. 2023 Jan;182:109641
DOI: https://doi.org/10.1016/j.resuscitation.2022.11.007  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Emergency medical services; Out-of-hospital cardiac arrest; Sodium bicarbonate.

Clinical paper

Introduction : Sodium bicarbonate ("bicarb") administration in out-of-hospital cardiac arrest (OHCA) is intended to counteract acidosis, although there is limited clinical evidence to support its routine administration. We sought to analyze the association of bicarb with resuscitation outcomes in non-traumatic OHCA.

Méthode : Records were obtained from the 2019-2020 ESO Data Collaborative prehospital electronic health record database, spanning 1,322 agencies in 50 states. OHCAs with resuscitations lasting 5-40 minutes were stratified by presenting ECG rhythm (VF/VT, pulseless electrical activity (PEA), asystole) for analysis. The outcomes of any prehospital ROSC and survival to discharge were compared by bicarb status using propensity score matching and logistic regressions with/without adjustment.

Résultats : We analyzed 23,567 records, 6,663 (28.3 %) of which included bicarb administration. Most patients presented in asystole (67.4 %), followed by PEA (16.6 %), and VF/VT (15.1 %). In the propensity-matched cohort, ROSC was higher in the bicarb group for the asystole group (bicarb 10.6 % vs control 8.8 %; p = 0.013), without differences in the PEA or VF/VT groups. Survival was higher in the bicarb group for asystole (bicarb 3.3 % vs control 2.4 %; p = 0.020) and for PEA (bicarb 8.1 % vs control 5.4 %; p = 0.034), without differences in the VF/VT group. These results were consistent across adjusted/unadjusted logistic regression analyses: bicarb was associated with ROSC and survival in asystole [uOR (95 % CI): ROSC 1.23 (1.04-1.44), survival 1.40 (1.05-1.87)] and with survival in PEA (1.54 (1.03-2.31).

Conclusion : Bicarb was associated with survival in non-shockable rhythms and ROSC in asystole. Findings from this observational study should be corroborated with prospective randomized work.

Conclusion (proposition de traduction) : Le bicarbonate a été associé à la survie en cas de rythme non choquable et de réanimation dans l'asystolie. Les résultats de cette étude observationnelle devraient être corroborés par des travaux prospectifs randomisés.

The use of 100% compared to 50% oxygen during ineffective experimental cardiopulmonary resuscitation improves brain oxygenation.
Nelskylä A, Humaloja J, Litonius E, Pekkarinen P, Babini G, Mäki-Aho TP, Heinonen JA, Skrifvars MB. | Resuscitation. 2023 Jan;182:109656
DOI: https://doi.org/10.1016/j.resuscitation.2022.11.022  | Télécharger l'article au format  
Keywords: Brain tissue oxygen; CPR; Cardiac arrest; Mechanical chest compressions; Regional cerebral oximetry.

Experimental paper

Introduction : Perfusion pressure and chest compression quality are generally considered key determinants of brain oxygenation during cardiopulmonary resuscitation (CPR) and the impact of oxygen administration is less clear. We compared ventilation with 100% and 50% oxygen during ineffective manual chest compressions and hypothesized that 100% oxygen would improve brain oxygenation.

Méthode : Ventricular fibrillation (VF) was induced electrically in anaesthetized pigs and left untreated for 5 minutes, followed by randomization to ineffective manual CPR with ventilation of 50% or 100% oxygen. The first defibrillation was performed 10 minutes after induction of VF, and CPR continued with mechanical chest compressions (LUCAS2^™) and defibrillation every 2 minutes until 36 minutes or return of spontaneous circulation (ROSC). Brain oxygenation was measured with near-infrared spectroscopy (rSO₂) and invasive brain tissue oxygen (PbtO₂) with a probe (NEUROVENT-PTO, RAUMEDIC) inserted into frontal brain tissue. Cerebral oxygenation was compared between groups with Mann-Whitney U tests and linear mixed models.

Résultats : Twenty-eight pigs were included in the study: 14 subjects in each group. During ineffective chest compressions relative PbtO₂ was higher in the group ventilated with 100% compared to 50% oxygen (5.2 mmHg [1.4-20.5] vs 2.2 [0.8-6.8], p = 0.001), but there was no difference in rSO₂ (22% [16-28] vs 18 [15-25], p = 0.090). The use of 50% or 100% oxygen showed no difference in relative PbtO₂ (p = 1.00) and rSO₂ (p = 0.206) during mechanical CPR.

Conclusion : The use of 100% compared to 50% oxygen during ineffective manual CPR improved brain oxygenation measured invasively in brain tissue, but there was no difference in rSO₂.

Conclusion (proposition de traduction) : L'utilisation de 100 % d'oxygène par rapport à 50 % pendant une RCP manuelle inefficace a amélioré l'oxygénation du cerveau mesurée de manière invasive dans le tissu cérébral, mais il n'y avait pas de différence en ce qui concerne la spectroscopie dans le proche infrarouge (rSO₂).

Diagnostic performance of biomarker S100B and guideline adherence in routine care of mild head trauma.
Faisal M, Vedin T, Edelhamre M, Forberg JL. | Scand J Trauma Resusc Emerg Med. 2023 Jan 10;31(1):3
DOI: https://doi.org/10.1186/s13049-022-01062-w  | Télécharger l'article au format  
Keywords: Adherence; Intracranial hemorrhage; S100B; SNC; Traumatic brain injury.

Original Research

Introduction : The Scandinavian Neurotrauma Committee (SNC) has recommended the use of serum S100B as a biomarker for mild low-risk Traumatic brain injuries (TBI). This study aimed to assess the adherence to the SNC guidelines in clinical practice and the diagnostic performance of S100B in patients with TBI. The aims of this study were to examine adherence to the SNC guideline and the diagnostic accuracy of serum protein S100B.

Méthode : Data of consecutive patients of 18 years and above who presented to the emergency department (ED) at Helsingborg Hospital with isolated head injuries, were retrieved from hospital records. Patients with multitrauma, follow-up visits, and visits managed by a nurse without physician involvement were excluded.

Résultats : A total of 1671 patients were included of which 93 (5.6%) had intracranial hemorrhage. CT scans were performed in 62% of patients. S100B was measured in 26% of patients and 30% of all measurements targeted the low-risk mild head injuries indicated by the guideline. S100B's recommended cut-off value (≥ 0.10 µg/L) had a 100% sensitivity, 47% specificity, 10.1% positive predictive value, and 100% negative predictive value-if applied to the target SNC category (SNC 4). If applied to all patients tested, the sensitivity was 93% for traumatic intracranial hemorrhage (TICH). Current ED practices were adherent to the SNC guideline in 55% of patients. Non-adherent practices occurred in 64% of patients with low-risk mild head injuries (SNC4) including overtesting or undertesting of S100B and CT scans.

Conclusion : Adherence to guidelines was low and associated with a higher admission rate than non-adherence practice but no significant increase in missed TICH or death associated with non-adherence to guideline was found. In routine care, we found that the sensitivity and NPV of serum protein S100B was excellent and safely ruled out TICH when measured in the patient category recommended by the guideline. However, measuring serum protein S100B in patients not recommended by the guideline rendered unacceptably low sensitivity with possible missed TICHs as a consequence. To further delineate the magnitude and impact of non-adherence, more studies are needed.

Conclusion (proposition de traduction) : L'adhésion aux lignes directrices était faible et associée à un taux d'admission plus élevé que la pratique de non-adhésion, mais aucune augmentation significative de l'hémorragie intracrânienne traumatique manquée ou du décès associé à la non-adhésion aux lignes directrices n'a été trouvée. Dans le cadre des soins de routine, nous avons constaté que la sensibilité et la VPN de la protéine S100B sérique étaient excellentes et permettaient d'exclure en toute sécurité une hémorragie intracrânienne traumatique lorsqu'elle était mesurée dans la catégorie de patients recommandée par la directive. Cependant, la mesure de la protéine S100B sérique chez les patients non concernés par la recommandation a donné une sensibilité inacceptable, avec pour conséquence la possibilité de manquer des hémorragies intracrâniennes traumatiques. Pour mieux définir l'ampleur et l'impact de la non-adhésion, d'autres études sont nécessaires.

Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema.
Arthur J, Caro D, Topp S, Chadwick S, Driver B, Henson M, Norse A, Spencer H, Godwin SA, Guirgis F. | Am J Emerg Med. 2023 Jan;63:44-49
DOI: https://doi.org/10.1016/j.ajem.2022.10.017
Keywords: Airway; Allergic reaction; Angioedema; Critical care.

Research article

Introduction : The objective of this study is to identify predictors of airway compromise among patients presenting to the emergency department with angioedema in order to develop and validate a risk score to augment clinician gestalt regarding need for intubation.

Méthode : Retrospective chart review of emergency department patients with a diagnosis of angioedema. After data extraction they were randomly divided into a training and test set. The training set was used to identify factors associated with intubation and to develop a model and risk score to predict intubation. The model and risk score were then applied to the test set.

Résultats : A total of 594 patients were included. Past medical history of hypertension, presence of shortness of breath, drooling, and anterior tongue or pharyngeal swelling were independent predictors included in our final model and risk score. The Area Under the Curve for the Receiver Operator Characteristic curve was 87.55% (83.42%-91.69%) for the training set and 86.1% (77.62%-94.60%) for the test set.

Conclusion : A simple scoring algorithm may aid in predicting angioedema patients at high and low risk for intubation. External validation of this score is necessary before wide-spread adoption of this decision aid.

Conclusion (proposition de traduction) : Un algorithme de score simple peut aider à prédire les patients présentant un angioedème à haut et bas risque d'intubation. Une validation externe de ce score est nécessaire avant l'adoption à grande échelle de cette aide à la décision.

Comparison of sinus conversion rates and body weights after 6 mg adenosine administration in supraventricular tachycardia.
An J, Kim H, Ko Y, Yang H. | Am J Emerg Med. 2023 Jan;63:55-60
DOI: https://doi.org/10.1016/j.ajem.2022.10.024
Keywords: Adenosine; Adult; Emergency department; Sinus rhythm; Supraventricular tachycardia.

Research article

Introduction : To evaluate the relationship between body weight and the success rate of supraventricular tachycardia (SVT) termination after an initial 6-mg adenosine administration.

Méthode : This retrospective observational study was conducted with medical records of patients who visited a single tertiary emergency department and underwent an electrophysiologic study with an SVT diagnosis. Patients under 18 years of age or those with SVT aberrancy, recurring SVT after radiofrequency catheter ablation, premedication of non-dihydropyridine calcium channel blocker, and signs of shock were excluded.

Résultats : Data from 124 patients were collected. There were 69 women (55.6%); mean age, 49.7 years. The mean weight and height were 66.8 kg and 164.8 cm, respectively. Adenosine dose was 0.09 mg/kg. For the first sinus conversion (SC) success group (83 patients, 67%), the mean weight, height, and adenosine dose were 61.0 ± 11.5 kg, 161.9 ± 8.1 cm, and 0.10 ± 0.02 mg/kg. For the first SC failure group, these values were 78.4 ± 17.0 kg, 170.7 ± 8.9 cm, and 0.079 ± 0.02 mg/kg, respectively. To evaluate factors associated with the first SC, we performed bivariate logistic regression with weight (odds ratio [OR]: 1.093; 95% confidence interval [CI]: 1.045-1.144; P < 0.001) and height (OR: 1.071; 95% CI: 1.008-1.138; P = 0.027). Receiver operating characteristics curves and the cut-off values for adenosine dose and weight were 0.90 mg/kg and 66.5 kg with 71.1% sensitivity and 73.2% specificity (area under the curve: 0.814; 95% CI: 0.73-0.90; P < 0.001).

Conclusion : Weight and height were significant predictors of the first SC success rate among SVT patients. Consequentially, it is necessary to consider other adenosine administration methods, including increasing the initial drug dose or changing the flushing strategy after adenosine injection.

Conclusion (proposition de traduction) : Le poids et la taille étaient des facteurs prédictifs significatifs du taux de réussite de la première conversion sinusale chez les patients présentant une tachycardie supraventriculaire. Par conséquent, il est nécessaire d'envisager d'autres méthodes d'administration de l'adénosine, notamment en augmentant la dose initiale du médicament ou en modifiant la stratégie de rinçage après l'injection d'adénosine.

Diagnostic value of end-tidal carbon dioxide in the differential diagnosis of unstable angina and non-cardiac chest pain.
Duyan M, Vural N. | Am J Emerg Med. 2023 Jan;63:69-73
DOI: https://doi.org/10.1016/j.ajem.2022.10.026
Keywords: Acute coronary syndrome; Diagnosis; End-tidal carbon dioxide; Non-cardiac chest pain; Unstable angina pectoris.

Research article

Introduction : This study aims to investigate the diagnostic value of End-tidal carbon dioxide (ETCO₂) measured non-invasively at the bedside in order to distinguish between unstable angina pectoris (UAP) and non-cardiac chest pain among patients who present to the emergency department with chest pain without a history of cardiac pathology.

Méthode : This clinical study is a prospective case-control study among patients presenting to the emergency department of a tertiary hospital with chest pain. After evaluating the inclusion and exclusion criteria, the patients were divided into two groups: 62 patients with UAP and 62 patients with non-cardiac chest pain. Receiver Operating Characteristic (ROC) analysis was used to determine the cut-off in diagnostic value measurements. For UAP prediction, the odds ratio of ETCO₂ (including 95% confidence intervals) was calculated using univariate with binary logistic regression analysis.

Résultats : ETCO₂ had an excellent diagnostic power in detecting UAP, with 35 cut-offs determined (AUC: 0.84, 95% Cl: 0.76-0.90, p < 0.001). When ETCO₂, which affects both non-cardiac chest pain and UAP, is evaluated, an ETCO₂ of <35 is statistically significant and 9.74 times more common among UAP patients than patients with non-cardiac chest pain.

Conclusion : ETCO₂, a non-invasive parameter that can be measured immediately at the bedside, may be proposed as a potential biomarker for differentiating patients with UAP from those with non-cardiac chest pain.

Conclusion (proposition de traduction) : L'ETCO₂, un paramètre non invasif qui peut être mesuré immédiatement au chevet du patient, peut être proposé comme biomarqueur potentiel pour différencier les patients souffrant d'angor instable de ceux souffrant de douleurs thoraciques non cardiaques.

High-dose nitroglycerin infusion description of safety and efficacy in sympathetic crashing acute pulmonary edema: The HI-DOSE SCAPE study.
Houseman BS, Martinelli AN, Oliver WD, Devabhakthuni S, Mattu A. | Am J Emerg Med. 2023 Jan;63:74-78
DOI: https://doi.org/10.1016/j.ajem.2022.10.018
Keywords: Acute decompensated heart failure; High-dose nitroglycerin; Hypertensive emergency; Nitroglycerin; Pulmonary edema; SCAPE.

Research article

Introduction : Sympathetic crashing acute pulmonary edema (SCAPE) is a medical emergency in which severe, acute elevation in blood pressure results in acute heart failure and fluid accumulation in the lungs. Without prompt recognition and treatment, the condition often progresses rapidly to respiratory failure necessitating intubation and intensive care unit (ICU) admission. In addition to non-invasive positive pressure ventilation (NIPPV), high-dose nitroglycerin (HDN) has become a mainstay of treatment; however, an optimal dosing strategy has not been established.

Méthode : The purpose of this study was to describe the characteristics and outcomes of patients who received an HDN infusion (≥ 100 μg/min) for the management of SCAPE in the Emergency Department (ED) of a large urban academic medical center. Outcomes were also analyzed to determine predictors of safety and efficacy including use of adjunct medication therapies.

Résultats : There were 67 adult patients who received HDN infusion for SCAPE from January 1, 2018 to December 31, 2018. The median (IQR) systolic blood pressure (SBP) on initiation of HDN infusion was 211 (192-233) mmHg. Patients were 63% male, 84% black, 51% had a history of heart failure (HF), and 36% had end-stage renal disease (ESRD). IV nitroglycerin (NTG) was initiated at a median (IQR) dose of 100 (100-200) mcg/min with median (IQR) peak rate in the first hour of 200 (127.5-200) mcg/min and an absolute maximum observed rate of 400 μg/min overall. 73% of patients received NIPPV, 48% sublingual (SL) or IV bolus nitroglycerin before HDN infusion, 58% loop diuretic, and 34% angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB). Rates of ICU admission, intubation, acute kidney injury (AKI) at 48 h, and hypotension were 37%, 21%, 13%, and 4% respectively.

Conclusion : This is the largest to date study describing the use of an HDN infusion (≥100 μg/min) strategy for the management of SCAPE. HDN infusion may be a safe alternative strategy to intermittent bolus HDN.

Conclusion (proposition de traduction) : Il s'agit de la plus grande étude à ce jour décrivant l'utilisation d'une stratégie de perfusion de dérivés nitrés à forte dose (≥100 μg/min) dans la prise en charge de l'œdème pulmonaire aigu par hyperstimulation sympathique (sympathetic crashing acute pulmonary edema - SCAPE). La perfusion de dérivés nitrés à forte dose peut être une stratégie alternative sûre à la nitroglycérine à forte dose en bolus intermittent.

Commentaire : Voir :
Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021 Jun;44:262-266  .

Ultrasound-guided selective peripheral nerve block compared with the sub-dissociative dose of ketamine for analgesia in patients with extremity injuries.
Mohanty CR, Varghese JJ, Panda R, Sahoo S, Mishra TS, Radhakrishnan RV, Topno N, Hansda U, Shaji IM, Behera SHP. | Am J Emerg Med. 2023 Jan;63:94-101
DOI: https://doi.org/10.1016/j.ajem.2022.10.020
Keywords: Extremity injuries; Ketamine; Peripheral nerve block; Sub-dissociate dose.

Research article

Introduction : To compare the analgesic efficacy of ultrasound-guided selective peripheral nerve block (PNB) and sub-dissociative dose ketamine (SDK) for management of acute pain in patients with extremity injuries presenting to the emergency department (ED).

Méthode : This prospective, open-label randomized clinical trial was conducted in the ED of a tertiary care Institute. The patients were provided with either ultrasound-guided selective PNB or SDK. The primary outcome was a reduction in pain in numerical rating scale (NRS) by at least 3 points without rescue analgesia. The secondary outcomes were the need for rescue analgesia, adverse events, and patient satisfaction on either arm.

Résultats : A total of 111 patients with isolated traumatic extremity injuries were included in the final analysis. The NRS score was significantly lower in the PNB group compared to the SDK group at 30, 60,120, 180-, and 240-min post-intervention [group ∼ time interaction, F (5, 647) = 21.53, p ≤ 0.001]. All the patients in the PNB group exhibited primary outcome (NRS ≥3 reductions) at 30 min post-intervention compared with 36 (65%) in the SDK group [-1.02(-1.422,0.622)]. Rescue analgesia was required in 10 (18%) patients in the SDK group compared to none in the PNB group [0.663(0.277,1.050)]. The decrease in NRS score from baseline at 30 min was significantly higher in PNB groups compared to the SDK group [-2.166(-2.640, -1.692)]. The most common side effect reported in the SDK group was dizziness 35(64%), followed by nausea 15(27%). None of the patients in the PNB group reported any complications. Patient satisfaction was higher in the PNB group than SDK group.

Conclusion : The study provides evidence that ultrasound-guided PNB is superior to SDK in terms of its analgesic efficacy in the management of acute pain due to extremity injuries and is associated with higher patient satisfaction. The need for rescue analgesia was significantly less in the PNB group. SDK was associated with a high incidence of dizziness and nausea.

Conclusion (proposition de traduction) : L'étude fournit des preuves que le bloc nerveux périphérique guidé par ultrasons est supérieur à la kétamine à dose sub-dissociative en termes d'efficacité analgésique dans la gestion de la douleur aiguë due aux blessures des extrémités et est associé à une plus grande satisfaction du patient. La nécessité d'une analgésie de secours était significativement moindre dans le groupe du bloc nerveux périphérique. La kétamine à dose sub-dissociative était associée à une incidence élevée de vertiges et de nausées.

Commentaire : La dose initiale dite sub-dissociative de kétamine est habituellement de 0.5 mg/kg IV (la dose dite dissociative étant de 1 mg/kg IV).

Clinician assessment of blood alcohol levels among emergency department patients.
Marco CA, Studebaker H, Repas SJ, Zinn E, Turner C, Clark A, Orshoki O, Hefner D. | Am J Emerg Med. 2023 Jan;63:110-112
DOI: https://doi.org/10.1016/j.ajem.2022.10.045
Keywords: Alcohol; Emergency.

Short communication

Introduction : Alcohol intoxication is a significant public health concern and is commonly seen among emergency department (ED) patients. This study was undertaken to identify the accuracy of clinician assessment of blood alcohol levels among emergency department patients.

Méthode : This prospective survey study was conducted at a Level 1 Trauma Center. Eligible study participants included physicians, nurses, and medical students involved in the care of patients who had BAC. Clinicians estimated the BAC prior to results availability.

Résultats : Among 243 clinicians, the mean difference between the estimated BAC and actual BAC was 17.4 (95% CI: 4.7 to 30.1). Providers tended to overestimate the actual BAC level. The accuracy between roles (attendings, residents, RNs, students) was not significant (ANOVA p-value 0.90). Accuracy was not correlated with age of the patient (Pearson correlation 0.04, p-value 0.54). Accuracy was not associated with the patient's gender (Student's t-test two-tailed p-value 0.90), ethnicity (White versus all others, t-test p-value 0.31), nor insurance (government versus not government, t-test p-value 0.81). The average accuracy value was associated with mode of arrival (t-test p-value 0.003). The average accuracy for walk-in subjects was -14.9 (CI: -32.8 to 3.1) compared to ambulance arrivals 28.3 (CI: 12.7 to 44.0). Providers underestimated BAC for walk-ins and overestimated BAC for ambulance arrivals. Among 107 patients with a BAC of 0, clinician estimates ranged from 0 to 350. Clinicians estimated non-zero BAC levels in 17% of patients with BAC of 0 (N = 18).

Conclusion : Clinicians' estimates of BAC were often inaccurate, and often overestimated the BAC.

Conclusion (proposition de traduction) : Les estimations du taux d'alcoolémie par les cliniciens étaient souvent inexactes, et surestimaient souvent le taux d'alcoolémie.

The benefits and clinical application of the digital rectal exam in trauma populations: Towards enhancing patient safety and quality outcomes.
Beeton G, Alter N, Zagales R, Wajeeh H, Elkbuli A. | Am J Emerg Med. 2023 Jan;63:132-137
DOI: https://doi.org/10.1016/j.ajem.2022.11.004
Keywords: Digital rectal exam; Outcomes; Reliability; Trauma; Validity.

Review article

Introduction : Current literature contains an extensive number of analyses on the diagnostic value and utilization of the direct rectal exam in trauma patients. Presently, ATLS recommends the application of the digital rectal exam in trauma patients following a primary assessment of traumatic injuries. We aim to assess the validity and diagnostic value of the digital rectal exam in trauma populations.

Méthode : PubMed, Google Scholar, EMBASE, ProQuest, and CINAHL databases were searched for studies from the date of database conception to August 6th, 2022. Studies that assessed the validity of the digital rectal exam performed in the emergency department or trauma bay, in both adult and pediatric trauma patients were included. Study outcomes and measurements of validity were summarized and compared.

Résultats : A total of 9 studies met inclusion criteria for both adult and pediatric trauma populations. The sensitivity of the digital rectal exam in detecting both spinal cord and urethral injuries in adult trauma populations ranged from 0 to 50%, while the sensitivity in detecting gastrointestinal injuries ranged from 0% to 51%. When compared to other clinical indicators, the digital rectal exam was consistently worse at detecting injuries. Within the pediatric trauma populations, the digital rectal exam resulted in high false negative rates ranging from 66% to 100%, failing to detect all urethral and gastrointestinal injuries and pelvic fractures.

Conclusion : The use of digital rectal exams in trauma patients illustrates limited to no validity and reliability in assessing pertinent injuries and does not influence the management of injuries. Trauma societies should consider creating guidelines and algorithms to clarify the use of digital rectal exams in specific situations and injury types.

Conclusion (proposition de traduction) : L'utilisation de le toucher rectal chez les patients traumatisés a une validité et une fiabilité limitées, voire inexistantes, pour évaluer les blessures importantes et n'influence pas la gestion des lésions. Les sociétés de traumatologie devraient envisager de créer des directives et des algorithmes pour clarifier l'utilisation du toucher rectal dans des situations et des types de blessures spécifiques.

Emergency contraception in the emergency department.
Mazer-Amirshahi M, Ye P. | Am J Emerg Med. 2023 Jan;63:102-105
DOI: https://doi.org/10.1016/j.ajem.2022.10.034
Keywords: Emergency contraception; Emergency department.

Review article

Introduction : On June 24, 2022, the Supreme Court overturned Roe v. Wade, which will limit legal abortion in many areas of the U.S., making the need for effective emergency contraception even more critical.

Méthode : This narrative review focuses on the approach to providing safe and effective emergency contraception in the emergency department (ED) with a focus on agents that are used in the U. S.; however, many of the agents discussed are also available and utilized in other countries.

Résultats : Emergency contraception methods included in this review are, ulipristal, levonorgestrel, combined oral contraceptive pills, and copper intrauterine devices (IUDs).

Conclusion : The efficacy of products used for emergency contraception depend on patient and temporal factors. Emergency physicians must have an understanding of the optimal use of these agents to prevent unwanted pregnancy, particularly in the setting of restricted abortion access.

Conclusion (proposition de traduction) : L'efficacité des produits utilisés pour la contraception d'urgence dépend de facteurs liés au patient et au facteur temps. Les urgentistes doivent comprendre l'utilisation optimale de ces médicaments pour prévenir une grossesse non désirée, en particulier dans le contexte d'un accès restreint à l'avortement.

Analysis of Clinical and Laboratory Risk Factors of Post-Traumatic Intracranial Hemorrhage in Patients on Direct Oral Anticoagulants with Mild Traumatic Brain Injury: An Observational Multicenter Cohort.
Turcato G, Zaboli A, Bonora A, Ricci G, Zannoni M, Maccagnani A, Zorzi E, Pfeifer N, Brigo F.. | J Emerg Med. 2023 Jan;64(1):1-13.
DOI: https://doi.org/10.1016/j.jemermed.2022.09.039
Keywords: DOAC; Direct oral anticoagulant; Intracranial hemorrhage; Mild traumatic brain injury; Oral anticoagulant therapy; Risk factor.v

Research article

Introduction : Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED).
/ Objective: This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI.

Méthode : A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED.

Résultats : Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumavtic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients.

Conclusion : Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.

Conclusion (proposition de traduction) : L'évaluation des caractéristiques cliniques présentées à l'admission aux urgences peut aider à identifier les patients sous anticoagulants oraux directs souffrant d'un traumatisme cérébral léger et présentant un risque d'hémorragie intracrânienne.

Is Lateral Decubitus or Upright Positioning Optimal for Lumbar Puncture Success in a Teaching Hospital?.
Thundiyil JG, O'Brien JF, Tymkowicz AE, Papa L. | J Emerg Med. 2023 Jan;64(1):14-21
DOI: https://doi.org/10.1016/j.jemermed.2022.09.002
Keywords: Lumbar puncture; Medical education; Positioning; Procedure.

Research article

Introduction : Lumbar puncture is a common procedure performed by emergency physicians and trainees. The optimal patient positioning for lumbar puncture procedures has not been studied adequately.

Méthode : We performed a prospective randomized study in an urban, level I academic trauma center. Patients of all ages were included. Patients were randomized to either lateral decubitus or upright positioning. Patient demographic characteristics, level of physician training and experience, number of needle insertions and redirections, need for repositioning, alternative operator use, and laboratory results of the cerebrospinal fluid were recorded. We compared the success rate of each position as our primary outcome measure. We also evaluated number of needle insertions and re-directions and success rates based on experience and patient age.

Résultats : A total of 116 patients were enrolled, with 55 patients assigned to lateral decubitus and 61 to upright position for initial lumbar puncture attempt. Spinal fluid was obtained successfully in 47 of the lateral decubitus group (85.5%; 95% CI 73.8-92.4%) vs. 49 (80.3%; 95% CI 68.7-88.4%) in the upright assignment group. Comparable results were also obtained for first-pass success, number of failures, and number of bloody taps. Postgraduate year 2 residents or those with 31-50 previous lumbar punctures had the highest success rates at 94.3% (95% CI 81.2-98.4%) and 90.3% (95% CI 75.1-96.7%), respectively.

Conclusion : Lateral decubitus and upright positioning for emergency lumbar puncture yielded equal success rates in emergency physicians and trainees.

Conclusion (proposition de traduction) : Le décubitus latéral et la position assis au bord du lit pour la ponction lombaire aux urgences ont donné des taux de réussite égaux chez les médecins urgentistes et les stagiaires.

Is Lateral Decubitus or Upright Positioning Optimal for Lumbar Puncture Success in a Teaching Hospital?.
Thundiyil JG, O'Brien JF, Tymkowicz AE, Papa L. | J Emerg Med. 2023 Jan;64(1):14-21
DOI: https://doi.org/10.1016/j.jemermed.2022.09.002
Keywords: Lumbar puncture; Medical education; Positioning; Procedure.

https://doi.org/10.1016/j.jemermed.2022.09.002

Introduction : Lumbar puncture is a common procedure performed by emergency physicians and trainees. The optimal patient positioning for lumbar puncture procedures has not been studied adequately.

Méthode : We performed a prospective randomized study in an urban, level I academic trauma center. Patients of all ages were included. Patients were randomized to either lateral decubitus or upright positioning. Patient demographic characteristics, level of physician training and experience, number of needle insertions and redirections, need for repositioning, alternative operator use, and laboratory results of the cerebrospinal fluid were recorded. We compared the success rate of each position as our primary outcome measure. We also evaluated number of needle insertions and re-directions and success rates based on experience and patient age.

Résultats : A total of 116 patients were enrolled, with 55 patients assigned to lateral decubitus and 61 to upright position for initial lumbar puncture attempt. Spinal fluid was obtained successfully in 47 of the lateral decubitus group (85.5%; 95% CI 73.8-92.4%) vs. 49 (80.3%; 95% CI 68.7-88.4%) in the upright assignment group. Comparable results were also obtained for first-pass success, number of failures, and number of bloody taps. Postgraduate year 2 residents or those with 31-50 previous lumbar punctures had the highest success rates at 94.3% (95% CI 81.2-98.4%) and 90.3% (95% CI 75.1-96.7%), respectively.

Conclusion : Lateral decubitus and upright positioning for emergency lumbar puncture yielded equal success rates in emergency physicians and trainees.

Conclusion (proposition de traduction) : Le décubitus latéral et la position verticale pour la ponction lombaire d'urgence ont donné des taux de réussite égaux chez les médecins urgentistes et les étudiants.

European guidelines on perinatal care: corticosteroids for women at risk of preterm birth.
Daskalakis G, Pergialiotis V, Domellöf M, Ehrhardt H, Di Renzo GC, Koç E, Malamitsi-Puchner A, Kacerovsky M, Modi N, Shennan A, Ayres-de-Campos D, Gliozheni E, Rull K, Braun T, Beke A, Kosińska-Kaczyńska K, Areia AL, Vladareanu S, Sršen TP, Schmitz T, Jacobsson B. | J Matern Fetal Neonatal Med. 2023 Janv;36(1):2160628
DOI: https://doi.org/10.1080/14767058.2022.2160628  | Télécharger l'article au format  
Keywords: Corticosteroids; guideline; preterm birth; antenatal

Guideline

Conclusion : Corticosteroids should be administered to women at a gestational age between 24⁺⁰ and 33⁺⁶ weeks, when preterm birth is anticipated in the next seven days, as these have been consistently shown to reduce neonatal mortality and morbidity. (Strong-quality evidence; strong recommendation). In selected cases, extension of this period up to 34⁺⁶ weeks may be considered (Expert opinion). Optimal benefits are found in infants delivered within 7 days of corticosteroid administration. Even a single-dose administration should be given to women with imminent preterm birth, as this is likely to improve neurodevelopmental outcome (Moderate-quality evidence; conditional recommendation).
2. Either betamethasone (12mg administered intramuscularly twice, 24-hours apart) or dexamethasone (6mg administered intramuscularly in four doses, 12-hours apart, or 12mg administered intramuscularly twice, 24-hours apart), may be used (Moderate-quality evidence; Strong recommendation). Administration of two “all” doses is named a “course of corticosteroids"…

Conclusion (proposition de traduction) : 1. Les corticostéroïdes doivent être administrés aux femmes dont l'âge gestationnel se situe entre 24+0 et 33+6 semaines, lorsque l'on prévoit une naissance prématurée dans les sept prochains jours, car il a été démontré de façon constante que ces médicaments réduisent la mortalité et la morbidité néonatales. (Preuves de qualité élevée ; recommandation forte). Dans certains cas, l'extension de cette période jusqu'à 34+6 semaines peut être envisagée (Avis d'expert). Les bénéfices optimaux sont constatés chez les nourrissons mis au monde dans les 7 jours suivant l'administration de corticostéroïdes. Même une administration à dose unique devrait être effectuée chez les femmes dont la naissance prématurée est imminente, car cela est susceptible d'améliorer le résultat du développement neurologique (preuves de qualité modérée ; recommandation conditionnelle).
2. On peut utiliser soit la bétaméthasone (12 mg administrés par voie intramusculaire deux fois, à 24 heures d'intervalle), soit la dexaméthasone (6 mg administrés par voie intramusculaire en quatre doses, à 12 heures d'intervalle, ou 12 mg administrés par voie intramusculaire deux fois, à 24 heures d'intervalle) (preuves de qualité modérée ; recommandation forte). L'administration de deux doses "complètes" est appelée "cure de corticostéroïdes"…

Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest.
Suverein MM, Delnoij TSR, Lorusso R, Brandon Bravo Bruinsma GJ, Otterspoor L, Elzo Kraemer CV, Vlaar APJ, van der Heijden JJ, Scholten E, den Uil C, Jansen T, van den Bogaard B, Kuijpers M, Lam KY, Montero Cabezas JM, Driessen AHG, Rittersma SZH, Heijnen BG, Dos Reis Miranda D, Bleeker G, de Metz J, Hermanides RS, Lopez Matta J, Eberl S, Donker DW, van Thiel RJ, Akin S, van Meer O, Henriques J, Bokhoven KC, Mandigers L, Bunge JJH, Bol ME, Winkens B, Essers B. | N Engl J Med. 2023 Jan 26;388(4):299-309
DOI: https://doi.org/10.1056/nejmoa2204511
Keywords: Aucun

Clinical paper

Introduction : Extracorporeal cardiopulmonary resuscitation (CPR) restores perfusion and oxygenation in a patient who does not have spontaneous circulation. The evidence with regard to the effect of extracorporeal CPR on survival with a favorable neurologic outcome in refractory out-of-hospital cardiac arrest is inconclusive.

Méthode : In this multicenter, randomized, controlled trial conducted in the Netherlands, we assigned patients with an out-of-hospital cardiac arrest to receive extracorporeal CPR or conventional CPR (standard advanced cardiac life support). Eligible patients were between 18 and 70 years of age, had received bystander CPR, had an initial ventricular arrhythmia, and did not have a return of spontaneous circulation within 15 minutes after CPR had been initiated. The primary outcome was survival with a favorable neurologic outcome, defined as a Cerebral Performance Category score of 1 or 2 (range, 1 to 5, with higher scores indicating more severe disability) at 30 days. Analyses were performed on an intention-to-treat basis.

Résultats : Of the 160 patients who underwent randomization, 70 were assigned to receive extracorporeal CPR and 64 to receive conventional CPR; 26 patients who did not meet the inclusion criteria at hospital admission were excluded. At 30 days, 14 patients (20%) in the extracorporeal-CPR group were alive with a favorable neurologic outcome, as compared with 10 patients (16%) in the conventional-CPR group (odds ratio, 1.4; 95% confidence interval, 0.5 to 3.5; P = 0.52). The number of serious adverse events per patient was similar in the two groups.

Conclusion : In patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR and conventional CPR had similar effects on survival with a favorable neurologic outcome.

Conclusion (proposition de traduction) : Chez les patients présentant un arrêt cardiaque extrahospitalier réfractaire, la RCP extracorporelle et la RCP conventionnelle ont eu des effets similaires sur la survie avec un résultat neurologique favorable.

Trial of an Intervention to Improve Acute Heart Failure Outcomes.
Lee DS, Straus SE, Farkouh ME, Austin PC, Taljaard M, Chong A, Fahim C, Poon S, Cram P, Smith S, McKelvie RS, Porepa L, Hartleib M, Mitoff P, Iwanochko RM, MacDougall A, Shadowitz S, Abrams H, Elbarasi E, Fang J, Udell JA, Schull MJ, Mak S, Ross HJ; COACH Trial Investigators. | N Engl J Med. 2023 Jan 5;388(1):22-32
DOI: https://doi.org/10.1056/nejmoa2211680
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Patients with acute heart failure are frequently or systematically hospitalized, often because the risk of adverse events is uncertain and the options for rapid follow-up are inadequate. Whether the use of a strategy to support clinicians in making decisions about discharging or admitting patients, coupled with rapid follow-up in an outpatient clinic, would affect outcomes remains uncertain.

Méthode : In a stepped-wedge, cluster-randomized trial conducted in Ontario, Canada, we randomly assigned 10 hospitals to staggered start dates for one-way crossover from the control phase (usual care) to the intervention phase, which involved the use of a point-of-care algorithm to stratify patients with acute heart failure according to the risk of death. During the intervention phase, low-risk patients were discharged early (in ≤3 days) and received standardized outpatient care, and high-risk patients were admitted to the hospital. The coprimary outcomes were a composite of death from any cause or hospitalization for cardiovascular causes within 30 days after presentation and the composite outcome within 20 months.

Résultats : A total of 5452 patients were enrolled in the trial (2972 during the control phase and 2480 during the intervention phase). Within 30 days, death from any cause or hospitalization for cardiovascular causes occurred in 301 patients (12.1%) who were enrolled during the intervention phase and in 430 patients (14.5%) who were enrolled during the control phase (adjusted hazard ratio, 0.88; 95% confidence interval [CI], 0.78 to 0.99; P = 0.04). Within 20 months, the cumulative incidence of primary-outcome events was 54.4% (95% CI, 48.6 to 59.9) among patients who were enrolled during the intervention phase and 56.2% (95% CI, 54.2 to 58.1) among patients who were enrolled during the control phase (adjusted hazard ratio, 0.95; 95% CI, 0.92 to 0.99). Fewer than six deaths or hospitalizations for any cause occurred in low- or intermediate-risk patients before the first outpatient visit within 30 days after discharge.

Conclusion : Among patients with acute heart failure who were seeking emergency care, the use of a hospital-based strategy to support clinical decision making and rapid follow-up led to a lower risk of the composite of death from any cause or hospitalization for cardiovascular causes within 30 days than usual care.

Conclusion (proposition de traduction) : Parmi les patients souffrant d'insuffisance cardiaque aiguë et consultant en urgence, l'utilisation d'une stratégie hospitalière pour faciliter la prise de décision clinique et le suivi rapide a permis de réduire le risque de décès, quelle qu'en soit la cause, ou d'hospitalisation pour des raisons cardiovasculaires dans les 30 jours, par rapport aux soins habituels.