Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review.
Niforatos JD, Ehmann MR, Balhara KS, Hinson JS, Ramcharran L, Lobner K, Weygandt PL. | Acad Emerg Med. 2023 Feb;30(2):124-132
DOI: https://doi.org/10.1111/acem.14618
Keywords: acute heart failure; atrial fibrillation; emergency department; intensive care unit; rapid ventricular response; systematic review; therapeutic management.

SYSTEMATIC REVIEWS (WITH OR WITHOUT META-ANALYSES)

Introduction : The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting.

Méthode : This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism.

Résultats : A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis.

Conclusion : High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.

Conclusion (proposition de traduction) : On manque de données de haut niveau pour guider la prise de décision clinique concernant la gestion efficiente et sûre des fibrillations atriales et des flutters auriculaires avec réponse ventriculaire rapide chez les patients souffrant d'insuffisance cardiaque aiguë décompensée dans le contexte des soins aigus.

Intra-articular lidocaine versus intravenous sedation for anterior shoulder dislocation reduction.
Long B, Gottlieb M. | Acad Emerg Med. 2023 Feb;30(2):151-153
DOI: https://doi.org/10.1111/acem.14653
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Anterior shoulder dislocation is the most common large joint dislocation managed in the emergency department (ED). Several analgesic techniques are available to assist with reduction, including intra-articular lidocaine, nerve blocks, and procedural sedation with intravenous (IV) medications. Each technique has distinct advantages (e.g., reduced length of stay with intra-articular lidocaine) and disadvantages (e.g., adverse event such as respiratory depression with procedural sedation). Indeed, several studies have compared these techniques, with a 2014 meta-analysis finding similar efficacy in reduction success rate using either procedural sedation or intra-articular lidocaine with fewer adverse events in the intra-articular lidocaine group. Since 2014, additional randomized controlled trials (RCTs) have been published, providing further data comparing intra-articular lidocaine and IV sedation.

Conclusion : Based on the available evidence, we have assigned a color recommendationof yellow (comparable efficacy) for the use of intra-articularlidocaine in reduction of anterior shoulder dislocation. It islikely that intra-articularlidocaine injection for anterior shoulder dislocationdoes not affect the procedure success rate, but it reducesthe risk of adverse events and shortens ED length of stay. However,the heterogeneity among trials and suboptimal level of evidence certaintycall for larger, more rigorous trials.

Conclusion (proposition de traduction) : Sur la base des preuves disponibles, nous avons attribué une recommandation de couleur jaune (efficacité comparable) à l'utilisation de la lidocaïne intra-articulaire dans la réduction de la luxation antérieure de l'épaule. Il est probable que l'injection intra-articulaire de lidocaïne pour la luxation antérieure de l'épaule n'affecte pas le taux de réussite de l'intervention, mais qu'elle réduise le risque d'événements indésirables et la durée du séjour au service des urgences. Cependant, l'hétérogénéité entre les essais et le niveau sous-optimal de certitude des preuves appellent à des essais plus importants et plus rigoureux.

Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes.
Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand T, Goldman MP, Prieto MM, Wing R, Breuer R, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. | Ann Emerg Med. 2023 Feb;81(2):113-122
DOI: https://doi.org/10.1016/j.annemergmed.2022.08.021
Keywords: Aucun

Pediatric

Introduction : To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes.

Méthode : We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes.

Résultats : The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95).

Conclusion : Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.

Conclusion (proposition de traduction) : La vidéo-laryngoscopie est associée à une augmentation de la réussite du premier essai et à une diminution des effets indésirables sur les voies respiratoires chez les patients intubés dans les services d'urgence pédiatriques. Il existe une grande disparité dans l'utilisation de la vidéo-laryngoscopie, et son utilisation importante est associée à des chances plus élevées de réussite de la première tentative.

What is the Impact of Low Tidal Volume Ventilation for Emergency Department Patients?.
Gottlieb M, Chesis M, Long B. | Ann Emerg Med. 2023 Feb;81(2):162-164
DOI: https://doi.org/10.1016/j.annemergmed.2022.04.002  | Télécharger l'article au format  
Keywords: Aucun

Airway

Introduction : The authors searched MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception to May 2021 for relevant studies. The authors also manually searched the abstracts presented at select emergency medicine and critical care conferences from 2016 to 2021 and the reference lists of the included articles. They searched ClinicalTrials.gov to identify completed but not yet published studies. Individual study investigators were contacted for additional data as needed.

Méthode : The inclusion criteria consisted of randomized and nonrandomized studies of adult emergency department (ED) patients receiving mechanical ventilation. There were no language restrictions. Case studies, reviews, correspondences, and editorials were not eligible. Two independent reviewers screened abstracts with disagreements resolved by a third reviewer. Included studies compared outcomes between patients receiving ED low tidal volume ventilation and nonlow tidal volume ventilation (defined as tidal volume >8 mL/kg predicted body weight). The primary outcome was hospital mortality. Secondary outcomes included the duration of mechanical ventilation, length of stay in the ICU, length of stay at the hospital, and the occurrence rate of acute respiratory distress syndrome after admission.

Résultats : The authors conducting the meta-analysis extracted study characteristics and assessed quality with the Newcastle- Ottawa Scale.1 Pooled effect sizes and 95% confidence intervals were calculated using random effects modeling. Tidal volumes were compared using an independent sample t test. Odds ratios were calculated for binary outcomes. Continuous variables were reported as mean differences, and overall effect estimates were generated using a Z test. Heterogeneity was assessed with I2.After evaluation, a “leave-one-out” analysis was also completed because one study contributed nearly all the heterogeneity seen in the pooled analysis. Publication bias was assessed using a funnel plot.

Conclusion : Among emergency department patients, low tidal volume ventilation is associated with reduced mortality, lower rates of developing acute respiratory distress syndrome, and more ventilator-free days. METHODS

Conclusion (proposition de traduction) : Chez les patients des services d'urgence, la ventilation à faible volume courant est associée à une réduction de la mortalité, à des taux plus faibles de développement d'un syndrome de détresse respiratoire aiguë et à un plus grand nombre de jours sans ventilation.

Implementation of the Modified Canadian C-Spine Rule by Paramedics.
Vaillancourt C, Charette M, Sinclair J, Dionne R, Kelly P, Maloney J, Nemnom MJ, Wells GA, Stiell IG. | Ann Emerg Med. 2023 Feb;81(2):187-196
DOI: https://doi.org/10.1016/j.annemergmed.2022.08.441  | Télécharger l'article au format  
Keywords: Aucun

Emergency Medical Services

Introduction : The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics.

Méthode : This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients.

Résultats : The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule.

Conclusion : Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.

Conclusion (proposition de traduction) : Les ambulanciers paramédicaux ont pu appliquer avec précision la règle canadienne modifiée de la colonne vertébrale (Modified Canadian C-Spine Rule) aux patients traumatisés à faible risque et réduire de manière significative la nécessité d'immobiliser la colonne vertébrale pendant le transport. Cela n'a entraîné aucun événement indésirable ni aucune lésion de la moelle épinière.

Managing Epistaxis.
Gottlieb M, Long B. | Ann Emerg Med. 2023 Feb;81(2):234-240
DOI: https://doi.org/10.1016/j.annemergmed.2022.07.002
Keywords: Aucun

General Medicine

Editorial : L'épistaxis est une affection fréquente dans les services d'urgence, représentant environ 1 visite sur 200 aux États-Unis. Sa répartition est bimodale, les personnes âgées de moins de 10 ans et de plus de 60 ans étant les plus touchées. La plupart des cas sont atraumatiques et la maladie est plus fréquente en hiver. L'étiologie est généralement divisée en causes locales (par exemple, manque d'humidification, traumatisme, médicaments intranasaux, infection, inflammation, tumeurs) et systémiques (par exemple, troubles de la crase sanguine, leucémie, athérosclérose). Des épisodes récurrents d'épistaxis sans cause déclenchante claire doivent faire craindre une étiologie systémique. L'épistaxis est également divisée en saignements antérieurs et postérieurs. L'épistaxis antérieure est la plus fréquente et se produit typiquement dans le septum antéro-inférieur, où se trouve le plexus de Kiesselbach. L'épistaxis postérieure est beaucoup plus rare, se produisant dans environ 5 à 10 % des cas, et nécessite généralement une prise en charge plus agressive en salle d'opération ou en radiologie interventionnelle.

Conclusion : Given the frequency of epistaxis, it is important for clinicians to be aware of approaches to the management of these patients. Although much of this paper will focus on anterior epistaxis, we will also discuss how to identify and treat posterior epistaxis. This paper is not intended to be a comprehensive review of all the aspects of the evaluation and management of patients with epistaxis; instead, we seek to distill key facets of management based on the current literature and years of practice.

Conclusion (proposition de traduction) : Compte tenu de la fréquence de l'épistaxis, il est important que les cliniciens connaissent les méthodes de prise en charge de ces patients. Bien qu'une grande partie de cet article se concentre sur l'épistaxis antérieure, nous discuterons également de la manière d'identifier et de traiter l'épistaxis postérieure. Ce document n'a pas pour but de passer en revue tous les aspects de l'évaluation et de la prise en charge des patients souffrant d'épistaxis ; nous cherchons plutôt à distiller les aspects clés de la prise en charge sur la base de la littérature actuelle et d'années de pratique.

Association of systolic, diastolic, mean, and pulse pressure with morbidity and mortality in septic ICU patients: a nationwide observational study.
Khanna AK, Kinoshita T, Natarajan A, Schwager E, Linn DD, Dong J, Ghosh E, Vicario F, Maheshwari K. | Ann Intensive Care. 2023 Feb 20;13(1):9
DOI: https://doi.org/10.1186/s13613-023-01101-4  | Télécharger l'article au format  
Keywords: Blood pressure; Components; Hypotension; Mortality; Sepsis.

RESEARCH

Introduction : Intensivists target different blood pressure component values to manage intensive care unit (ICU) patients with sepsis. We aimed to evaluate the relationship between individual blood pressure components and organ dysfunction in critically ill septic patients.

Méthode : In this retrospective observational study, we evaluated 77,328 septic patients in 364 ICUs in the eICU Research Institute database. Primary exposure was the lowest cumulative value of each component; mean, systolic, diastolic, and pulse pressure, sustained for at least 120 min during ICU stay. Primary outcome was ICU mortality and secondary outcomes were composite outcomes of acute kidney injury or death and myocardial injury or death during ICU stay. Multivariable logistic regression spline and threshold regression adjusting for potential confounders were conducted to evaluate associations between exposures and outcomes. Sensitivity analysis was conducted in 4211 patients with septic shock.

Résultats : Lower values of all blood pressures components were associated with a higher risk of ICU mortality. Estimated change-points for the risk of ICU mortality were 69 mmHg for mean, 100 mmHg for systolic, 60 mmHg for diastolic, and 57 mmHg for pulse pressure. The strength of association between blood pressure components and ICU mortality as determined by slopes of threshold regression were mean (- 0.13), systolic (- 0.11), diastolic (- 0.09), and pulse pressure (- 0.05). Equivalent non-linear associations between blood pressure components and ICU mortality were confirmed in septic shock patients. We observed a similar relationship between blood pressure components and secondary outcomes.

Conclusion : Blood pressure component association with ICU mortality is the strongest for mean followed by systolic, diastolic, and weakest for pulse pressure. Critical care teams should continue to follow MAP-based resuscitation, though exploratory analysis focusing on blood pressure components in different sepsis phenotypes in critically ill ICU patients is needed.

Conclusion (proposition de traduction) : L'association entre les composantes de la pression artérielle et la mortalité en USI est la plus forte pour la pression moyenne, suivie de la pression systolique et diastolique, et la plus faible pour la pression pulsée. Les équipes de soins intensifs devraient continuer à utiliser une réanimation basée sur la PAM, bien qu'une analyse exploratoire axée sur les composantes de la pression artérielle dans différents phénotypes de sepsis chez les patients gravement malades des unités de soins intensifs soit nécessaire.

Commentaire : Les points de rupture estimés pour le risque de mortalité en USI étaient de 69 mmHg pour la pression moyenne, 100 mmHg pour la pression systolique, 60 mmHg pour la pression diastolique et 57 mmHg pour la pression pulsée.

La pression pulsée ou pression différentielle est la différence entre le pic systolique de pression et la pression de fin de diastole. Elle dépend du Volume d'éjection systolique (VES) et de la compliance vasculaire (propriétés visco-élastique), c’est-à-dire de la capacité d’un vaisseau (artère) d’être étiré.
L’interprétation de la pression pulsée est un moyen de reconnaître le vieillissement artériel, facteur reconnu de maladies cardio-vasculaires. La rigidité des gros troncs artériels qui accompagne le vieillissement artériel entraîne une élévation de la pression systolique et une baisse de la pression de la fin de diastole ce qui augmente la pression pulsée, tandis que la valeur de la pression artérielle moyenne reste inchangée.

High-Dose IV Hydroxocobalamin (Vitamin B12) in Septic Shock: A Double-Blind, Allocation-Concealed, Placebo-Controlled Single-Center Pilot Randomized Controlled Trial (The Intravenous Hydroxocobalamin in Septic Shock Trial).
Patel JJ, Willoughby R, Peterson J, Carver T, Zelten J, Markiewicz A, Spiegelhoff K, Hipp LA, Canales B, Szabo A, Heyland DK, Stoppe C, Zielonka J, Freed JK. | Chest. 2023 Feb;163(2):303-312
DOI: https://doi.org/10.1016/j.chest.2022.09.021  | Télécharger l'article au format  
Keywords: ICU; critical care; feasibility; hydrogen sulfide; hydroxocobalamin; outcomes; sepsis; septic shock; vasodilatory shock; vitamin B12.

Original Research

Introduction : Elevated hydrogen sulfide (H2S) contributes to vasodilatation and hypotension in septic shock, and traditional therapies do not target this pathophysiologic mechanism. High-dose IV hydroxocobalamin scavenges and prevents H2S formation, which may restore vascular tone and may accentuate recovery. No experimental human studies have tested high-dose IV hydroxocobalamin in adults with septic shock.
Research question: In adults with septic shock, is comparing high-dose IV hydroxocobalamin with placebo feasible?

Méthode : We conducted a phase 2 single-center, double-blind, allocation-concealed, placebo-controlled, parallel-group pilot randomized controlled trial comparing high-dose IV hydroxocobalamin with placebo in critically ill adults with septic shock. Patients meeting Sepsis 3 criteria were randomized 1:1 to receive a single 5-g dose of high-dose IV hydroxocobalamin or equivalent volume 0.9% saline solution as placebo. The primary outcome was study feasibility (enrollment rate, clinical and laboratory compliance rate, and contamination rate). Secondary outcomes included between-group differences in plasma H2S concentrations and vasopressor dose before and after infusion.

Résultats : Twenty patients were enrolled over 19 months, establishing an enrollment rate of 1.05 patients per month. Protocol adherence rates were 100% with zero contamination. In the high-dose IV hydroxocobalamin group, compared to placebo, there was a greater reduction in vasopressor dose between randomization and postinfusion (-36% vs 4%, P < .001) and randomization and 3-h postinfusion (-28% vs 10%, P = .019). In the high-dose IV hydroxocobalamin group, the plasma H2S level was reduced over 45 mins by -0.80 ± 1.73 μM, as compared with -0.21 ± 0.64 μM in the placebo group (P = .3).

Conclusion : This pilot trial established favorable feasibility metrics. Consistent with the proposed mechanism of benefit, high-dose IV hydroxocobalamin compared with placebo was associated with reduced vasopressor dose and H2S levels at all time points and without serious adverse events. These data provide the first proof of concept for feasibility of delivering high-dose IV hydroxocobalamin in septic shock.

Conclusion (proposition de traduction) : Cet essai pilote a permis d'établir des critères de faisabilité favorables. Conformément au mécanisme de bénéfice proposé, l'hydroxocobalamine IV à forte dose, comparée au placebo, a été associée à une réduction de la dose de vasopresseurs et des niveaux de sulfure d'hydrogène à tous les stades de l'étude et sans événements indésirables graves. Ces données fournissent la première preuve de concept de la faisabilité de l'administration de fortes doses d'hydroxocobalamine par voie intraveineuse dans le cadre d'un choc septique.

Recall of Awareness During Paralysis Among ED Patients Undergoing Tracheal Intubation.
Driver BE, Prekker ME, Wagner E, Cole JB, Puskarich MA, Stang J, DeVries P, Maruggi E, Miner JR. | Chest. 2023 Feb;163(2):313-323
DOI: https://doi.org/10.1016/j.chest.2022.08.2232  | Télécharger l'article au format  
Keywords: awareness of paralysis; critical illness; mechanical ventilation; neuromuscular blocking agents; sedation.

Research article

Introduction : Critically ill patients sometimes remember periods of neuromuscular blockade.
Research question: What is the prevalence of recalled awareness during paralysis in patients who underwent emergency tracheal intubation and mechanical ventilation, and what clinical variables are associated with this outcome?

Méthode : This study analyzed data from a prospectively collected continuous quality improvement database of emergency tracheal intubation in an urban, county hospital. Patients who received a neuromuscular blocking agent to facilitate emergency tracheal intubation in the ED were included. The database contained details of intubation management, including medications received and patient mental status prior to intubation. Patient recall of awareness of paralysis was assessed by trained staff during an in-person interview following extubation using a modified Brice questionnaire. For this analysis, three expert reviewers used these data to adjudicate whether patients may have had awareness of paralysis, the primary outcome. A logistic regression model was constructed to determine whether clinical variables were associated with the primary outcome.

Résultats : A total of 886 patients were analyzed. There were 66 patients (7.4%; 95% CI, 5.8-9.4) determined to possibly (61 patients) or definitely (5 patients) have experienced and recalled awareness of paralysis. A logistic regression model revealed that a decreased level of consciousness prior to intubation was associated with lower odds of awareness (adjusted OR, 0.39; 95% CI, 0.22-0.69), whereas the class of neuromuscular blocking agent used, sedative used, preintubation shock index, and postintubation sedation were not significantly associated with recall of this outcome.

Conclusion : Among patients intubated emergently using a neuromuscular blocking agent, 7.4% of patients recalled awareness without being able to move, which was more likely when patients had a normal level of consciousness prior to intubation.

Conclusion (proposition de traduction) : Parmi les patients intubés en urgence à l'aide d'un curare, 7,4 % se sont souvenus d'avoir été conscients sans pouvoir bouger, ce qui était plus susceptible de se produire lorsque les patients avaient un niveau de conscience normal avant l'intubation.

Impact of prehospital opioid dose on angiographic and clinical outcomes in acute coronary syndromes.
Fernando H, Nehme Z, Dinh D, Andrew E, Brennan A, Shi W, Bloom J, Duffy SJ, Shaw J, Peter K, Nadurata V, Chan W, Layland J, Freeman M, Van Gaal W, Bernard S, Lefkovits J, Liew D, Stephenson M, Smith K, Stub D. | Emerg Med J. 2023 Feb;40(2):101-107
DOI: https://doi.org/10.1136/emermed-2021-211519
Keywords: acute coronary syndrome; acute myocardial infarct; emergency ambulance systems.

Original research

Introduction : An adverse interaction whereby opioids impair and delay the gastrointestinal absorption of oral P2Y12 inhibitors has been established, however the clinical significance of this in acute coronary syndrome (ACS) is uncertain. We sought to characterise the relationship between prehospital opioid dose and clinical outcomes in patients with ACS.

Méthode : Patients given opioid treatment by emergency medical services (EMS) with ACS who underwent percutaneous coronary intervention (PCI) between 1 January 2014 and 31 December 2018 were included in this retrospective cohort analysis using data linkage between the Ambulance Victoria, Victorian Cardiac Outcomes Registry and Melbourne Interventional Group databases. Patients with cardiogenic shock, out-of-hospital cardiac arrest and fibrinolysis were excluded. The primary end point was the risk-adjusted odds of 30-day major adverse cardiac events (MACE) between patients who received opioids and those that did not.

Résultats : 10 531 patients were included in the primary analysis. There was no significant difference in 30-day MACE between patients receiving opioids and those who did not after adjusting for key patient and clinical factors. Among patients with ST-elevation myocardial infarction (STEMI), there were significantly more patients with thrombolysis in myocardial infarction (TIMI) 0 or 1 flow pre-PCI in a subset of patients with high opioid dose versus no opioids (56% vs 25%, p<0.001). This remained significant after adjusting for known confounders with a higher predicted probability of TIMI 0/1 flow in the high versus no opioid groups (33% vs 11%, p<0.001).

Conclusion : Opioid use was not associated with 30-day MACE. There were higher rates of TIMI 0/1 flow pre-PCI in patients with STEMI prescribed opioids. Future prospective research is required to verify these findings and investigate alternative analgesia for ischaemic chest pain.

Conclusion (proposition de traduction) : L'administration de morphiniques n'a pas été associée à des événements cardiaques indésirables majeurs à 30 jours. Les taux de flux TIMI 0/1 avant intervention coronarienne percutanée étaient plus élevés chez les patients ayant présenté un infarctus du myocarde avec sus-décalage du segment ST et à qui l'on avait prescrit des opiacés. De futures recherches prospectives sont nécessaires pour vérifier ces résultats et étudier des analgésies alternatives pour les douleurs thoraciques ischémiques.

Commentaire : Probabilité prédite de flux TIMI 0/1 plus élevée dans le groupe à forte dose de morphinimimétique que dans le groupe sans opioïdes (33 % contre 11 %, p<0,001).

Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. .
Wilkinson-Stokes M, Betson J, Sawyer S. . | Emerg Med J. 2023 Feb;40(2):108-113
DOI: https://doi.org/10.1136/emermed-2021-212294
Keywords: acute myocardial infarct; analgesia; safety.

Systematic reviewThe current guidelines of the American Hear

Introduction : The current guidelines of the American Heart Association (AHA) and European Society of Cardiology (ESC) recommend that when right ventricular myocardial infarction (RVMI) is present patients are not administered nitrates, due to the risk that decreasing preload in the setting of already compromised right ventricular ejection fraction may reduce cardiac output and precipitate hypotension. The cohort study (n=40) underlying this recommendation was recently challenged by new studies suitable for meta-analysis (cumulatively, n=1050), suggesting that this topic merits systematic review.

Méthode : The protocol was registered on PROSPERO and published in Evidence Synthesis. Six databases were systematically searched in May 2022: PubMed, Embase, MEDLINE Complete, Cochrane CENTRAL Register, CINAHL and Google Scholar. Two investigators independently assessed for quality and bias and extracted data using Joanna Briggs Institute tools and methods. Risk ratios and 95% CIs were calculated, and meta-analysis performed using the random effects inverse variance method.

Résultats : Five studies (n=1113) were suitable. Outcomes included haemodynamics, GCS, syncope, arrest and death. Arrest and death did not occur in the RVMI group. Meta-analysis was possible for sublingual nitroglycerin 400 μg (2 studies, n=1050) and found no statistically significant difference in relative risk to combined inferior and RVMI at 1.31 (95% CI 0.81 to 2.12, p=0.27), with an absolute effect of 3 additional adverse events per 100 treatments. Results remained robust under sensitivity analysis.

Conclusion : This review suggests that the AHA and ESC contraindications are not supported by evidence. Key limitations include all studies having concomitant inferior and RVMI, not evaluating beneficial effects and very low certainty of evidence. As adverse events are transient and easily managed, nitrates are a reasonable treatment modality to consider during RVMI on current evidence.

Conclusion (proposition de traduction) : Cette revue suggère que les contre-indications de l'AHA et de l'ESC ne sont pas étayées par des preuves. Les principales limites sont les suivantes : toutes les études présentaient un infarctus du myocarde inférieur et ventriculaire droit concomitant, les effets bénéfiques n'ont pas été évalués et la certitude des preuves est très faible. Les effets indésirables étant transitoires et faciles à gérer, les dérivés nitrés constituent une modalité de traitement raisonnable à envisager en cas d'infarctus du myocarde ventriculaire droit, selon les données actuelles.

Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience.
Lukosiute-Urboniene A, Nekrosius D, Dekeryte I, Kilda A, Malcius D. | Emerg Med J. 2023 Feb;40(2):134-139
DOI: https://doi.org/10.1136/emermed-2021-211946
Keywords: pediatric emergency medicine; pediatrics; ultrasonography; urogenital system.

Original research

Introduction : We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment.

Méthode : We retrospectively reviewed all medical records of patients (0-17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients' demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay.

Résultats : A search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US.

Conclusion : Pubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.

Conclusion (proposition de traduction) : L'âge pubère, la durée des symptômes <7 heures, les nausées/vomissements, la palpation d'un testicule dur, les douleurs abdominales et le gonflement du scrotum sont des facteurs prédictifs de torsion testiculaire. Le temps perdu entre l'apparition des symptômes et la recherche de soins médicaux, et entre l'arrivée et l'échographie, est associé à la nécessité d'une orchidectomie. Un flux sanguin préservé à l'échographie n'exclut pas une torsion testiculaire et peut contribuer à retarder l'intervention chirurgicale.

Radiographic assessment of acute vs chronic vertebral compression fractures.
Strickland CD, DeWitt PE, Jesse MK, Durst MJ, Korf JA. | Emerg Radiol. 2023 Feb;30(1):11-18
DOI: https://doi.org/10.1007/s10140-022-02092-8
Keywords: MRI; Radiography; Vertebral compression fracture.

Original Article

Introduction : Distinguishing between acute and chronic vertebral compression fractures typically requires advanced imaging techniques such as magnetic resonance imaging (MRI). Recognizing specific radiographic findings associated with fracture acuity may improve the accuracy of radiographic assessment.

Méthode : Patients with compression fractures that had both radiographic and MRI studies of the lumbar spine within a 30-day time frame were retrospectively reviewed. MRI studies were used to determine compression fracture acuity. Radiographs were interpreted by a separate group of radiologists blinded to the MRI results. Radiographic findings of endplate osteophyte, subendplate density, subendplate cleft, and subendplate cyst were recorded as was the overall impression of fracture acuity.

Résultats : Sensitivity and specificity for radiographic reporting of acute fracture were 0.52 (95% CI: 0.42, 0.61) and 0.95 (95% CI: 0.93, 0.97) respectively. For chronic fractures, the sensitivity and specificity were 0.52 (95% CI: 0.41, 0.63) and 0.94 (95% CI: 0.92, 0.96). The radiographic presence of a subendplate cleft increased the odds of a fracture being acute by a factor of 1.75 (95% CI: 1.09, 2.81; P = 0.0202). The radiographic presence of subendplate density increased the odds of a fracture being acute by a factor of 1.78 (95% CI: 1.21, 2.63; P = 0.0037). The presence of an endplate osteophyte or subendplate cyst was not significantly associated with fracture acuity.

Conclusion : Radiographs are relatively insensitive in distinguishing between acute and chronic lumbar compression fractures but the presence of a subendplate cleft or subendplate density increases the likelihood that a given fracture is acute.

Conclusion (proposition de traduction) : Les radiographies sont relativement peu sensibles pour faire la différence entre les fractures lombaires aiguës et chroniques, mais la présence d'une fissure ou de la (ndlr : modification de la) densité du plateau vertébral vertébrale augmente la probabilité qu'une fracture spécifique soit aiguë.

Point-of-care ultrasound: impact on emergency department length of stay for suspected lower extremity DVT.
Estrella Y, Bronzo A, Fey L, Ryoo A, Ayala S, Lin M, Gaeta T. | Emerg Radiol. 2023 Apr;30(2):203-207
DOI: https://doi.org/10.1007/s10140-023-02123-y
Keywords: Deep vein thrombosis; Lower extremity compression; POCUS.

ORIGINAL ARTICLE

Introduction : Point-of-care ultrasound (POCUS) has demonstrated excellent sensitivity and specificity for the diagnosis of DVT in the emergency department (ED). Before POCUS became widespread, patients underwent radiology department comprehensive lower extremity venous duplex ultrasounds (RADUS) which may be associated with a prolonged length of stay.
Objectives: The goal of this study is to evaluate the impact of POCUS on ED arrival to disposition (ATD) time for patients presenting to the ED with suspected lower extremity DVT.

Méthode : This is a retrospective chart analysis of ED visits to an urban, university-affiliated community hospital from January 2019 to December 2020. This study compared ATD between patients who underwent POCUS by an emergency medicine physician and RADUS by the radiology department.

Résultats : In total, 1204 patients underwent POCUS, and 1582 patients were evaluated with RADUS. The POCUS mean ATD was 313 ± 16.8 min compared to the RADUS arm average of 323 ± 57.9 min (p = 0.56). Order to disposition time (OTD) was prolonged among the RADUS group relative to POCUS. ATD was significantly reduced in the POCUS subgroup of patients presenting during night shift when RADUS was not available, 326 ± 28.2 min versus 630 ± 109 min (p < 0.05).

Conclusion : ED POCUS scans decrease the amount of time between order placement and disposition when compared to RADUS. POCUS significantly decreases length of stay in the ED when RADUS is not available.

Conclusion (proposition de traduction) : L'échographie au point d'intervention réduit le délai entre la prescription et la prise en charge par rapport à l'échographie duplex veineuse des membres inférieurs réalisée par le service de radiologie. L'échographie au point d'intervention réduit de manière significative la durée de séjour aux urgences lorsque l'échographie duplex veineux des membres inférieurs n'est pas disponible dans le service de radiologie.

External validation and comparison of the Glasgow-Blatchford score, modified Glasgow-Blatchford score, Rockall score and AIMS65 score in patients with upper gastrointestinal bleeding: a cross-sectional observational study in Western Switzerland.
Rivieri S, Carron PN, Schoepfer A, Ageron FX. | Eur J Emerg Med. 2023 Feb 1;30(1):32-39
DOI: https://doi.org/10.1097/mej.0000000000000983  | Télécharger l'article au format  
Keywords: AIMS65 score, emergency department, endoscopy, Glasgow-Blatchford score, hematemesis, melena, risk assessment, Rockall score, upper gastrointestinal bleeding

Original article

Editorial : Upper gastrointestinal bleeding (UGIB) presents a high incidence in an emergency department (ED) and requires careful evaluation of the patient's risk level to ensure optimal management. The primary aim of this study was to externally validate and compare the performance of the Rockall score, Glasgow-Blatchford score (GBS), modified GBS and AIMS65 score to predict death and the need for an intervention among patients with UGIB. This was a cross-sectional observational study of patients consulting the ED of a Swiss tertiary care hospital with UGIB. Primary outcomes were the inhospital need for an intervention, including transfusion, or an endoscopic procedure or surgery or inhospital death. The secondary outcome was inhospital death. We included 1521 patients with UGIB, median age, 68 (52-81) years; 940 (62%) were men. Melena or hematemesis were the most common complaints in 1020 (73%) patients. Among 422 (28%) patients who needed an intervention or died, 76 (5%) died in the hospital. Accuracy of the scoring systems assessed by receiver operating characteristic curves showed that the Glasgow-Blatchford bleeding and modified GBSs had the highest discriminatory capacity to determine inhospital death or the need of an intervention [AUC, 0.77 (95% CI, 0.75-0.80) and 0.78 (95% CI, 0.76-0.81), respectively]. AIMS65 and the pre-endoscopic Rockall score showed a lower discrimination [AUC, 0.68 (95% CI, 0.66-0.71) and 0.65 (95% CI, 0.62-0.68), respectively]. For a GBS of 0, only one patient (0.8%) needed an endoscopic intervention. The modified Glasgow-Blatchford and Glasgow-Blatchford bleeding scores appear to be the most accurate scores to predict the need for intervention or inhospital death.

Conclusion : In this retrospective study, mGBS and GBS appear to be the most accurate scores to predict the need for urgent intervention or death. The use of these scores could help in decision-making. However, clinical judgment remains essential, especially in low-to-moderate risk patients.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, le score de Glasgow-Blatchford modifié et le score de Glasgow-Blatchford semblent être les scores les plus précis pour prédire la nécessité d'une intervention urgente ou le décès. L'utilisation de ces scores pourrait aider à la prise de décision. Cependant, le jugement clinique reste essentiel, en particulier chez les patients à risque faible ou modéré.

Prediction of significant coronary artery disease in acute chest pain without infarction in emergency department: MAPAC Cardio-PreTest model.
Fernandez-Felix BM, Corres J, Estelles Lerga P, Arana-Arri E, Arenaza Choperena G, Castillo M, Pecharromán I, San José-Saras D, Piqueras Olmeda R, García de Vicuña A, Gómez Usabiaga V, Vicente A, Zamora J. | Eur J Emerg Med. 2023 Feb 1;30(1):40-46
DOI: https://doi.org/10.1097/mej.0000000000000992
Keywords: coronary artery disease, emergency department, predictive model

Original article

Editorial : Acute nontraumatic chest pain is a frequent reaso n for consultation in emergency departments and represents a diagnostic challenge. The objective is to estimate the risk of significant coronary artery disease (CAD) in patients with cardiogenic acute chest pain for whom the diagnosis of infarction was ruled out in the emergency department with a nondiagnostic ECG and negative high-sensitivity troponins. We prospectively recruited 1625 patients from emergency departments of seven Spanish hospitals. The outcome was presence of significant CAD determined by presence of ischaemia in functional tests or more than 70% stenosis in imaging tests. In this study, we developed a predictive model and evaluated its performance and clinical utility. The prevalence of significant CAD was 14% [227/1625; 95% confidence interval (CI), 12-16]. MAPAC Cardio-PreTest model included seven predictors: age, sex, smoking, history of hypertension, family history of CAD, history of hyperuricaemia, and type of chest pain. The optimism-adjusted model discrimination was C-statistic 0.654 (95% CI, 0.618-0.693). Calibration plot showed good agreement between the predicted and observed risks, and calibration slope was 0.880 (95% CI, 0.731-1.108) and calibration-in-the-large -0.001 (95% CI, -0.141 to 0.132). The model increased net benefit and improved risk classification over the recommended approach by the European Society of Cardiology [Net Reclassification Index (NRI) of events = 5.3%, NRI of nonevents = 7.0%]. MAPAC Cardio-PreTest model is an online prediction tool to estimate the individualised probability of significant CAD in patients with acute chest pain without a diagnosis of infarction in emergency department. The model was more useful than the current alternatives in helping patients and clinicians make individually tailored choices about the intensity of monitoring or additional coronary tests.

Conclusion : In summary, the MAPAC Cardio-PreTest model is a simple seven-item prediction tool to estimate the individualised probability of significant CAD in patients with cardiogenic acute chest pain for whom the diagnosis of cardiac infarction has been ruled out at the emergency department. The model has shown promise as being more useful than alternative approaches in terms of net benefit, although it warrants external validation studies to assess its predictive performance in wider populations as well as randomised controlled trials assessing its actual impact in clinical important outcomes. The model could help to guide individually tailored choices made by patients and clinicians, which may influence the intensity of monitoring or additional coronary tests. It can be readily applied using an online tool.

Conclusion (proposition de traduction) : En résumé, le modèle MAPAC Cardio-PreTest est un outil simple de prédiction en sept points permettant d'estimer la probabilité individuelle d'une maladie coronarienne significative chez les patients souffrant d'une douleur thoracique aiguë d'origine cardiaque et pour lesquels le diagnostic d'infarctus a été exclu au service des urgences. Le modèle s'est révélé plus utile que d'autres approches en termes de bénéfice net, bien qu'il nécessite des études de validation externes pour évaluer sa performance prédictive dans des populations plus larges, ainsi que des essais contrôlés randomisés pour évaluer son impact réel sur les résultats cliniques importants. Le modèle pourrait aider à orienter les choix individuels des patients et des cliniciens, ce qui pourrait influencer le degré de surveillance ou les examens coronariens complémentaires. Il peut être facilement appliqué à l'aide d'un outil en ligne.

Commentaire : Le modèle MAPAC Cardio-PreTest est un outil simple de prédiction en 7 points permettant d'estimer la probabilité individualisée de maladie coronarienne chez les patients présentant une douleur thoracique aiguë cardiogénique et pour lesquels le diagnostic d'infarctus a été exclu au service des urgences :
Site Internet MAPAC Cardio-PreTest model  

Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial.
Lari A, Jarragh A, Alherz M, Nouri A, Behbehani M, Alnusif N. | Eur J Trauma Emerg Surg. 2023 Feb;49(1):107-113
DOI: https://doi.org/10.1007/s00068-022-02078-8  | Télécharger l'article au format  
Keywords: Analgesia; Distal radius fracture; Hematoma block; Nonoperative management; Periosteal block; Reduction.

ORIGINAL ARTICLE

Introduction : To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB).

Méthode : This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques.

Résultats : Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages.

Conclusion : The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique.

Conclusion (proposition de traduction) : Le bloc périostique circonférentiel fournit un effet analgésique supérieur à celui du bloc intra-focal conventionnel sans aucune complication documentée dans l'une ou l'autre technique.

Commentaire :  
Bloc périosté circonférentiel :
Après une première injection d'anesthésique local pour anesthésier la peau sur la face latérale du radius, une deuxième injection permet une anesthésie circonférentielle autour du radius et du cubitus (environ 6 cm à proximité de l'articulation du poignet).
Lidocaïne 1 % (10 mg/ml) 10-15 ml (100-150 mg) chez les adultes et environ 0,2-0,3 ml par kg de poids corporel (ne dépassant pas 3 mg par kg de poids corporel chez les enfants).

Bloc intra-focal : Insérer l'aiguille avec le biseau vers le bas et avec un angle d'environ 30°, en direction de la fracture.
Lidocaine 1 % 10 mg/ml, 3 mg/kg (dose maximale), jusqu'à 210 mg pour un patient de 70 kg.

Does tranexamic acid reliably reduce blood loss in proximal femur fracture surgery?.
Fenwick A, Antonovska I, Pfann M, Mayr J, Wiedl A, Nuber S, Förch S, Mayr E. | Eur J Trauma Emerg Surg. 2023 Feb;49(1):209-216
DOI: https://doi.org/10.1007/s00068-022-02042-6  | Télécharger l'article au format  
Keywords: Blood loss; Proximal femur fracture; Tranexamic acid; Transfusion rate.

Original Article

Introduction : The aim of our study was to investigate the use of tranexamic acid in patients with proximal femoral fractures and compare the total blood loss, transfusion rates, complications, and the application method.

Méthode : A retrospective single center cohort study (level I trauma center) with 1479 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 was performed. 1 g of tranexamic acid was applied (systemic, topic or combined application). Patient data, surgical procedure, complications, and mortality were assessed. Hemoglobin levels, blood loss and transfusion rates for patients with and without tranexamic acid and the application methods were compared.

Résultats : 667 femoral neck fractures, 701 pertrochanteric and 109 subtrochanteric fractures were included. Mean age was 80.8 years. 274 patients received tranexamic acid. At admission average hemoglobin was 12.2 g/l. Hemoglobin drop postoperatively was less after tranexamic acid (9.72 vs. 9.35 g/dl). Transfusion rates were lowered significantly by 17.1% after tranexamic acid. Blood loss was reduced for all patients after tranexamic acid independent of fracture morphology. The combination of 1 g i.v. and 1 g topical-applied tranexamic acid seems to be more effective. Complication rates did not differ.

Conclusion : Tranexamic acid is effective in reducing blood loss and transfusion rates, without increasing the risk of thromboembolic events after proximal femoral fractures. For open reduction and nailing and arthroplasty in fracture setting combined topical and single i.v. application seems most effective and closed reduction with nailing can be treated by single dose i.v. application of 1 g tranexamic acid.

Conclusion (proposition de traduction) : L'acide tranexamique est efficace pour réduire les pertes sanguines et les taux de transfusion, sans augmenter le risque d'événements thromboemboliques après des fractures fémorales proximales. Pour la réduction ouverte, l'enclouage et l'arthroplastie en cas de fracture, une application topique combinée et une administration i.v. unique semblent les plus efficaces, et la réduction fermée avec enclouage peut être traitée par une administration i.v. unique de 1 g d'acide tranexamique.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults.
Garner A, Poynter E, Parsell R, Weatherall A, Morgan M, Lee A. | Eur J Trauma Emerg Surg. 2023 Feb;49(1):571-581
DOI: https://doi.org/10.1007/s00068-022-02049-z
Keywords: Thoracic trauma; Thoracostomy; Tension pneumothorax; Prehospital; HEMS

ORIGINAL ARTICLE

Introduction : We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy.

Méthode : In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique.

Résultats : Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85).

Conclusion : There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Conclusion (proposition de traduction) : Il n'a pas été clairement démontré que la thoracostomie au doigt permettait de réduire les taux de complications globales, les taux d'infection ou les durées d'intervention, mais le nombre de tension physiologies récurrentes était significativement plus élevé. Par conséquent, la mise en place du tube est recommandée dès que possible après la décompression thoracique.

How to use biomarkers of infection or sepsis at the bedside: guide to clinicians.
Póvoa P, Coelho L, Dal-Pizzol F, Ferrer R, Huttner A, Conway Morris A, Nobre V, Ramirez P, Rouze A, Salluh J, Singer M, Sweeney DA, Torres A, Waterer G, Kalil AC. | Intensive Care Med. 2023 Feb;49(2):142-153
DOI: https://doi.org/10.1007/s00134-022-06956-y  | Télécharger l'article au format  
Keywords: Antibiotic stewardship; Biomarkers; Diagnosis; Intensive care unit; Sepsis.

Narrative Review

Editorial : Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. In this context, biomarkers could be considered as indicators of either infection or dysregulated host response or response to treatment and/or aid clinicians to prognosticate patient risk. More than 250 biomarkers have been identified and evaluated over the last few decades, but no biomarker accurately differentiates between sepsis and sepsis-like syndrome. Published data support the use of biomarkers for pathogen identification, clinical diagnosis, and optimization of antibiotic treatment. In this narrative review, we highlight how clinicians could improve the use of pathogen-specific and of the most used host-response biomarkers, procalcitonin and C-reactive protein, to improve the clinical care of patients with sepsis. Biomarker kinetics are more useful than single values in predicting sepsis, when making the diagnosis and assessing the response to antibiotic therapy. Finally, integrated biomarker-guided algorithms may hold promise to improve both the diagnosis and prognosis of sepsis. Herein, we provide current data on the clinical utility of pathogen-specific and host-response biomarkers, offer guidance on how to optimize their use, and propose the needs for future research.

Conclusion : In summary, moving forward from where we currentlyare with biomarkers of sepsis to a point where we haveclinically useful markers driving patient treatment pathwaysto improve outcomes will require a significantchange in approach. Single center, unidimensional studieswill unlikely bring much progress. Large multi-centercohort studies, utilizing state-of-the-art omics, bioinformatics,and machine learning algorithms to identifybiomarkers that predict differential responses to interventionsin specific clinical endotypes are what is needed.The combination of existing tools in multicenter andmultidisciplinary collaborations will be the most effectiveway of discovering new biomarkers that can be implementedinto clinical practice to optimize patient care.Until then, biomarkers of sepsis can be useful adjunctivetools when clinicians need additional information tooptimize patient care at the bedside. Serial determinationsare more informative than a single value and biomarkersshould never be used as a stand-alone test, butalways in conjunction with a thorough clinical evaluation and a comprehensive knowledge of biomarkers’ biology,interferences, strengths, and limitations.

Conclusion (proposition de traduction) : En résumé, pour passer de la situation actuelle en matière de biomarqueurs du sepsis à un stade où nous disposons de marqueurs cliniquement pertinents permettant d'améliorer le traitement des patients, il faudra changer radicalement d'approche. Les études unicentriques et unidimensionnelles n'apporteront probablement pas beaucoup de progrès. La combinaison des outils existants dans des projets multicentriques et multidisciplinaires sera le moyen le plus efficace pour découvrir de nouveaux biomarqueurs qui peuvent être mis en œuvre dans la pratique clinique afin d'optimiser les soins aux patients. En attendant, les biomarqueurs du sepsis peuvent être des outils complémentaires utiles lorsque les cliniciens ont besoin d'informations supplémentaires pour optimiser les soins aux patients au chevet du malade. Les analyses en série sont plus informatives qu'une valeur unique et les biomarqueurs ne devraient jamais être utilisés comme un test isolé, mais toujours en association avec une évaluation clinique approfondie et une connaissance approfondie de la biologie, des interactions, des points forts et des limites des biomarqueurs.

BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation-a randomized multicenter clinical trial.
Baden DN, Roetman MH, Boeije T, Mullaart N, Boden R, Houwert RM, Heng M, Groenwold RHH, van der Meijden OAJ. | Int J Emerg Med. 2023 Feb 24;16(1):14
DOI: https://doi.org/10.1186/s12245-023-00480-6  | Télécharger l'article au format  
Keywords: Anterior shoulder dislocation; Biomechanical reduction techniques; Emergency department; Length-of-stay; No medication; Reduction rate.

RESEARCH

Introduction : Biomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate.

Méthode : A randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications.

Résultats : Three hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( -). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques.

Conclusion : A combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate.

Conclusion (proposition de traduction) : Une combinaison de techniques biomécaniques a permis d'obtenir une durée de séjour aux urgences similaire et des scores de douleur similaires, avec un taux de réussite de réduction globalement élevé. Dans les deux groupes, la technique de Milch modifiée présentait le taux de réussite le plus élevé pour la première réduction.

Commentaire : 

Acute Coronary Occlusion in Patients With Non-ST-Segment Elevation Out-of-Hospital Cardiac Arrest.
Spirito A, Vaisnora L, Papadis A, Iacovelli F, Sardu C, Selberg A, Bär S, Kavaliauskaite R, Temperli F, Asatryan B, Pilgrim T, Hunziker L, Heg D, Valgimigli M, Windecker S, Räber L. | J Am Coll Cardiol. 2023 Feb 7;81(5):446-456
DOI: https://doi.org/10.1016/j.jacc.2022.10.039
Keywords: coronary angiography; coronary occlusion; death; non–ST-segment elevation; out-of-hospital cardiac arrest

Original Investigation

Introduction : According to current guidelines, hemodynamic status should guide the decision between immediate and delayed coronary angiography (CAG) in out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation. A delayed strategy is advised in hemodynamically stable patients, and an immediate approach is recommended in unstable patients.
Objectives: This study sought to assess the frequency, predictors, and clinical impact of acute coronary occlusion in hemodynamically stable and unstable OHCA patients without ST-segment elevation.

Méthode : Consecutive unconscious OHCA patients without ST-segment elevation who were undergoing CAG at Bern University Hospital (Bern, Switzerland) between 2011 and 2019 were included. Frequency and predictors of acute coronary artery occlusions and their impact on all-cause and cardiovascular mortality at 1 year were assessed.

Résultats : Among the 386 patients, 169 (43.8%) were hemodynamically stable. Acute coronary occlusions were found in 19.5% of stable and 24.0% of unstable OHCA patients (P = 0.407), and the presence of these occlusions was predicted by initial chest pain and shockable rhythm, but not by hemodynamic status. Acute coronary occlusion was associated with an increased risk of cardiovascular death (adjusted HR: 2.74; 95% CI: 1.22-6.15) but not of all-cause death (adjusted HR: 0.72; 95% CI: 0.44-1.18). Hemodynamic instability was not predictive of fatal outcomes.

Conclusion : Acute coronary artery occlusions were found in 1 in 5 OHCA patients without ST-segment elevation. The frequency of these occlusions did not differ between stable and unstable patients, and the occlusions were associated with a higher risk of cardiovascular death. In OHCA patients without ST-segment elevation, chest pain or shockable rhythm rather than hemodynamic status identifies patients with acute coronary occlusion.

Conclusion (proposition de traduction) : Des occlusions aiguës des artères coronaires ont été constatées chez un patient sur cinq ayant fait un arrêt cardiaque extrahospitalier sans élévation du segment ST. La fréquence de ces occlusions ne différait pas entre les patients stables et instables, et les occlusions étaient associées à un risque plus élevé de décès cardiovasculaire. Chez les patients ayant fait un arrêt cardiaque extrahospitalier sans élévation du segment ST, la douleur thoracique ou le rythme choquable, plutôt que l'état hémodynamique, permet d'identifier les patients présentant une occlusion coronarienne aiguë.

Clinical Validation of 5 Direct-to-Consumer Wearable Smart Devices to Detect Atrial Fibrillation: BASEL Wearable Study.
Mannhart D, Lischer M, Knecht S, du Fay de Lavallaz J, Strebel I, Serban T, Vögeli D, Schaer B, Osswald S, Mueller C, Kühne M, Sticherling C, Badertscher P. | JACC Clin Electrophysiol. 2023 Feb;9(2):232-242
DOI: https://doi.org/10.1016/j.jacep.2022.09.011
Keywords: Aucun

ORIGINAL RESEARCH

Introduction : Multiple smart devices capable to detect atrial fibrillation (AF) are presently available. Sensitivity and specificity for the detection of AF may differ between available smart devices, and this has not yet been adequately investigated.
Objectives: The aim was to assess the accuracy of 5 smart devices in identifying AF compared with a physician-interpreted 12-lead electrocardiogram as the reference standard in a real-world cohort of patients.

Méthode : We consecutively enrolled patients presenting to a cardiology service at a tertiary referral center in a prospective, diagnostic study.

Résultats : We prospectively analyzed 201 patients (31% women, median age 66.7 years). AF was present in 62 (31%) patients. Sensitivity and specificity for the detection of AF were comparable between devices: 85% and 75% for the Apple Watch 6, 85% and 75% for the Samsung Galaxy Watch 3, 58% and 75% for the Withings Scanwatch, 66% and 79% for the Fitbit Sense, and 79% and 69% for the AliveCor KardiaMobile, respectively. The rate of inconclusive tracings (the algorithm was unable to determine the heart rhythm) was 18%, 17%, 24%, 21%, and 26% for the Apple Watch 6, Samsung Galaxy Watch 3, Withings Scan Watch, Fitbit Sense, and AliveCor KardiaMobile (P < 0.01 for pairwise comparison), respectively. By manual review of inconclusive tracings, the rhythm could be determined in 955 (99%) of 969 single-lead electrocardiograms. Regarding patient acceptance, the Apple Watch was ranked first (39% of participants).

Discussion : In this clinical validation of 5 direct-to-consumer smart devices, we found differences in the amount of inconclusive tracings diminishing sensitivity and specificity of the smart devices. In a clinical setting, manual review of tracings is required in about one-fourth of cases.

Conclusion : Dans cette validation clinique de 5 dispositifs intelligents en vente directe, nous avons constaté des différences dans le nombre de tracés non concluants, ce qui diminue la sensibilité et la spécificité des dispositifs intelligents. Dans un contexte clinique, l'examen manuel des tracés est nécessaire dans environ un quart des cas.

Conclusion (proposition de traduction) : atrial fibrillation; digital health; intelligent ECG; smartwatch

Management of Thoracic Aortic Dissection.
Hameed I, Cifu AS, Vallabhajosyula P. | JAMA. 2023 Mar 7;329(9):756-757
DOI: https://doi.org/10.1001/jama.2023.0265
Keywords: Aucun

JAMA Clinical Guidelines Synopsis

Editorial : Acute type A aortic dissection and type B aortic dissection (involving the ascending and descending aorta, respectively) are associated with high morbidity and mortality. Patients often present emergently in critical condition. Health care clinicians across different specialties encounter aortic dissection, and initial management is important to patient survival and long-term outcome. This article summarizes 2 guidelines on initial management and stabilization of patients presenting with acute type A aortic dissection or type B aortic dissection.

Conclusion : Major recommendations
β-Blockers and pain relief are recommended in the initial management of acute type A aortic dissection (ATAAD) without severe aortic regurgitation (strong recommendation; strong evidence).
For patients with ATAAD, emergency surgery is recommended. When cardiac surgery is not immediately available or for patients with complicated ATAAD, transfer to a comprehensive aortic center is recommended (moderate recommendation; moderate evidence).
For type B aortic dissection (TBAD), a stepwise approach is recommended to assess organ malperfusion or other indications of complicated disease (strong recommendation; moderate evidence).
If malperfusion, defined as end-organ ischemia, is not present, optimal medical therapy (OMT) is the mainstay for treatment of patients with uncomplicated TBAD (strong recommendation; moderate evidence).

Conclusion (proposition de traduction) : Principales recommandations
Les β-bloquants et le soulagement de la douleur sont recommandés dans la prise en charge initiale de la dissection aortique aiguë de type A (ATAAD) sans régurgitation aortique sévère (forte recommandation ; fortes preuves).
Pour les patients souffrant d'une dissection aortique aiguë de type A, une intervention chirurgicale d'urgence est recommandée. Lorsque la chirurgie cardiaque n'est pas immédiatement disponible ou pour les patients présentant une dissection aortique de type A compliquée, le transfert vers un centre aortique complet est recommandé (recommandation modérée ; preuves modérées).
Pour la dissection aortique de type B (TBAD), une approche par étapes est recommandée pour évaluer la mauvaise perfusion des organes ou d'autres signes de complication de la maladie (recommandation forte ; niveau de preuve modéré).
En l'absence de mauvaise perfusion, définie comme une ischémie de l'organe cible, un traitement médical optimal (OMT) est la base du traitement des patients souffrant d'une dissection aortique de type B non compliquée (recommandation forte ; niveau de preuve modéré).

High-Flow Oxygen and Other Noninvasive Respiratory Support Therapies in Bronchiolitis: Systematic Review and Network Meta-Analyses.
Gutiérrez Moreno M, Del Villar Guerra P, Medina A, Modesto I Alapont V, Castro Bournissen L, Mirás Veiga A, Ochoa-Sangrador C. | Pediatr Crit Care Med. 2023 Feb 1;24(2):133-142
DOI: https://doi.org/10.1097/pcc.0000000000003139
Keywords: Aucun

REVIEW ARTICLES

Introduction : We present a systematic review on the effectiveness of noninvasive respiratory support techniques in bronchiolitis.
Data sources: Systematic review with pairwise meta-analyses of all studies and network meta-analyses of the clinical trials.

Méthode : Patients below 24 months old with bronchiolitis who require noninvasive respiratory support were included in randomized controlled trials (RCTs), non-RCT, and cohort studies in which high-flow nasal cannula (HFNC) was compared with conventional low-flow oxygen therapy (LFOT) and/or noninvasive ventilation (NIV).
Data extraction: Emergency wards and hospitalized patients with bronchiolitis.

Résultats : A total of 3,367 patients were analyzed in 14 RCTs and 8,385 patients in 14 non-RCTs studies. Only in nonexperimental studies, HFNC is associated with a lower risk of invasive mechanical ventilation (MV) than NIV (odds ratio, 0.49; 95% CI, 0.42-0.58), with no differences in experimental studies. There were no differences between HFNC and NIV in other outcomes. HFNC is more effective than LFOT in reducing oxygen days and treatment failure. In the network meta-analyses of clinical trials, NIV was the most effective intervention to avoid invasive MV (surface under the cumulative ranking curve [SUCRA], 57.03%) and to reduce days under oxygen therapy (SUCRA, 79.42%), although crossover effect estimates between interventions showed no significant differences. The included studies show methodological heterogeneity, but it is only statistically significant for the reduction of days of oxygen therapy and length of hospital stay.

Conclusion : Experimental evidence does not suggest that high-flow oxygen therapy has advantages over LFOT as initial treatment nor over NIV as a rescue treatment.

Conclusion (proposition de traduction) : Les données expérimentales ne suggèrent pas que l'oxygénothérapie à haut débit présente des avantages par rapport à l'oxygénothérapie conventionnelle à bas débit en tant que traitement initial ou par rapport à la ventilation non invasive en tant que traitement de secours.

Ventilation devices for neonatal resuscitation at birth: A systematic review and meta-analysis.
Tribolet S, Hennuy N, Rigo V. | Resuscitation. 2023 Feb;183:109681
DOI: https://doi.org/10.1016/j.resuscitation.2022.109681  | Télécharger l'article au format  
Keywords: Birth; Neonatal resuscitation; Tpiece; Ventilation devices.

Review

Introduction : Initial management of inadequate adaptation to extrauterine life relies on non-invasive respiratory support. Two types of devices are avail- able: fixed pressure devices (FPD; T-pieces or ventilators) and hand driven pressure devices (HDPD; self- or flow-inflating bags). This systematic review and meta-analysis aims to compare clinical outcomes after neonatal resuscitation according to device type.

Méthode : Four databases were searched from inception to 2022, January. Search strategies included Mesh/Emtree terms as well as free language without any restriction. Randomized, quasi-randomized studies and prospective cohorts comparing the use of the two types of devices in neonatal resuscitation were included.

Résultats : Nine studies recruiting 3621 newborns were included: 5 RCTs, 2 RCTs with interventions bundles and 2 prospective cohorts. Meta- analysis of the 5 RCTs demonstrated significant reductions in bronchopulmonary dysplasia (RR0,68[0,48–0,96]-NNT 31) and other respiratory out- comes: intubation in the delivery room (RR0,72[0,58–0,88]-NNT 13,4), mechanical ventilation requirements (RR0,81[0,67–0,96]-NNT 17) and dura- tion (MD-1,54 days[
3,03-
0,05]), need for surfactant (RR0,79[0,64–0,96]-NNT 7,3).
The overall analysis found a lower mortality in the FPD group (OR0,57[0,47–0,69]-NNT 12,7) and confirmed decreases in intubation, surfactant requirement and mechanical ventilation rates (OR 0,56[0,40–0,79]- NNT7,5; OR 0,67[0,55–0,82]-NNT10,7 and OR0,58[0,42–0,80]- NNT 7,4 respec- tively). The risk of cystic periventricular leukomalacia (cPVL) decreased significantly with FPD (OR0.59[0.41–0.85]–NNT 27). Pneumothorax rates were similar (OR0.82[0.44–1.52]).

Conclusion : This review and meta-analysis compared the use of fixed pressure devices (such as T-piece resuscitators) and hand driven pressure devices (such as self-inflating bags). Resuscitation at birth with FPD appears to improve respiratory transition and may contribute to resuscitation strategies aiming to protect lung and brain.
We found significant reductions in BPD, DR intubation, mechan- ical ventilation and need for surfactant without increased morbidity, including pneumothorax. Expending the analysis with bundled inter- vention RCT and prospective cohorts additionally suggests decreases in mortality and cPVL. However, the certainty of evidence according to GRADE is very low to moderate and further studies are needed to confirm those results and to complete data about comor- bidities of prematurity and HIE. Where possible, FPD should prevail to support neonatal transition.
Resuscitation at birth with FPD improves respiratory transition and decreases BPD with a very low to moderate cer- tainty of evidence. There is suggestion of decreases in mortality and cPVL. Further studies are still needed to confirm those results.

Conclusion (proposition de traduction) : Cette revue et méta-analyse a comparé l'utilisation de dispositifs de pression fixes (tels que les réanimateurs en T) et de dispositifs de pression manuels (tels que les ballons autogonflants). La réanimation à la naissance à l'aide d'appareils à pression fixe semble améliorer la transition respiratoire et peut contribuer aux stratégies de réanimation visant à protéger les poumons et le cerveau.
Nous avons constaté une réduction significative de la dysplasie broncho-pulmonaire, de l'intubation en salle d'accouchement, de la ventilation mécanique et du besoin de surfactant, sans augmentation de la morbidité, y compris du pneumothorax. L'extension de l'analyse à des essais contrôlés randomisés avec intervention groupée et à des cohortes prospectives suggère en outre une diminution de la mortalité et de la leucomalacie périventriculaire kystique. Cependant, la certitude des preuves selon GRADE est très faible à modérée et d'autres études sont nécessaires pour confirmer ces résultats et compléter les données sur les comorbidités de la prématurité et l'encéphalopathie hypoxique-ischémique. Dans la mesure du possible, les dispositifs à pression fixe devraient prévaloir pour favoriser la transition néonatale.
La réanimation à la naissance à l'aide de dispositifs à pression fixe améliore la transition respiratoire et réduit la dysplasie broncho-pulmonaire avec une certitude de preuve très faible à modérée. Il semble que la mortalité et la leucomalacie périventriculaire kystique diminuent. D'autres études sont encore nécessaires pour confirmer ces résultats.

Commentaire : Le Neopuff, appareils de réanimation à pièce en T, délivre une pression inspiratoire de crête (Pcrête) et une pression expiratoire positive (PEP) davantage contrôlées et constantes, qui aide à protéger les poumons des nouveau-nés.

PrehospitaL Ultrasound in Undifferentiated DyspnEa (PreLUDE): a prospective, clinical, observational study.
Gundersen EA, Juhl-Olsen P, Bach A, Rostgaard-Knudsen M, Nielsen BRR, Skaarup SH, Petersen HØ, Fjølner J, Poulsen MGG, Bøtker MT. | Scand J Trauma Resusc Emerg Med. 2023 Feb 5;31(1):6
DOI: https://doi.org/10.1186/s13049-023-01070-4  | Télécharger l'article au format  
Keywords: Dyspnea; Heart failure; Point-of-care ultrasound; Prehospital.

ORIGINAL RESEARCH

Introduction : Diagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy.

Méthode : Prospective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea.

Résultats : In total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%).

Conclusion : Supplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure.

Conclusion (proposition de traduction) : L'échographie additionnelle préhospitalière au point d'intervention conduit à une amélioration de la précision diagnostique de l'insuffisance cardiaque et des exacerbations aiguës de la BPCO/asthme, décrite globalement par l'aire sous la courbe ROC, mais l'augmentation de la sensibilité pour les diagnostics d'insuffisance cardiaque aiguë n'a pas atteint le seuil de signification statistique. L'utilisation adaptée des résultats de l'échographie au point d'intervention optimise la précision du diagnostic pour l'exclusion et l'inclusion de l'insuffisance cardiaque aiguë.

T-MACS score vs HEART score identification of major adverse cardiac events in the emergency department.
Akman G, Hökenek NM, Yusufoğlu K, Akman D, Haği O, Bayramoğlu B, Yavuz BG, Çolak Ş. | Am J Emerg Med. 2023 Feb;64:21-25
DOI: https://doi.org/10.1016/j.ajem.2022.11.015
Keywords: Chest pain; Emergency department; HEART score; T-MACS score.

Original Contribution

Introduction : Ischemic heart disease is the leading cause of mortality worldwide, and its prevalence is rising.
Objective: The goal of this study was to evaluate the HEART and T-MACS scores for predicting major cardiac events (MACE) in patients presenting to the emergency department with chest pain.

Méthode : This study was single center and prospectively conducted. The demographic information, T-MACS and HEART scores of the participants were recorded and calculated. Acute myocardial infarction (AMI), mortality, and the need for coronary revascularization were considered as major adverse cardiac events (MACEs). The statistical analysis was carried out using SPSS (IBM Statistics, New York) version 24, and significance was determined at the p < 0.05 level.

Résultats : The 514 patients included in our study had a mean age of 52.01 ± 19.10 years, with 55.3% were female and 44.7% was male. A total of 78(%15.1) cases were diagnosed with AMI. Fifty patients (%9.7) underwent percutaneous coronary intervention, 12 (%2.3) patients underwent coronary artery by-pass graft, and 8 (%1.5) patients died within a one-month period. The sensitivity and negative predictive values of the T-MACS score for the very low risk classification were 93.90% (86.3%-98.0%) and 97.7% (94.7%-99.0%), respectively, and the sensitivity and negative predictive values of the HEART score for the low risk classification were 89.59% (77.3%-93.1%) and 96.6% (94.2%-98.0%), respectively. The specificity and positive predictive values for the high risk classification were 99.77% (98.7%-100%) and 97.2% (82.9%-99.6%), respectively for the T-MACS score and 95.14% (92.7%-97%) and 63.2% (51.4%-73.5%), respectively for the HEART score.

Conclusion : The T-MACS score was shown to be more accurate than the HEART score in predicting low risk (very low risk for the T-MACS score), high risk, and anticipated one-month risk for MACE in patients coming to the emergency department with chest pain.

Conclusion (proposition de traduction) : Le score T-MACS s'est avéré plus précis que le score HEART pour prédire le risque faible (risque très faible pour le score T-MACS), le risque élevé et le risque prévu à un mois d'événements cardiaques majeurs chez les patients se présentant aux urgences avec une douleur thoracique.

Esmolol, vector change, and dose-capped epinephrine for prehospital ventricular fibrillation or pulseless ventricular tachycardia.
Stupca K, Scaturo N, Shomo E, King T, Frank M. | Am J Emerg Med. 2023 Feb;64:46-50
DOI: https://doi.org/10.1016/j.ajem.2022.11.019
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Defibrillation; Esmolol; Refractory ventricular fibrillation; Vector change.

Original Contribution

Introduction : Refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) cardiac arrest describes a subset of patients who do not respond to standard Advanced Cardiac Life Support (ACLS) interventions and are associated with poor outcomes. Esmolol administration and vector change defibrillation have shown promise in improving outcomes in these patients, however evidence is limited.
Objectives: This study compares clinical outcomes between patients with prehospital refractory VF/pVT who received an Emergency Medical Service (EMS) bundle, comprised of esmolol administration, vector change defibrillation, and dose-capped epinephrine at 3 mg, to patients who received standard ACLS interventions.

Méthode : This multicenter, retrospective, cohort study evaluated medical records between October 18, 2017 and March 15, 2022. Patients were enrolled if they experienced a prehospital cardiac arrest with the rhythm VF or pVT, had received at least three standard defibrillations, at least 3 mg of epinephrine, and 300 mg of amiodarone. Patients who received the EMS bundle after its implementation were compared to patients who received standard ACLS interventions prior to its implementation. The primary outcome was sustained return of spontaneous circulation (ROSC), defined as ROSC lasting 20 min without recurrence of cardiac arrest. Secondary outcomes included the incidence of any ROSC, survival to hospital arrival, survival at hospital discharge, and neurologically intact survival at hospital discharge.

Résultats : Eighty-three patients were included in the study. Thirty-six were included in the pre-EMS bundle group and 47 patients were included in the post-EMS bundle group. Patients in the pre-EMS bundle group achieved significantly higher rates of sustained ROSC (58.3% vs 17%, p < 0.001), any ROSC (66.7% vs 19.1%, p < 0.001), and survival to hospital arrival (55.6% vs 17%, p < 0.001). The rates of survival to hospital discharge (16.7% vs 6.4%, p = 0.17) and neurologically intact survival at hospital discharge (5.9% vs 4.3%, p = 1.00) were not significantly different between groups.

Conclusion : Patients who received the EMS bundle achieved sustained ROSC significantly less often and were less likely to have pulses at hospital arrival. The incidence of neurologically intact survival was low and similar between groups.

Conclusion (proposition de traduction) : Les patients qui ont reçu l'ensemble des soins médicaux d'urgence ont moins souvent obtenu une récupération d’une activité circulatoire spontanée et étaient moins susceptibles d'avoir un pouls à l'arrivée à l'hôpital. L'incidence de la survie neurologiquement intacte était faible et similaire entre les groupes.

Extracorporeal cardiopulmonary resuscitation location, coronary angiography and survival in out-of-hospital cardiac arrest.
Kim Y, Park JH, Lee SY, Ro YS, Hong KJ, Song KJ, Shin SD. | Am J Emerg Med. 2023 Feb;64:142-149
DOI: https://doi.org/10.1016/j.ajem.2022.11.013
Keywords: Cardiopulmonary resuscitation; Coronary angiography; Extracorporeal Membrane Oxygenation; Out-of-hospital cardiac arrest; Survival.

Original contribution

Introduction : The best location for safe and timely implementation of extracorporeal cardiopulmonary resuscitation (ECPR) is currently uncertain. We aimed to evaluate the association between the location of ECPR and survival outcomes in out-of-hospital cardiac arrest (OHCA) patients. We also evaluated whether the effects of ECPR location on survival differed between patients who underwent coronary angiography (CAG) and those who did not.

Méthode : We used data collected between 2013 and 2020 from a nationwide OHCA database. Adult OHCA patients with presumed cardiac etiology who underwent ECPR were included in the study. The primary outcome was survival to discharge. The main exposure was the ECPR location (emergency department [ED] or cardiac catheterization laboratory [Cath lab]). We compared primary outcomes of ECPR between the ED and Cath lab using multivariable logistic regression. The interaction between ECPR location and CAG was also evaluated.

Résultats : Of 564 ECPR patients, 448 (79.4%) and 116 (20.6%) underwent ECPR in the ED and Cath lab, respectively. CAG was observed in 52.5% and 72.4% of the patients in the ED and Cath lab groups, respectively. There were no significant differences in survival to discharge between the ED and Cath lab groups (14.1% vs. 12.9%, p = 0.75, adjusted odds ratio [AOR] [95% confidence interval] 1.87 [0.85-4.11]). AOR of interaction analysis (95% CI) for survival to discharge of the ED group was 2.34 (1.02-5.40) in patients with CAG and 0.28 (0.04-1.84) in patients without CAG (p for interaction was 0.04).

Conclusion : In adult OHCA patients who underwent ECPR and CAG, ECPR in the ED shortened time to ECMO pump-on time and increased survival to discharge compared to ECPR in the Cath lab.

Conclusion (proposition de traduction) : Chez les adultes victimes d'un arrêt cardiaque extrahospitalier ayant bénéficié d'une réanimation cardiopulmonaire extracorporelle et d'une coronarographie, la réanimation cardiopulmonaire extracorporelle pratiquée aux urgences a raccourci le délai de mise en route de la pompe ECMO et augmenté le taux de survie jusqu'à la sortie de l'hôpital par rapport à la réanimation cardiopulmonaire extracorporelle pratiquée dans le laboratoire de cathétérisme.

Recent developments and controversies in therapeutic hypothermia after cardiopulmonary resuscitation.
Li P, Sun Z, Tian T, Yu D, Tian H, Gong P. | Am J Emerg Med. 2023 Feb;64:1-7
DOI: https://doi.org/10.1016/j.ajem.2022.11.002
Keywords: Cardiopulmonary resuscitation; Return of spontaneous circulation; Targeted temperature management; Temperature control; Therapeutic hypothermia.

Review article

Editorial : L'hypothermie thérapeutique était recommandée comme seul traitement neuroprotecteur chez les patients comateux après le retour de la circulation spontanée (ROSC). De nouvelles données suggérant un effet neuroprotecteur similaire de 36 °C et 33 °C, le terme "hypothermie thérapeutique" a été remplacé par "gestion ciblée de la température" en 2011, qui à son tour a été remplacé par le terme "contrôle de la température" en 2022 en raison de nouvelles données sur les effets similaires de la normothermie ciblée et de 33 °C. Cependant, il n'existe pas de consensus clair sur l'efficacité de l'hypothermie thérapeutique. Dans cet article, nous présentons une vue d'ensemble des données récentes issues de la recherche fondamentale et clinique concernant l'hypothermie thérapeutique et réévaluons son application en tant qu'intervention neuroprotectrice post-RACS dans des contextes cliniques.

Conclusion : Based on the available evidence, the optimal target temperature is yet to be elucidated. In addition, it should be noted that the key message from TTM and TTM2 trials is not to stop using high-quality TH, but how to better control temperature and prevent fever. The controversy pertaining to TH could be addressed through the contin- ued translation of preclinical evidence into clinical practice. Espe- cially, other robust RCTs are required for an objective evaluation of TH in different subpopulations of post-ROSC patients, to optimize the implementation of TH, and to maximize its benefits in clinical settings. Notably, recent opinion appears to support the incorpora- tion of targeted normothermia with fever prevention into the bun- dles of post-ROSC care.

Conclusion (proposition de traduction) : Sur la base des données disponibles, la température cible optimale n'a pas encore été déterminée. En outre, il convient de noter que le message clé des essais de gestion ciblée de la température (TTM) et de TTM2 n'est pas de cesser d'utiliser l'hypothermie thérapeutique de haute qualité, mais de mieux contrôler la température et de prévenir la fièvre. La controverse relative à l'hypothermie thérapeutique pourrait être résolue en continuant à transposer les données précliniques dans la pratique clinique. En particulier, d'autres essai randomisé contrôlé solides sont nécessaires pour une évaluation objective de l'hypothermie thérapeutique dans différentes sous-populations de patients post-RACS, pour optimiser la mise en œuvre de l'hypothermie thérapeutique et pour maximiser ses avantages dans les contextes cliniques. Notamment, l'opinion récente semble soutenir l'incorporation de la normothermie ciblée avec la prévention de la fièvre dans l'ensemble des soins post-RACS.

Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting.
White JJ, Cambron JD, Gottlieb M, Long B. | J Emerg Med. 2023 Feb;64(2):145-155
DOI: https://doi.org/10.1016/j.jemermed.2022.12.008
Keywords: airway; airway obstruction, aspiration; foreign body.

Clinical Review

Introduction : Airway foreign body can be a life-threatening issue in pediatric and adult patients, and the majority of these patients will first present to the emergency department.

Méthode : This article provides a narrative review of the diagnosis and management of airway foreign bodies for the emergency clinician.

Discussion : Foreign bodies in the upper and lower airways are potentially life threatening. This affects all age groups but is more common in pediatric patients. A history of a witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body. Patients with upper-airway foreign bodies are more likely to present in respiratory distress when compared with lower-airway foreign bodies, which often present with more subtle signs. Stridor, drooling, and wheezing suggest respiratory distress, but the presenting clinical picture is often unclear and may only include a cough. Immediate intervention is required in the patient with hemodynamic instability or respiratory distress. Airway management including laryngoscopy, fiberoptic bronchoscopy, and cricothyrotomy may be needed in these patients, with the emphasis on removing the obstructing foreign body and securing the airway. Specialist consultation can assist in retrieving the foreign body and managing the airway. If the patient is stable, imaging and specialist consultation for potential operating room intervention should be considered.

Conclusion : An understanding of the presentation, evaluation, and management of the patient with an airway foreign body is essential for emergency clinicians.

Conclusion (proposition de traduction) : La compréhension de la présentation, de l'évaluation et de la prise en charge du patient présentant un corps étranger dans les voies aériennes est essentielle pour les urgentistes.

Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial.
Wang Y, Li S, Pan Y, Li H, Parsons MW, Campbell BCV, Schwamm LH, Fisher M, Che F, Dai H, Li D, Li R, Wang J, Wang Y, Zhao X, Li Z, Zheng H, Xiong Y, Meng X; TRACE-2 Investigators. | Lancet. 2023 Feb 25;401(10377):645-654
DOI: https://doi.org/10.1016/s0140-6736(22)02600-9
Keywords: Aucun

Article

Introduction : There is increasing interest in replacing alteplase with tenecteplase as the preferred thrombolytic treatment for patients with acute ischaemic stroke. We aimed to establish the non-inferiority of tenecteplase to alteplase for these patients.

Méthode : In this multicentre, prospective, open-label, blinded-endpoint, randomised controlled, non-inferiority trial, adults with an acute ischaemic stroke who were eligible for standard intravenous thrombolysis but ineligible for endovascular thrombectomy were enrolled from 53 centres in China and randomly assigned (1:1) to receive intravenous tenecteplase (0·25 mg/kg, maximum dose of 25 mg) or intravenous alteplase (0·9 mg/kg, maximum dose of 90 mg). Participants had to be able to receive treatment within 4·5 h of stroke, have a modified Rankin Scale (mRS) score of no more than 1 before enrolment, and have a National Institutes of Health Stroke Scale score of 5–25. Patients and treating clinicians were not masked to group assignment; clinicians evaluating outcomes were masked to treatment type. The primary efficacy outcome was the proportion of participants who had a mRS score of 0–1 at 90 days, assessed in the modified intention-to-treat population (all randomly assigned participants who received the allocated thrombolytic), with a non-inferiority margin of 0·937 for the risk ratio (RR). The primary safety outcome was symptomatic intracranial haemorrhage within 36 h, assessed in all participants who received study drug and had a safety assessment available. The trial is registered with ClinicalTrials.gov, NCT04797013, and has been completed.

Résultats : Between June 12, 2021, and May 29, 2022, 1430 participants were enrolled and randomly assigned to tenecteplase (n=716) or alteplase (n=714). Six patients assigned to tenecteplase and seven to alteplase did not receive study product, and five participants in the tenecteplase group and 11 in the alteplase group were lost to follow-up at 90 days. The primary outcome in the modified intention-to-treat population occurred in 439 (62%) of 705 in the tenecteplase group versus 405 (58%) of 696 in the alteplase group (RR 1·07, 95% CI 0·98–1·16). The lower limit of the RR’s 95% CI was greater than the non-inferiority margin. Symptomatic intracranial haemorrhage within 36 h was observed in 15 (2%) of 711 in the tenecteplase group and 13 (2%) of 706 in the alteplase group (RR 1·18, 95% CI 0·56–2·50). Mortality within 90 days occurred in 46 (7%) individuals in the tenecteplase group versus 35 (5%) in the alteplase group (RR 1·31, 95% CI 0·86–2·01).

Conclusion : Tenecteplase was non-inferior to alteplase in people with ischaemic stroke who were eligible for standard intravenous thrombolytic but ineligible for or refused endovascular thrombectomy.

Conclusion (proposition de traduction) : Le ténecteplase s'est avéré non inférieur à l'altéplase chez les personnes ayant présenté un accident vasculaire cérébral ischémique qui étaient éligibles pour un traitement thrombolytique intraveineux standard mais qui n'étaient pas éligibles pour une thrombectomie endovasculaire ou qui l'avaient refusée.

Assessment of infant position and timing of stylet removal to improve lumbar puncture success in neonates (NeoCLEAR): an open-label, 2 × 2 factorial, randomised, controlled trial.
Marshall ASJ, Scrivens A, Bell JL, Linsell L, Hardy P, Yong J, Williams R, Adams E, Sadarangani M, Juszczak E, Roehr CC; NeoCLEAR Collaborative Group. | Lancet Child Adolesc Health. 2023 Feb;7(2):91-100
DOI: https://doi.org/10.1016/s2352-4642(22)00343-1  | Télécharger l'article au format  
Keywords: Aucun

Article

Introduction : Newborn infants are the highest-risk age group for bacterial meningitis. Lumbar punctures are therefore frequently performed in neonates, but success rates are low (50-60%). In Neonatal Champagne Lumbar punctures Every time-A Randomised Controlled Trial (NeoCLEAR), we sought to optimise infant lumbar puncture by evaluating two modifications to traditional technique: sitting position versus lying down and early stylet removal (stylet removal after transecting the subcutaneous tissue) versus late stylet removal.

Méthode : NeoCLEAR was an open-label, 2 × 2 factorial, randomised, controlled trial, conducted in 21 UK neonatal and maternity units. Infants requiring lumbar puncture at 27⁺⁰ to 44⁺⁰ weeks corrected gestational age and weighing 1000 g or more were randomly assigned (1:1:1:1) to sitting position and early stylet removal, sitting position and late stylet removal, lying position and early stylet removal, or lying position and late stylet removal using a 24/7, web-based, secure, central randomisation system. Block randomisation was stratified within site by corrected gestational age (27⁺⁰ to 31⁺⁶ weeks, 32⁺⁰ to 36⁺⁶ weeks, 37⁺⁰ to 40⁺⁶ weeks, or 41⁺⁰ to 44⁺⁰ weeks), using variable block sizes of four and eight with equal frequency. Laboratory staff were masked to allocation. The primary outcome was successful first lumbar puncture, defined as obtaining a cerebrospinal fluid sample with a red blood cell count of less than 10 000 cells per μL. The primary and secondary (including safety) outcomes were analysed by the groups to which infants were assigned regardless of deviation from the protocol or allocation received, but with exclusion of infants who were withdrawn before data collection or who did not undergo lumbar puncture (modified intention-to-treat analysis).

Résultats : Between Aug 3, 2018, and Aug 31, 2020, 1082 infants were randomly assigned to sitting (n=546) or lying (n=536), and early (n=549) or late (n=533) stylet removal. 1076 infants were followed-up until discharge and included in the modified intention-to-treat analysis. 961 (89%) infants were term, and 936 (87%) were younger than 3 days. Successful first lumbar puncture was more frequently observed in sitting than in lying position (346 [63·7%] of 543 vs 307 [57·6%] of 533; adjusted risk ratio 1·10 [95% CI 1·01 to 1·21], p=0·029; number needed to treat=16). Timing of stylet removal had no discernible effect on the primary outcome (338 [62·0%] of 545 infants in the early stylet removal group and 315 [59·3%] of 531 in the late stylet removal group had a successful first lumbar puncture; adjusted risk ratio 1·04 [95% CI 0·94-1·15], p=0·45). Sitting was associated with fewer desaturations than was lying (median lowest oxygen saturations during first lumbar puncture 93% [IQR 89-96] vs 90% [85-94]; median difference 3·0% [2·1-3·9], p<0·0001). One infant from the sitting plus late stylet removal group developed a scrotal haematoma 2 days after lumbar puncture, which was deemed to be possibly related to lumbar puncture.

Conclusion : NeoCLEAR is the largest trial investigating paediatric lumbar puncture so far. Success rates were improved when sitting rather than lying. Sitting lumbar puncture is safe, cost neutral, and well tolerated. We predominantly recruited term neonates younger than 3 days; other populations warrant further study. Neonatal lumbar puncture is commonly performed worldwide; these results therefore strongly support the widespread adoption of sitting technique for neonatal lumbar puncture.

Conclusion (proposition de traduction) : NeoCLEAR est le plus grand essai portant sur la ponction lombaire pédiatrique à ce jour. Les taux de réussite sont meilleurs en position assise qu'en position couchée. La ponction lombaire en position assise est sûre, peu coûteuse et bien tolérée. Nous avons principalement recruté des nouveau-nés à terme de moins de 3 jours ; d'autres populations méritent d'être étudiées. La ponction lombaire néonatale est couramment pratiquée dans le monde entier ; ces résultats plaident donc fortement en faveur de l'adoption généralisée de la technique de la position assise pour la ponction lombaire néonatale.

Commentaire : 

Can absence of cardiac activity on point-of-care echocardiography predict death in out-of-hospital cardiac arrest? A systematic review and meta-analysis.
Albaroudi O, Albaroudi B, Haddad M, Abdle-Rahman ME, Kumar TSS, Jarman RD, Harris T. | Ultrasound J. 2024 Feb 20;16(1):10
DOI: https://doi.org/10.1186/s13089-024-00360-x  | Télécharger l'article au format  
Keywords: CPR; Cardiac arrest; Death; Echocardiography; Emergency medicine; OHCA; PoCUS; Point-of-care; Resuscitation; Survival; Ultrasound.

Review

Introduction : The purpose of this systematic review and meta-analysis was to evaluate the accuracy of the absence of cardiac motion on point-of-care echocardiography (PCE) in predicting termination of resuscitation (TOR), short-term death (STD), and long-term death (LTD), in adult patients with cardiac arrest of all etiologies in out-of-hospital and emergency department setting.

Méthode : A systematic review and meta-analysis was conducted based on PRISMA guidelines. A literature search in Medline, EMBASE, Cochrane, WHO registry, and ClinicalTrials.gov was performed from inspection to August 2022. Risk of bias was evaluated using QUADAS-2 tool. Meta-analysis was divided into medical cardiac arrest (MCA) and traumatic cardiac arrest (TCA). Sensitivity and specificity were calculated using bivariate random-effects, and heterogeneity was analyzed using I² statistic.

Résultats : A total of 27 studies (3657 patients) were included in systematic review. There was a substantial variation in methodologies across the studies, with notable difference in inclusion criteria, PCE timing, and cardiac activity definition. In MCA (15 studies, 2239 patients), the absence of cardiac activity on PCE had a sensitivity of 72% [95% CI 62-80%] and specificity of 80% [95% CI 58-92%] to predict LTD. Although the low numbers of studies in TCA preluded meta-analysis, all patients who lacked cardiac activity on PCE eventually died.

Conclusion : The absence of cardiac motion on PCE for MCA predicts higher likelihood of death but does not have sufficient accuracy to be used as a stand-alone tool to terminate resuscitation. In TCA, the absence of cardiac activity is associated with 100% mortality rate, but low number of patients requires further studies to validate this finding. Future work would benefit from a standardized protocol for PCE timing and agreement on cardiac activity definition.

Conclusion (proposition de traduction) : L'absence de mouvement cardiaque à l'échocardiographie au point d'intervention lors d'un arrêt cardiaque médical prédit une plus grande probabilité de décès, mais n'est pas suffisamment précise pour être utilisée comme un outil autonome permettant de mettre fin à la réanimation. Dans le cas d'un arrêt cardiaque traumatique, l'absence d'activité cardiaque est associée à un taux de mortalité de 100 %, mais le faible nombre de patients nécessite d'autres études pour valider ce résultat. Les travaux futurs bénéficieraient d'un protocole normalisé pour le chronométrage de l'échocardiographie au point d'intervention et d'un accord sur la définition de l'activité cardiaque.