Microbiota-derived psychedelics: Lessons from COVID-19.
Sfera A, Hazan S, Kozlakidis Z, Klein C. | Adv Clin Exp Med. 2023 Apr;32(4):395-399
DOI: https://doi.org/10.17219/acem/159477 | Télécharger l'article au format
Keywords: gut microbes; serotonergic hallucinogens; severe psychiatric illness
Editorial : Emil Kraepelin pensait que la dementia praecox, le trouble que nous appelons aujourd'hui schizophrénie, était causée par l'empoisonnement du cerveau par des toxines générées dans d'autres parties du corps, en particulier la bouche, l'intestin ou les organes génitaux. À cet égard, Kraepelin a fait allusion au microbiote et a conceptualisé les molécules microbiennes comme moteurs de maladies psychiatriques graves. Cependant, il a fallu attendre la pandémie de coronavirus (COVID-19) pour que le paradigme de Kraepelin gagne du terrain, notamment parce que ce virus était associé à la fois à une perturbation de la barrière intestinale et à une psychose d'apparition récente.
De même, malgré de nombreuses études établissant un lien entre les maladies psychiatriques graves et les lésions génomiques et le dysfonctionnement de la réparation de l'ADN, ce mécanisme pathogénique était sous-estimé avant la pandémie de COVID-19. L'utilisation d'un anesthésique psychotomimétique, la kétamine, pour traiter les dépressions résistantes a ravivé l'intérêt pour les substances hallucinogènes sérotoninergiques endogènes, en particulier la tryptamine et la N,N-diméthyltryptamine (DMT), qui sont bénéfiques pour la dépression mais associés à la psychose.
Dans cet éditorial, nous examinons de plus près le rôle du microbiote dans la psychopathologie, en tentant de répondre à deux questions :
1. Pourquoi les substances hallucinogènes sérotoninergiques prédisposant à la psychose peuvent-elles soulager la dépression ?
2. Les substances hallucinogènes produites par le microbiote font-elles partie d'un système antidépresseur intégré similaire aux opioïdes endogènes ?
Conclusion : Gut microbiota, comprised of bacteria, fungi and viruses, can underlie pathological circumstances and translocate outside the GI tract, triggering immunogenicity and hyperinflammation that may disrupt both the host genome and DDR, engendering SPI.
Gut microbiota-generated endogenous hallucinogens, acting via TAARs, likely comprise an inbuilt antidepressant system akin to endogenous opioids. Dysfunctional AhR signaling can damage neuronal DNA, inducing SPI by neurotoxic microglia.
More studies are needed to elucidate the antidepressant function as well as the nonmicrobial sources of endogenous hallucinogens, as it is currently uncertain whether these compounds are also synthesized in the human brain.
Conclusion (proposition de traduction) : Le microbiote intestinal, composé de bactéries, de champignons et de virus, peut être à l'origine de circonstances pathologiques et se déplacer en dehors du tractus gastro-intestinal, déclenchant une immunogénicité et une hyperinflammation susceptibles de perturber le génome de l'hôte et la réparation des lésions de l'ADN, engendrant ainsi des maladies psychiatriques graves.
Les substances hallucinogènes endogènes produites par le microbiote intestinal, qui agissent par l'intermédiaire des récepteurs associés aux amines traces (TAAR), constituent probablement un système antidépresseur intégré semblable aux opioïdes endogènes. La signalisation dysfonctionnelle des récepteurs des hydrocarbures aryliques (AhR) peut endommager l'ADN neuronal et induire des maladies psychiatriques graves par le biais d'une microglie neurotoxique.
D'autres études sont nécessaires pour élucider la fonction antidépressive ainsi que les sources non microbiennes des substances hallucinogènes endogènes, car on ne sait pas encore si ces composés sont également synthétisés dans le cerveau humain.
Commentaire : Voir l'analyse de l'article sur le site Univadis : Le microbiote intestinal : ami ou ennemi de la santé mentale ? . Rédigé par Agnès Lara, le 19 mai 2023.
A Systematic Review With Pairwise and Network Meta-analysis of Closed Reduction Methods for Anterior Shoulder Dislocation.
Gonai S, Yoneoka D, Miyoshi T, da Silva Lopes K. | Ann Emerg Med. 2023 Apr;81(4):453-465
Introduction : To review closed reduction methods for anterior shoulder dislocation and perform the first comprehensive comparison of the individual methods in terms of success rate, pain, and reduction time.
Méthode : We searched MEDLINE, PubMed, EMBASE, Cochrane, and ClinicalTrials.gov for randomized controlled trials registered until December 31, 2020. We performed a pairwise and network meta-analysis using a Bayesian random-effects model. Two authors independently performed screening and risk-of-bias assessment.
Résultats : We found 14 studies with 1,189 patients. In a pairwise meta-analysis, no significant difference was found in the only comparable pair, namely, the Kocher method versus the Hippocratic method (success rate: odds ratio, 1.21; 95% confidence interval [CI], 0.53, 2.75: pain during reduction [visual analog scale]: standard mean difference, -0.33; 95% CI, -0.69, 0.02; reduction time [minutes]: mean difference, 0.19, 95% CI, -1.77, 2.15). In network meta-analysis, FARES (Fast, Reliable, and Safe) was the only method significantly less painful than the Kocher method (mean difference, -4.0; 95% credible interval, -7.6, -0.40). In the surface under the cumulative ranking (SUCRA) plot of success rate, FARES, and the Boss-Holzach-Matter/Davos method showed high values. For pain during reduction, FARES had the highest SUCRA value in the overall analysis. In the SUCRA plot of reduction time, modified external rotation and FARES had high values. The only complication was 1 case of fracture with the Kocher method.
Conclusion : Overall, Boss-Holzach-Matter/Davos, and FARES demonstrated the most favorable value for success rates, whereas both FARES and modified external rotation were more favorable in reduction times. FARES had the most favorable SUCRA for pain during reduction. Future work directly comparing techniques is needed to better understand the difference in reduction success and complications.
Conclusion (proposition de traduction) : Dans l'ensemble, la technique de Davos (Boss-Holzach-Matter) par traction-contre-traction auto-administrée et méthode FARES (rapide, fiable, sûre) ont démontré les meilleurs taux de réussite, tandis que la méthode FARES et la rotation externe modifiée ont été les plus efficaces en termes de temps de réduction. La méthode FARES a eu la surface sous la courbe de classement cumulatif la plus favorable pour la douleur pendant la réduction. Des travaux futurs comparant directement les techniques sont nécessaires pour mieux comprendre les différences en termes de succès de la réduction et de complications.
Commentaire : La méthode de la métaanalyse par paires, afin d’obtenir une estimation agrégative de l’efficacité clinique, est appliquée pour la comparaison entre deux interventions dans les soins de santé.
La métaanalyse en réseau élargit le cadre de la métaanalyse par paires standard à un réseau de comparaisons, ce qui permet la comparaison simultanée de multiples interventions même si aucune étude ne compare entre elles toutes les interventions d’intérêt.
La surface sous la courbe de classement cumulatif (Surface Under the Cumulative Ranking, SUCRA) est un outil qui pourrait aider le clinicien à interpréter plus facilement le résultat d’une méta-analyse en réseau.
Defining Successful Intubation on the First Attempt Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data.
Self WH, Smith LM, Stempek S, Vonderhaar DJ, West JR, Whitson MR, Ginde AA, Casey JD, Semler MW. | Ann Emerg Med. 2023 Apr 17:S0196-0644(23)00213-5.
AIRWAY/BRIEF RESEARCH REPORT
Introduction : Successful intubation on the first attempt has historically been defined as successful placement of an endotracheal tube (ETT) using a single laryngoscope insertion. More recent studies have defined successful placement of an ETT using a single laryngoscope insertion followed by a single ETT insertion. We sought to estimate the prevalence of first-attempt success using these 2 definitions and estimate their associations with the duration of intubation and serious complications.
Méthode : We performed a secondary analysis of data from 2 multicenter randomized trials of critically ill adults being intubated in the emergency department or ICU. We calculated the percent difference in successful intubations on the first attempt, median difference in the duration of intubation, and percent difference in the development of serious complications by definition.
Résultats : The study population included 1,863 patients. Successful intubation on the first attempt decreased by 4.9% (95% confidence interval 2.5% to 7.3%) when defined as 1 laryngoscope insertion followed by 1 ETT insertion (81.2%) compared with when defined as only 1 laryngoscope insertion (86.0%). When successful intubation with 1 laryngoscope and 1 ETT insertion was compared with 1 laryngoscope and multiple ETT insertions, the median duration of intubation decreased by 35.0 seconds (95% confidence interval 8.9 to 61.1 seconds).
Conclusion : Defining successful intubation on the first attempt as placement of an ETT in the trachea using 1 laryngoscope and 1 ETT insertion identifies attempts with the shortest apneic time.
Conclusion (proposition de traduction) : Définir l'intubation comme réussie dès la première tentative en insérant une sonde endotrachéale dans la trachée à l'aide d'un laryngoscope et d'une insertion de la sonde endotrachéale permet d'identifier les tentatives avec le temps d'apnée le plus court.
Cardiac Arrest During Delivery Hospitalization : A Cohort Study.
Ford ND, DeSisto CL, Galang RR, Kuklina EV, Sperling LS, Ko JY. | Ann Intern Med. 2023 Apr;176(4):472-479
DOI: https://doi.org/10.7326/m22-2750 | Télécharger l'article au format
Introduction : Estimates of cardiac arrest occurring during delivery guide evidence-based strategies to reduce pregnancy-related death.
Objective: To investigate rate of, maternal characteristics associated with, and survival after cardiac arrest during delivery hospitalization.
Méthode : Retrospective cohort study. Setting: U.S. acute care hospitals, 2017 to 2019. Participants: Delivery hospitalizations among women aged 12 to 55 years included in the National Inpatient Sample database. Measurements: Delivery hospitalizations, cardiac arrest, underlying medical conditions, obstetric outcomes, and severe maternal complications were identified using codes from the International Classification of Diseases, 10th Revision, Clinical Modification. Survival to hospital discharge was based on discharge disposition.
Résultats : Among 10 921 784 U.S. delivery hospitalizations, the cardiac arrest rate was 13.4 per 100 000. Of the 1465 patients who had cardiac arrest, 68.6% (95% CI, 63.2% to 74.0%) survived to hospital discharge. Cardiac arrest was more common among patients who were older, were non-Hispanic Black, had Medicare or Medicaid, or had underlying medical conditions. Acute respiratory distress syndrome was the most common co-occurring diagnosis (56.0% [CI, 50.2% to 61.7%]). Among co-occurring procedures or interventions examined, mechanical ventilation was the most common (53.2% [CI, 47.5% to 59.0%]). The rate of survival to hospital discharge after cardiac arrest was lower with co-occurring disseminated intravascular coagulation (DIC) without or with transfusion (50.0% [CI, 35.8% to 64.2%] or 54.3% [CI, 39.2% to 69.5%], respectively).
Conclusion : Cardiac arrests occurring outside delivery hospitalizations were not included. The temporality of arrest relative to the delivery or other maternal complications is unknown. Data do not distinguish cause of cardiac arrest, such as pregnancy-related complications or other underlying causes among pregnant women.
Conclusion (proposition de traduction) : Les arrêts cardiaques survenant en dehors des hospitalisations pour accouchement n'ont pas été inclus. La chronologie de l'arrêt cardiaque par rapport à l'accouchement ou à d'autres complications maternelles n'est pas connue. Les données ne permettent pas de distinguer la cause de l'arrêt cardiaque, comme les complications liées à la grossesse ou d'autres causes sous-jacentes chez les femmes enceintes.
EasyTBSA as a method for calculating total body surface area burned: a validation study.
Colson CD, Alberto EC, Milestone ZP, Batra N, Salvador T, Fooladi H, Cleary K, Izem R, Burd RS. | Emerg Med J. 2023 Apr;40(4):279-284
Keywords: ED; burns; clinical assessment; emergency responders; triage.
Introduction : Current methods of burn estimation can lead to incorrect estimates of the total body surface area (TBSA) burned, especially among injured children. Inaccurate estimation of burn size can impact initial management, including unnecessary transfer to burn centres and fluid overload during resuscitation. To address these challenges, we developed a smartphone application (EasyTBSA) that calculates the TBSA of a burn using a body-part by body-part approach. The aims of this study were to assess the accuracy of the EasyTBSA application and compare its performance to three established methods of burn size estimation (Lund-Browder Chart, Rule of Nines and Rule of Palms).
Méthode : Twenty-four healthcare providers used each method to estimate burn sizes on moulaged manikins. The manikins represented different ages (infant, child and adult) with different TBSA burns (small <20%, medium 20%-49% and large >49%). We calculated the accuracy of each method as the difference between the user-estimated and actual TBSA. The true value of the complete body surface area of the manikins was obtained by three-dimensional scans. We used multivariable modelling to control for manikin size and method.
Résultats : Among all age groups and burn sizes, the EasyTBSA application had the greatest accuracy for burn size estimation (-0.01%, SD 3.59%) followed by the Rule of Palms (3.92%, SD 10.71%), the Lund-Browder Chart (4.42%, SD 5.52%) and the Rule of Nines (5.05%, SD 6.87%).
Conclusion : The EasyTBSA application may improve the estimation of TBSA compared with existing methods.
Conclusion (proposition de traduction) : L'application EasyTBSA peut améliorer l'estimation de la surface corporelle totale brûlée par rapport aux méthodes existantes.
Commentaire : L'application EasyTBSA sur trouve sur l'Apple Store et Google Play .
Elle donne des informations similaires à l'application E-burn (Apple Store et Google Play ) de la Société Francophone de Brûlologie.
Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach.
Miller KA, Prieto MM, Wing R, Goldman MP, Polikoff LA, Nishisaki A, Nagler J. | Emerg Med J. 2023 Apr;40(4):287-292
Keywords: airway; pediatric emergency medicine; quality improvement.
Introduction : Airway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED is lacking.
Méthode : A multidisciplinary panel of 14 experts in airway management within and outside of paediatric emergency medicine participated in a modified Delphi approach to develop consensus on the appropriate components for a paediatric airway management checklist for the ED. Panel members reviewed, modified and added to the components from the National Emergency Airway Registry for Children airway safety checklist for paediatric intensive care units using a 9-point appropriateness scale. Components with a median score of 7.0-9.0 and a 25th percentile score ≥7.0 achieved consensus for inclusion. A priori, the modified Delphi method was limited to a maximum of two rounds for consensus on essential components and one additional round for checklist creation.
Résultats : All experts participated in both rounds. Consensus was achieved on 22 components. Twelve were original candidate items and 10 were newly suggested or modified items. Consensus components included the following categories: patient assessment and plan (5 items), patient preparation (5 items), pharmacy (2 items), equipment (7 items) and personnel (3 items). The components were formatted into a 17-item clinically usable checklist.
Conclusion : Using the modified Delphi method, consensus was established among airway management experts around essential components for an airway management checklist intended for paediatric tracheal intubation in the ED.
Conclusion (proposition de traduction) : En utilisant la méthode Delphi modifiée, un consensus a été établi entre les experts en matière de gestion des voies aériennes autour des éléments essentiels d'une checklist de gestion des voies aériennes destinée à l'intubation trachéale pédiatrique dans le service des urgences.
Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis.
Turner JS, Hunter BR, Haseltine ID, Motzkus CA, DeLuna HM, Cooper DD, Ellender TJ, Sarmiento EJ, Menard LM, Kirschner JM. | Emerg Med J. 2023 Apr;40(4):293-299
Introduction : Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation.
Méthode : A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach.
Résultats : A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes.
Conclusion : This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.
Conclusion (proposition de traduction) : Cette revue systématique et cette méta-analyse n'ont pas mis en évidence d'avantages ou d'inconvénients liés à la position en position inclinée par rapport à la position en décubitus dorsal du patient pendant l'intubation endotrachéale, quel que soit le contexte.
Cervical spine movements during laryngoscopy and orotracheal intubation: a systematic review and meta-analysis.
Correa JBB, Felice VB, Sbruzzi G, Friedman G. | Emerg Med J. 2023 Apr;40(4):300-307
Keywords: airway; anaesthesia; spine.
Introduction : Airway management is challenging in trauma patients because of the fear of worsening cervical spinal cord damage. Video-integrated and optic-integrated devices and intubation laryngeal mask airways have been proposed as alternatives to direct laryngoscopy with the Macintosh laryngoscope (MAC). We performed a meta-analysis to clarify which devices cause less cervical movement during airway management.
Méthode : We searched MEDLINE, Cochrane Central, Embase and LILACS from inception to January 2022. We selected randomised controlled trials comparing alternative devices with the MAC for cervical movement from C0 to C5 in adult patients, evaluated by radiological examination. Additionally, cervical spine immobilisation (CSI) techniques were evaluated. We used the Cochrane Risk of Bias Tool to evaluate the risk of bias, and the principles of the Grading of Recommendations, Assessment, Development, and Evaluations system to assess the quality of the body of evidence.
Résultats : Twenty-one studies (530 patients) were included. Alternative devices caused statistically significantly less cervical movement than MAC during laryngoscopy with mean differences of -3.43 (95% CI -4.93 to -1.92) at C0-C1, -3.19 (-4.04 to -2.35) at C1-C2, -1.35 (-2.19 to -0.51) at C2-C3, and -2.61 (-3.62 to -1.60) at C3-C4; and during intubation: -3.60 (-5.08 to -2.12) at C0-C1, -2.38 (-3.17 to -1.58) at C1-C2, -1.20 (-2.09 to -0.31) at C2-C3. The Airtraq and the Intubation Laryngeal Mask Airway caused statistically significant less movement than MAC restricted to some cervical segments, as well as CSI. Heterogeneity was low to moderate in most results. The quality of the body of evidence was 'low' and 'very low'.
Conclusion : Compared with the MAC, alternative devices caused less movement during laryngoscopy (C0-C4) and intubation (C0-C3). Due to the high risk of bias and the very low grade of evidence of the studies, further research is necessary to clarify the benefit of each device and to determine the efficacy of cervical immobilisation during airway management.
Conclusion (proposition de traduction) : Par rapport au laryngoscope Macintosh, les dispositifs alternatifs ont provoqué moins de mouvements pendant la laryngoscopie (C0-C4) et l'intubation (C0-C3). En raison du risque élevé de biais et du très faible niveau de preuve des études, des recherches supplémentaires sont nécessaires pour clarifier les avantages de chaque dispositif et pour déterminer l'efficacité de l'immobilisation cervicale pendant la gestion des voies respiratoires.
Midazolam versus morphine in acute cardiogenic pulmonary edema patients with and without atrial fibrillation: findings from the MIMO trial.
Domínguez-Rodríguez A, Hernandez-Vaquero D, Suero-Mendez C, Burillo-Putze G, Gil V, Calvo-Rodriguez R, Piñera-Salmeron P, Llorens P, Martín-Sánchez FJ, Abreu-Gonzalez P, Miró Ò; MIMO (MIdazolam versus MOrphine) Trial Investigators. | Eur J Emerg Med. 2023 Apr 1;30(2):78-84
Introduction : The MIMO clinical trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had fewer serious adverse events than those treated with morphine. Atrial fibrillation (AF) is a common comorbidity in heart failure and affects patient's outcome.
Méthode : The primary endpoint of this substudy is to know if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine. The first secondary endpoint is to know if AF modified the reduced risk of serious adverse events or death at 30 days in the midazolam arm. The second secondary objective of this substudy is to analyze whether AF modified the reduced risk of midazolam against morphine on the total number of serious adverse events per patient.
Design : We conducted a secondary analysis of the MIMO trial. Patients more than 18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine.
Outcome measures and analysis: In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without AF. Calculating the Cochran-Mantel-Haenszel interaction test, we evaluated if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine.
Résultats : One hundred eleven patients (median = 78.9 years; IQR, 72.3-83.7; women, 52.2%) were randomized in the MIMO trial, 55 to receive midazolam and 56 to morphine. All randomized patients received the assigned drug and there were no losses to follow-up. Forty-four patients (39.6%) had AF. In the AF group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.42 (95% CI, 0.14-1.3). In the group without AF, the RR was 0.46 (95% CI, 0.21-1). The presence of AF did not modify the reduced risk of serious adverse events in the midazolam arm compared with morphine ( P for interaction = 0.88).
Conclusion : This post hoc analysis of the MIMO trial suggests that the reduced risk of serious adverse events in the midazolam group compared to morphine is similar in patients with and without AF.
Conclusion (proposition de traduction) : Cette analyse post hoc de l'essai MIMO suggère que la réduction du risque d'événements indésirables graves dans le groupe midazolam par rapport à la morphine est similaire chez les patients avec et sans fibrillation auriculaire.
Door-to-furosemide time and clinical outcomes in acute heart failure.
Marques P, Brito MT, Vasques-Nóvoa F, Ferreira JP, Jardim AL, Gouveia R, Besteiro B, Vieira JT, Gomes F, Leite-Moreira A, Bettencourt P, Almeida J, Friões F. | Eur J Emerg Med. 2023 Apr 1;30(2):85-90
Keywords: acute heart failure, diuretic therapy, door-to-furosemide
Introduction : Acute heart failure (AHF) is one of the main causes of unplanned hospitalization in patients >65 years of age and is associated with adverse outcomes in this population. Observational studies suggest that intravenous diuretic therapy given in the first hour of presentation for AHF was associated with favorable outcomes.
Objectives: To study the short-term prognostic associations of the timing of intravenous diuretic therapy in patients admitted to the emergency department (ED) for acute AHF.
Méthode : Patients treated in the ED with intravenous diuretics were selected from the Estratificação de Doentes com InsuFIciência Cardíaca Aguda (EDIFICA) registry, a prospective study including AHF hospitalized patients. Early and non-early furosemide treatment groups were considered using the 1-h cutoff: door-to-furosemide ≤1 h and >1 h.
Outcomes measure and analysis: Primary outcomes were a composite of heart failure re-hospitalizations or cardiovascular death at 30- and 90-days.
Résultats : Four-hundred ninety-three patients were included in the analysis. The median (interquartile range) door-to-furosemide time was 85 (41-220) min, and 210 (43%) patients had diuretics in the first hour. Patients in the ≤1 h group had higher evaluation priority according to the Manchester Triage System, presented more often with acute pulmonary edema, warm-wet clinical profile, higher blood pressure, and signs of left-side heart failure, while >1 h group had higher Get With the Guidelines-heart failure risk score, more frequent signs of right-side heart failure, higher circulating B-type natriuretic peptides and lower albumin. Door-to-furosemide ≤ 1 h was independently associated with lower 30-day heart failure hospitalizations and composite of heart failure hospitalizations or cardiovascular death (adjusted analysis Heart Failure Hospitalizations: odds ratios (OR) 3.65; 95% confidence interval (CI), 1.22-10.9; P = 0.020; heart failure hospitalizations or cardiovascular death: OR 3.15; 95% CI, 1.49-6.64; P < 0.001). These independent associations lost significance at 90 days.
Conclusion : Door-to-furosemide ≤1 h was associated with a lower short-term risk of heart failure hospitalizations or cardiovascular death in AHF patients. Our findings add to the existing evidence that early identification and intravenous diuretic therapy of AHF patients may improve outcomes.
Conclusion (proposition de traduction) : Le délai admission-à-administration de furosémide ≤ 1 h a été associé à un risque plus faible à court terme d'hospitalisations pour insuffisance cardiaque ou de décès cardiovasculaire chez les patients souffrant d'insuffisance cardiaque aiguë. Nos résultats ajoutent aux preuves existantes que l'identification précoce et le traitement diurétique intraveineux des patients atteints d'insuffisance cardiaque aiguë peuvent améliorer les résultats.
Prehospital predictors of the need for transfusion in patients with major trauma.
Gaessler H, Helm M, Kulla M, Hossfeld B, Riedel J, Kerschowski J, Bretschneider I. | Eur J Trauma Emerg Surg. 2023 Apr;49(2):803-812
DOI: https://doi.org/10.1007/s00068-022-02132-5 | Télécharger l'article au format
Keywords: Blood gas analysis; Blood transfusion; Emergency medical services; Haemorrhage; Trauma.
Introduction : Severe haemorrhage is a leading cause of early mortality following major trauma. By early identification of patients at risk, blood transfusion could already be initiated in the prehospital period. Aim of the study was to evaluate the extent to which prehospital lactate and base excess, which are known to be associated with trauma-induced coagulopathy, and additional clinical parameters are associated with the need for early transfusion.
Méthode : In this prospective, single-centre observational study, trauma patients treated by a helicopter emergency medical service were included, regardless of the injury severity. Patients with coagulation-influencing drugs in long-term therapy were excluded. Blood samples obtained at the beginning of the prehospital treatment were analysed. Primary outcome was the association of lactate and base excess with the need for early transfusion (resuscitation room or immediate surgery). Receiver operating characteristic curves were created, and the area under the curve (AUROC) was calculated.
Résultats : Between 2015 and 2018, 21 out of 130 adult trauma patients received blood products during the early in-hospital treatment. Both prehospital lactate and base excess were associated with the transfusion (AUROC 0.731 and 0.798, respectively). The optimal calculated cut-off values were 4 mmol/l (lactate) and - 2.5 mmol/l (base excess). When circulatory instability and suspected relevant bleeding were included, the association further improved (AUROC 0.871 and 0.866, respectively).
Conclusion : Prehospital lactate and base excess could be used in combination with other clinical parameters as indicators of the need for early transfusion. This relationship has yet to be confirmed in the current validation study.
Conclusion (proposition de traduction) : Le lactate préhospitalier et l'excès de base pourraient être utilisés en combinaison avec d'autres paramètres cliniques comme indicateurs de la nécessité d'une transfusion précoce. Cette relation doit encore être confirmée dans l'étude de validation actuelle.
Double sequential external defibrillation for refractory ventricular fibrillation.
Cheskes S, McLeod S, Scales DC. | Intensive Care Med. 2023 Apr;49(4):455-457
DOI: https://doi.org/10.1007/s00134-023-06993-1 | Télécharger l'article au format
WHAT’S NEW IN INTENSIVE CARE
Editorial : Sudden cardiac arrest is the third leading cause of death in industrialized nations, resulting in more than 700,000 deaths in Europe and the United States of America (USA) annually, with nearly one-third attributed to ventricular fibrillation (VF) or pulseless ventricular tachycardia. However, despite multiple defibrillation attempts, almost half of these patients remain in shock refractory VF. Further defibrillation without modifying the defibrillation method is usually unsuccessful and survival to hospital discharge decreases rapidly with additional defibrillation attempts. Different approaches have been proposed for treating patients with shock refractory VF. Vector change (VC) defibrillation, the technique of switching defibrillation pads from anterior-lateral to anterior-posterior position, has been proposed as a strategy to defibrillate a portion of the ventricle that may not be completely defibrillated by pads in the standard anterior-lateral position. Double sequential external defibrillation (DSED, also referred to as dual sequential external defibrillation) involves the provision of rapid sequential shocks via two defibrillators with defibrillation pads placed in both planes (anterior-lateral and anterior– posterior.
Conclusion : DSED and VC defibrillation are exciting and innova- tive strategies that can improve survival for patients pre- senting with refractory VF. Time will tell if these will be broadly implemented and embraced by paramedics and clinicians.
Conclusion (proposition de traduction) : La double défibrillation externe séquentielle et la défibrillation par changement de vecteur sont des stratégies innovantes et intéressantes qui peuvent améliorer la survie des patients présentant une fibrillation ventriculaire réfractaire. L'avenir nous dira si elles seront largement mises en œuvre et adoptées par les ambulanciers et les cliniciens.
Placement des électrodes pour les différentes stratégies de défibrillation.
Les électrodes de défibrillation bleu foncé indiquent que l'électrodes est placée en position antéro-latérale. Les électrodes de défibrillation bleu clair indiquent que l'électrodes est placée en position antéro-postérieure (changement de vecteur). La double défibrillation externe séquentielle utilise les deux configurations.
Severe hyponatraemia (P-Na < 116 mmol/l) in the emergency department: a series of 394 cases.
Mustajoki S | Intern Emerg Med. 2023 Apr;18(3):781-789
DOI: https://doi.org/10.1007/s11739-023-03221-y | Télécharger l'article au format
Keywords: Emergency department; Hyponatraemia; Mortality; Osmotic demyelination syndrome; Sodium correction.
IM - ORIGINAL
Introduction : To evaluate the significance of severe hyponatraemia presented at the emergency department (ED).
Méthode : A retrospective hospital records study of all patients with plasma sodium levels of < 116 mmol/l from 2016 to 2020 in a single tertiary referral centre.
Résultats : A total of 394 visits of 363 individual severely hyponatraemic patients represented 0.08% of all ED visits. The mean age was 68 years and the male-to-female ratio was 1:1.3. The symptoms and signs were diffuse and varying, while half of the patients had neurologic symptoms. The aetiology of hyponatraemia was often multifactorial. The aetiologies varied by age, and the most common ones were the syndrome of inappropriate antidiuresis (34%), diuretic use (27%), alcohol-related (19%) and dehydration (19%). The mean sodium correction rates were 6.6, 4.9 and 3.8 mmol/l/24 h at 24, 48 and 72 h, respectively. The mean maximum correction rate over any 24-h time interval was 10.2 mmol/l. The vital signs (National Early Warning Score, NEWS) of severely hyponatraemic patients were mostly normal. All-cause mortality was 18% for 1-year follow-up. Malignancies, especially small-cell lung cancer, and end-stage liver disease caused most of the deaths. Osmotic demyelination syndrome (ODS) was diagnosed in five (1.4%) patients.
Conclusion : Patients with severe hyponatraemia in the ED presented with non-specific complaints. The aetiology of hyponatraemia was often multifactorial and varied by age. The need for intensive care was poorly predicted by NEWS. The one-year mortality rate was 18% and the incidence of ODS 1.4% after an episode of severe hyponatraemia.
Conclusion (proposition de traduction) : Les patients présentant une hyponatrémie sévère aux urgences se sont présentés avec des plaintes non spécifiques. L'étiologie de l'hyponatrémie était souvent multifactorielle et variait selon l'âge. La nécessité d'une prise en charge en soins intensifs était mal prédite par le score NEWS. Le taux de mortalité à un an était de 18 % et l'incidence de l'ODS de 1,4 % après un épisode d'hyponatrémie sévère.
Complications related to pacemakers and other cardiac implantable electronic devices: essentials for internists and emergency physicians.
Arcinas LA, Sheldon RS. | Intern Emerg Med. 2023 Apr;18(3):851-862
Keywords: Pacemakers; cardiac implantable electronic devices; emergency department; pacemaker complications.
EM - REVIEW
Editorial : With the aging population, improving technology, and expanding indications for diagnosing and treating arrhythmias and heart failure, many patients are receiving cardiac implantable electronic devices (CIEDs) such as pacemakers and implantable cardioverter defibrillators. Consequently, patients with CIEDs are frequently encountered in the emergency department and in the wards. It is imperative that emergency physicians and internists have a strong foundation on CIEDs and their potential complications. This review aims to help physicians develop a framework in approaching CIEDs and to recognize and manage clinical scenarios that may arise from CIED complications.
Conclusion : Patients with cardiac implantable electronic devices are commonly encountered in the emergency department and the wards. The most common indications for pacemakers include symptomatic bradycardia and irreversible advanced atrioventricular block. All transvenous defibrillators and cardiac resynchronization therapies are pacemakers with specialized function, with specific indications. Physicians need to be aware of the common complications associated with CIEDs and their associated clinical presentation. A clinically oriented approach, incorporated with the patient’s history, physical exam, and a thorough understanding of relevant investigations such as chest radiography and the paced electrocardiogram are almost always sufficient in identifying and appropriately treating CIED-related events and complications.
Conclusion (proposition de traduction) : Les patients porteurs de dispositifs électroniques implantables cardiaques (DEIC) sont fréquemment accueillis dans les services d'urgence et les unités de soins. Les indications les plus courantes pour les stimulateurs cardiaques sont la bradycardie symptomatique et le bloc auriculo-ventriculaire avancé irréversible. Tous les défibrillateurs avec abord veineux et les traitements de resynchronisation cardiaque sont des stimulateurs cardiaques dotés d'une fonction spécialisée et d'indications spécifiques. Les médecins doivent être conscients des complications courantes associées aux DEIC et de leur présentation clinique. Une approche clinique, basée sur les antécédents du patient, l'examen physique et une compréhension approfondie des examens pertinents tels que la radiographie thoracique et l'électrocardiogramme stimulé, est presque toujours suffisante pour identifier et traiter de manière appropriée les événements et les complications liés aux DEIC.
Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial.
Bouzat P, Charbit J, Abback PS, Huet-Garrigue D, Delhaye N, Leone M, Marcotte G, David JS, Levrat A, Asehnoune K, Pottecher J, Duranteau J, Courvalin E, Adolle A, Sourd D, Bosson JL, Riou B, Gauss T, Payen JF; PROCOAG Study Group. | JAMA. 2023 Apr 25;329(16):1367-1375
Introduction : Optimal transfusion strategies in traumatic hemorrhage are unknown. Reports suggest a beneficial effect of 4-factor prothrombin complex concentrate (4F-PCC) on blood product consumption.
Objective: To investigate the efficacy and safety of 4F-PCC administration in patients at risk of massive transfusion.
Méthode : Double-blind, randomized, placebo-controlled superiority trial in 12 French designated level I trauma centers from December 29, 2017, to August 31, 2021, involving consecutive patients with trauma at risk of massive transfusion. Follow-up was completed on August 31, 2021.
Interventions: Intravenous administration of 1 mL/kg of 4F-PCC (25 IU of factor IX/kg) vs 1 mL/kg of saline solution (placebo). Patients, investigators, and data analysts were blinded to treatment assignment. All patients received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1) and were treated according to European traumatic hemorrhage guidelines.
Main outcomes and measures: The primary outcome was 24-hour all blood product consumption (efficacy); arterial or venous thromboembolic events were a secondary outcome (safety).
Résultats : Of 4313 patients with the highest trauma level activation, 350 were eligible for emergency inclusion, 327 were randomized, and 324 were analyzed (164 in the 4F-PCC group and 160 in the placebo group). The median (IQR) age of participants was 39 (27-56) years, Injury Severity Score was 36 (26-50 [major trauma]), and admission blood lactate level was 4.6 (2.8-7.4) mmol/L; prehospital arterial systolic blood pressure was less than 90 mm Hg in 179 of 324 patients (59%), 233 patients (73%) were men, and 226 (69%) required expedient hemorrhage control. There was no statistically or clinically significant between-group difference in median (IQR) total 24-hour blood product consumption (12 [5-19] U in the 4F-PCC group vs 11 [6-19] U in the placebo group; absolute difference, 0.2 U [95% CI, -2.99 to 3.33]; P = .72). In the 4F-PCC group, 56 patients (35%) presented with at least 1 thromboembolic event vs 37 patients (24%) in the placebo group (absolute difference, 11% [95% CI, 1%-21%]; relative risk, 1.48 [95% CI, 1.04-2.10]; P = .03).
Conclusion : Among patients with trauma at risk of massive transfusion, there was no significant reduction of 24-hour blood product consumption after administration of 4F-PCC, but thromboembolic events were more common. These findings do not support systematic use of 4F-PCC in patients at risk of massive transfusion.
Conclusion (proposition de traduction) : Chez les patients traumatisés présentant un risque de transfusion massive, il n'y a pas eu de réduction significative de la consommation de produits sanguins sur 24 heures après l'administration de 4F-PCC, mais les événements thromboemboliques ont été plus fréquents. Ces résultats ne justifient pas l'utilisation systématique du 4F-PCC chez les patients présentant un risque de transfusion massive.
The Use of Ketamine Sedation for the Treatment of Nail Bed Repairs in the Pediatric Emergency Department.
Stewart C, Bradley A, Faulkner J, Jatan A. | Pediatr Emerg Care. 2023 Apr 1;39(4):265-267
Méthode : This study aimed to determine if sedation with ketamine is safe and effective for the treatment of nail bed injuries in the pediatric emergency department (PED).
Résultats : A retrospective cohort study was carried out during a 9-month period in children aged between 18 months and 15 years, presenting to PED requiring nail bed repair. We documented complications of sedation, clinical outcome of the repair both immediate and at follow-up, and parental satisfaction at 4 months. A cost analysis was also undertaken.
Discussion : Ten repairs were performed. There were no serious adverse events. The average satisfaction score was 9.4/10. All patients were discharged from follow-up by 3 months. There was a cost saving of approximately £1500 per case.
Conclusion : We have demonstrated nail bed injury repair facilitated by sedation with ketamine to be safe, effective, and cost efficient in the PED. This management strategy, brought to the fore during the COVID-19 pandemic, should be adopted widely in PEDs.
Conclusion (proposition de traduction) : Nous avons démontré que la réparation des lésions du lit de l'ongle facilitée par la sédation à la kétamine est sûre, efficace et rentable dans les services d'urgences pédiatriques. Cette stratégie de gestion, mise en avant lors de la pandémie de COVID-19, devrait être largement adoptée dans les PED.
Commentaire : Protocole de traitement : Une dose de 1mg/kg de kétamine est administrée par voie intraveineuse, les signes vitaux étant mesurés avant et 3 minutes après l'administration. Si la sédation n'est pas suffisante, une dose supplémentaire de 0,5 mg/kg est administrée. Une liste de contrôle de la sédation est remplie avant de commencer ; la tension artérielle, le pouls, la fréquence respiratoire, la saturation en oxygène et l'heure sont surveillés et enregistrés.
La durée maximale de la sédation procédurale sous kétamine était de vingt minutes, conformément aux lignes directrices du Royal College of Emergency Medicine.
Effect of video laryngoscopy for non-trauma out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis.
Risse J, Fischer M, Meggiolaro KM, Fariq-Spiegel K, Pabst D, Manegold R, Kill C, Fistera D. | Resuscitation. 2023 Apr;185:109688
DOI: https://doi.org/10.1016/j.resuscitation.2023.109688 | Télécharger l'article au format
Keywords: Airway management; Cardiopulmonary resuscitation; Endotracheal intubation; German Resuscitation Registry; Multivariate logistic regression model; Out-of-hospital cardiac arrest; Video laryngoscopy.
Introduction : Videolaryngoscopy (VL) is a promising tool to provide a safe airway during cardiopulmonary resuscitation (CPR) and to ensure early reoxygenation. Using data from the German Resuscitation Registry, we investigated the outcome of non-traumatic out-of-hospital cardiac arrest (OHCA) patients treated with VL versus direct laryngoscopy (DL) for airway management.
Méthode : We analysed retrospective data of 14,387 patients from 1 January 2018 until 31 December 2021 (VL group, n = 2201; DL group, n = 12186). Primary endpoint was discharge with cerebral performance categories one and two (CPC1/2). Secondary endpoints were the rate of return of spontaneous circulation (ROSC), hospital admission, hospital admission with ongoing cardiopulmonary resuscitation, 30-day survival/ hospital discharge and airway management complications. We used multivariate binary logistic regression analysis to identify the effects on outcome of known influencing variables and of VL vs DL.
Résultats : The multivariate regression model revealed that VL was an independent predictor of CPC1/2 survival (OR = 1.34, 95% CI = 1.12-1.61, p = 0.002) and of hospital discharge/30-day survival (OR = 1.26, 95% CI = 1.08-1.47, p = 0,004).
Conclusion : VL for endotracheal intubation (ETI) at OHCA was associated with better neurological outcome in patients with ROSC. Therefore, the use of VL for OHCA offers a promising perspective. Further prospective studies are required.
Conclusion (proposition de traduction) : La vidéolaryngoscopie pour l'intubation endotrachéale au cours d'un arrêt cardiaque extrahospitalier a été associée à de meilleurs résultats neurologiques chez les patients dont la circulation spontanée a été rétablie. Par conséquent, l'utilisation de la vidéolaryngoscopie lors d'un arrêt cardiaque extrahospitalier offre une perspective prometteuse. D'autres études prospectives sont nécessaires.
The effect of hand position on chest compression quality during CPR in young children: Findings from the Videography in Pediatric Resuscitation (VIPER) collaborative.
O'Connell KJ, Sandler A, Dutta A, Ahmed R, Neubrand T, Myers S, Kerrey B, Donoghue A. | Resuscitation. 2023 Apr;185:109741
Keywords: Cardiopulmonary resuscitation; Chest compressions; Pediatrics.
Introduction : To determine the effect of hand position on chest compression (CC) quality during CPR in young children.
Méthode : Prospective observational exploratory study. Patients < 8 years receiving CC for > 2 minutes were enrolled. Data was collected from video review and CC monitor device and analyzed in 'CC segments' (periods of CC by individual providers). Four techniques were compared: two thumbs (2 T), hands encircling the chest; two fingers (2F) on the sternum; one hand on sternum (1H); two hands on sternum (2H). Univariate analysis of CC rate and depth between hand positions was performed through nonparametric testing, stratified by age category.
Résultats : 47 patients received 824 minutes of CC. Among 270 CC segments in infants < 1 yo, 2 T was used in 27%; 2F 3%; 1H 18%; 2H 26%. Among 189 CC segments in children aged 1 to 8 yo, 1H was used in 26%; 2H 74%. Across all segments, median CC rate was 117 cpm (IQR 110-125). Median depth was 2.92 cm (IQR 2.44 - 4.04) in infants < 1 yo, 3.56 cm (IQR 2.92 - 4.14) in children 1 to 8 yo. 1H achieved greater depth than 2 T in infants (p < 0.01), and 2H achieved greater depth than 1H in children > 1 (p < 0.001).
Conclusion : In infants, 1H resulted in greater CC depth than 2 T. In children 1 to 8 yo, 2H resulted in greater depth than 1H.. These data suggest that different hand position during CPR in young children from what is currently recommended may result in better CPR quality.
Conclusion (proposition de traduction) : Chez les nourrissons, une main sur le sternum entraîne une plus grande profondeur de compression thoracique que deux pouces. Chez les enfants de 1 à 8 ans, deux mains sur le sternum donnent une plus grande profondeur qu'une seule main sur le sternum. Ces données suggèrent qu'une position des mains différente de celle actuellement recommandée pendant la RCP chez les jeunes enfants peut améliorer la qualité de la RCP.
Commentaire : En conclusion :
Pour le massage cardiaque, chez les enfants de moins de 1 an : technique à une ou deux mains.
Chez les enfants de 1 à 8 ans : technique à deux mains.
Gestalt clinical severity score (GCSS) as a predictor of patient severity of illness or injury.
Shiber J, Fontane E, Patel J, Akinleye A, Kerwin A, Chiu W, Scalea T. | Am J Emerg Med. 2023 Apr;66:11-15
Keywords: Gestalt; Injury and illness; Severity scoring.
Introduction : To determine if clinical judgement is accurate to predict the severity of injury or illness, and can be used at patient arrival when other formal scoring systems are not yet available.
Design: A multicenter pilot study using a prospective observational convenience sample of patients arriving by EMS to the emergency department (ED) or Trauma Center.
Méthode : Two urban, Level 1 trauma centers at academic tertiary care hospitals.
Patients: Medical and trauma patients age 18 and older transported by EMS (N = 216). Exclusion criteria (prior to arrival): intubation, assisted ventilation (BVM or NPPV), CPR in progress, prisoners, or previously present motor or speech deficits.
Measurements: Completion of a novel 15-point scale of Verbal, Motor, and Facial Expression within 1-2 min of arrival by a clinician outside of the treatment team. Primary endpoint was the immediate disposition from the ED or Trauma Center: Home, Brief Observation (<24 h), Admission to Floor, ICU (OR and IR as surrogates since these patients ultimately go to the ICU), or Morgue.
Résultats : Univariate analysis revealed a strong, positive monotonic correlation between GCSS and disposition (Rho = 0.693, p < .0001). Multivariable logistic regression revealed the "best" model included GCSS and age (group 18-44 years old versus all the other age groups) (p < .0001). There was a 156% increase in the odds of being discharged home (versus being admitted) for a one-unit increase in GCSS (OR = 2.56, 95% CI 1.94, 3.37).
Conclusion : Physicians can make accurate predictions of severity of injury and illness using a gestalt method and the scoring system we have developed as patient disposition correlates well with GCSS score. GCSS is most accurate with the 18-44 age group.
Conclusion (proposition de traduction) : Les médecins peuvent prédire avec précision la gravité des blessures et des maladies en utilisant une méthode fondée sur l'intuition et le système de calcul que nous avons mis au point, car la propension des patients est en bonne corrélation avec le score GCSS. Le GCSS est le plus précis pour le groupe d'âge 18-44 ans.
Impact of rigid cervical collars on the vital signs and cervical vasculature: Should we be on the alert for anything?.
Tatliparmak AC, Yilmaz S. | Am J Emerg Med. 2023 Apr;66:31-35
Keywords: Common carotid artery; Hemodynamics; Internal jugular vein; Neck vascular structures; Rigid cervical collar; Trauma; Vital signs.
Introduction : In this study, it was aimed to reveal the effect of RCC application on vital signs and physiology of the neck vascular structures.
Méthode : The study was designed as a prospective interventional study on 11 volunteers. The factors that would affect the hemodynamics of the volunteers were standardized before the measurements. The vital signs before and after RCC were measured and under the guidance of ultrasonography (USG), internal jugular vein cross-sectional area (CSA), diameter of the common carotid artery (CCAD), peak systolic velocity (PSV). end-diastolic velocity (EDV), time-averaged maximum velocity (TAMAX), Pulsatility Index, Resistivity Index, time averaged mean velocity (TAMEAN), Volume Flow (FV) measurements were made and compared with each other.
Résultats : Among 11 volunteers, the study included 5 women (45.5%). 10 min of RCC application was associated with a reduction of the heart rate by 7.9 bpm (95% CI 4.84-10.98) (pre-collar 74.73 + -8.84, post-collar 66.82 + -9.05, p < 0.001). A corresponding 7.18 mmHg (95% CI 2.11-12.25) decrease in systolic blood pressure (pre-collar mean 115.82 mmHg + -12.55, post-collar mean 108.64 mmHg + -11.46, p = 0.01) and 108.55 mL/min reduction of mean common carotid artery blood volume (95% CI 22.28-194.82) (pre-collar 590.14 mL/min + -194.63, post-collar 481.59 mL/min + -279.36, p = 0.019) were noted. Internal jugular vein CSA has decreased for 0.17 cm2 (95% CI 0.05-0.29) (pre-collar CSA 0.53 + -0.29, post-collar CSA 0.36 + -0.17, p = 0.012).
Conclusion : In healthy volunteers, RCC application lasting for ten minutes may reduce systolic blood pressure and heart rate, while decreasing blood volume in both the common carotid artery and the internal jugular vein. It has also been noted that the collapse is larger in the internal jugular vein than in the common carotid artery following the pressure applied by RCC.
Conclusion (proposition de traduction) : Chez des volontaires sains, l'application d'un collier cervical rigide pendant dix minutes peut réduire la pression artérielle systolique et la fréquence cardiaque, tout en diminuant le volume sanguin dans l'artère carotide commune et la veine jugulaire interne. Il a également été noté que l'affaissement est plus important dans la veine jugulaire interne que dans l'artère carotide commune à la suite de la pression appliquée par le collier cervical rigide.
Point of care ultrasound impact in acute heart failure hospitalization: A retrospective cohort study.
Núñez-Ramos JA, Aguirre-Acevedo DC, Pana-Toloza MC. | Am J Emerg Med. 2023 Apr;66:141-145
Keywords: Clinical outcomes; Heart failure; Lung ultrasound; POCUS; Ultrasound.
Introduction : Acute decompensated heart failure (ADHF) is one of the most frequent causes of emergency department (ED) visits. Point-of-Care Ultrasound (POCUS) is a reliable, easy-to-use, and available tool for an accurate diagnosis of ADHF. We aimed to analyze the impact of introducing POCUS as an additional tool to clinical standard diagnosis in clinical times of hospitalized heart failure patients.
Méthode : Retrospective cohort study comparing patients consulting to ED for heart failure acute decompensation previous to the rutinary use of POCUS versus patients who received an ultrasound-guided diagnosis at entrance. Ultrasound evaluation was additional to standard diagnosis (which included natriuretic peptides, images, etc). Cumulative incidence functions were calculated for time to treatment, time to disposition decision, and time to discharge. We used a flexible parametric model for estimate the time ratio (TR) in order to reflect the effect of POCUS.
Résultats : A total of 149 patients were included. The most frequent comorbid condition was hypertension (71.8%) followed by type 2 diabetes (36.2%). B type natriuretic peptide (BNP) was over 500 ng/ml. Most patients had Stevenson B profile (83.9%) at admission. In the cumulative incidence model (Fig. A), the TR (time ratio) for the outcome time to treatment was 1.539 (CI 95% 0.88 to 2.69). The TR for the outcome time to disposition decision was 0.665 (CI 95% 0.48 to 0.99). The TR for the outcome time to discharge (hospital length of stay) was 0.663 (CI 95% 0.49 to 0.90).
Conclusion : In our study, the introduction of POCUS to ADHF patients decreases time to disposition decision and total length of hospital stay. Conversely, time to treatment augments. There is need for the evaluation of ultrasound as an intervention in clinical trials to confirm these findings.
Conclusion (proposition de traduction) : Dans notre étude, l'introduction de l'échographie au point d'intervention chez les patients présentant une insuffisance cardiaque aiguë réduit le temps nécessaire à la prise de décision et la durée totale du séjour à l'hôpital. Inversement, le délai de prise en charge s'allonge. Il est nécessaire d'évaluer l'échographie en tant que stratégie d'intervention dans le cadre d'essais cliniques afin de confirmer ces résultats.
Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces.
Banks KC, Mooney CM, Mazzolini K, Browder TD, Victorino GP. | Am J Emerg Med. 2023 Apr;66:36-39
Keywords: Observation; Outcome; Traumatic pneumothorax; Tube Thoracostomy.
Introduction : Traumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy.
Méthode : We retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean.
Résultats : Of patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema.
Conclusion : Select patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.
Conclusion (proposition de traduction) : Les patients sélectionnés présentant de petits pneumothorax traumatiques sur la radiographie thoracique initiale et traités par surveillance ont connu une durée de séjour moyenne inférieure de plus de deux jours à celle des patients traités par drainage thoracique. Les résultats étaient par ailleurs similaires entre les deux groupes, ce qui suggère qu'une stratégie privilégiant la mise en observation pourrait constituer une approche thérapeutique supérieure pour ces patients.
High risk and low prevalence diseases: Testicular torsion.
Lacy A, Smith A, Koyfman A, Long B. | Am J Emerg Med. 2023 Apr;66:98-104
Keywords: Acute scrotum; Testicular pain; Testicular torsion; Urology.
Introduction : esticular torsion is a serious condition that carries with it a high rate of morbidity.
Méthode : This review highlights the pearls and pitfalls of testicular torsion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.
Discussion : Testicular torsion is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow. A key risk factor is the presence of a bell-clapper deformity. The most common population affected includes children in a bimodal distribution with the most cases occurring in the first year of life and between 12 and 18 years, although cases do occur in adults. Acute, severe, unilateral scrotal pain is the most common presenting symptom. Nausea and vomiting are common, but the presence or absence of a cremasteric reflex is not a reliable indicator of disease. The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain but should not be used in isolation. If torsion is suspected or confirmed, consultation with the urology specialist should not be delayed, as outcomes are time sensitive. Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED. Manual detorsion can be attempted in the ED while awaiting transfer or consultation.
Conclusion : An understanding of testicular torsion can assist emergency clinicians in diagnosing and managing this disease.
Conclusion (proposition de traduction) : Une bonne compréhension de la torsion testiculaire peut aider les médecins urgentistes à diagnostiquer et à prendre en charge cette maladie.
Timing and Outcomes After Coronary Angiography Following Out-of-Hospital Cardiac Arrest Without Signs of ST-Segment Elevation Myocardial Infarction.
Helber AR, Helfer DR, Ferko AR, Klein DD, Elchediak D, Deaner TS, Slagle D, White WB, Buckler DG, Mitchell OJL, Fiorilli PN, Isenberg DL, Nomura JT, Murphy KA, Sigal A, Saif H, Reihart MJ, Vernon TM, Abella BS. | J Emerg Med. 2023 Apr;64(4):439-447
Keywords: cardiac arrest; coronary angiography; coronary artery disease; resuscitation.
Introduction : There is broad consensus that resuscitated out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation myocardial infarction (STEMI) should receive immediate coronary angiography (CAG); however, factors that guide patient selection and optimal timing of CAG for post-arrest patients without evidence of STEMI remain incompletely described.
Objective: We sought to describe the timing of post-arrest CAG in actual practice, patient characteristics associated with decision to perform immediate vs. delayed CAG, and patient outcomes after CAG.
Méthode : We conducted a retrospective cohort study at seven U.S. academic hospitals. Resuscitated adult patients with OHCA were included if they presented between January 1, 2015 and December 31, 2019 and received CAG during hospitalization. Emergency medical services run sheets and hospital records were analyzed. Patients without evidence of STEMI were grouped and compared based on time from arrival to CAG performance into "early" (≤ 6 h) and "delayed" (> 6 h).
Résultats : Two hundred twenty-one patients were included. Median time to CAG was 18.6 h (interquartile range [IQR] 1.5-94.6 h). Early catheterization was performed on 94 patients (42.5%) and delayed catheterization was performed on 127 patients (57.5%). Patients in the early group were older (61 years [IQR 55-70 years] vs. 57 years [IQR 47-65] years) and more likely to be male (79.8% vs. 59.8%). Those in the early group were more likely to have clinically significant lesions (58.5% vs. 39.4%) and receive revascularization (41.5% vs. 19.7%). Patients were more likely to die in the early group (47.9% vs. 33.1%). Among survivors, there was no significant difference in neurologic recovery at discharge.
Conclusion : OHCA patients without evidence of STEMI who received early CAG were older and more likely to be male. This group was more likely to have intervenable lesions and receive revascularization.
Conclusion (proposition de traduction) : Les patients ayant fait un arrêt cardiaque sans signe d'infarctus du myocarde avec sus-décalage du segment ST et ayant bénéficié d'une coronarographie précoce étaient plus âgés et plus souvent de sexe masculin. Ce groupe était plus susceptible d'avoir des lésions réversibles et de bénéficier d'une revascularisation.
Short Axis In-Plane Ultrasound-Guided Technique for Internal Jugular Vein Cannulation.
Cheong I, Otero Castro V, Feijoo J, Mármol PDB, Tamagnone FM. | J Emerg Med. 2023 Apr;64(4):488-490
Keywords: jugular vein cannulation; point-of-care ultrasound; short axis in-plane.
Techniques and Procedures
Introduction : Real-time ultrasound (US)-guided venipuncture has become the standard of care due to its reduced complications and higher success rate. There are various techniques for US-guided cannulation of the internal jugular vein (IJV); the transversal and longitudinal views are the most widely used. There is a less commonly used technique that combines the benefits of both methods.
Discussion : Two main techniques for central line US-guided cannulation of the IJV are based on the location of the probe relative to the vessel and are known as the transversal view and the longitudinal view. The transversal view may make it difficult to identify the tip of the needle as it enters the vein, and the longitudinal view may not allow for visualization of surrounding structures. A third and less commonly used technique, the short axis in-plan view, aims to combine the benefits of both previous methods. In this technique, the entire needle can be tracked in real time as it enters the IJV, while also providing visualization of surrounding structures.
Conclusion : The short axis in-plane view technique for central venous line placements allows for real-time US-guided needle venipuncture with simultaneous visualization of surrounding structures.
Conclusion (proposition de traduction) : La technique guidée par ultrasons en court axe pour la pose de cathéters veineux centraux permet une ponction veineuse à l'aiguille guidée par les ultrasons en temps réel avec une visualisation simultanée des structures environnantes.
Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial.
Dirksen MT, Ruifrok WPT, Everaert BRC, Van Mieghem C, Elscot JJ, Cummins P, Lenzen M, Brugaletta S, Boersma E, Van Mieghem NM; BIOVASC Investigators. | Lancet. 2023 Apr 8;401(10383):1172-1182
Introduction : In patients with acute coronary syndrome and multivessel coronary disease, complete revascularisation by percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. We aimed to investigate whether PCI for non-culprit lesions should be attempted during the index procedure or staged.
Méthode : This prospective, open-label, non-inferiority, randomised trial was done at 29 hospitals across Belgium, Italy, the Netherlands, and Spain. We included patients aged 18-85 years presenting with ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndrome and multivessel (ie, two or more coronary arteries with a diameter of 2·5 mm or more and ≥70% stenosis based on visual estimation or positive coronary physiology testing) coronary artery disease with a clearly identifiable culprit lesion. A web-based randomisation module was used to randomly assign patients (1:1), with a random block size of four to eight, stratified by study centre, to undergo immediate complete revascularisation (PCI of the culprit lesion first, followed by other non-culprit lesions deemed to be clinically significant by the operator during the index procedure) or staged complete revascularisation (PCI of only the culprit lesion during the index procedure and PCI of all non-culprit lesions deemed to be clinically significant by the operator within 6 weeks after the index procedure). The primary outcome was the composite of all-cause mortality, myocardial infarction, any unplanned ischaemia-driven revascularisation, or cerebrovascular events at 1 year after the index procedure. Secondary outcomes included all-cause mortality, myocardial infarction, and unplanned ischaemia-driven revascularisation at 1 year after the index procedure. Primary and secondary outcomes were assessed in all randomly assigned patients by intention to treat. Non-inferiority of immediate to staged complete revascularisation was considered to be met if the upper boundary of the 95% CI of the hazard ratio (HR) for the primary outcome did not exceed 1·39.
Résultats : Between June 26, 2018, and Oct 21, 2021, 764 patients (median age 65·7 years [IQR 57·2-72·9] and 598 [78·3%] males) were randomly assigned to the immediate complete revascularisation group and 761 patients (median age 65·3 years [58·6-72·9] and 589 [77·4%] males) were randomly assigned to the staged complete revascularisation group, and were included in the intention-to-treat population. The primary outcome at 1 year occurred in 57 (7·6%) of 764 patients in the immediate complete revascularisation group and in 71 (9·4%) of 761 patients in the staged complete revascularisation group (HR 0·78, 95% CI 0·55-1·11, pnon-inferiority=0·0011). There was no difference in all-cause death between the immediate and staged complete revascularisation groups (14 [1·9%] vs nine [1·2%]; HR 1·56, 95% CI 0·68-3·61, p=0·30). Myocardial infarction occurred in 14 (1·9%) patients in the immediate complete revascularisation group and in 34 (4·5%) patients in the staged complete revascularisation group (HR 0·41, 95% CI 0·22-0·76, p=0·0045). More unplanned ischaemia-driven revascularisations were performed in the staged complete revascularisation group than in the immediate complete revascularisation group (50 [6·7%] patients vs 31 [4·2%] patients; HR 0·61, 95% CI 0·39-0·95, p=0·030).
Conclusion : In patients presenting with acute coronary syndrome and multivessel disease, immediate complete revascularisation was non-inferior to staged complete revascularisation for the primary composite outcome and was associated with a reduction in myocardial infarction and unplanned ischaemia-driven revascularisation.
Conclusion (proposition de traduction) : Chez les patients présentant un syndrome coronarien aigu et une maladie multi-vaisseaux, la revascularisation complète immédiate était non inférieure à la revascularisation complète par étapes pour le résultat composite principal et était associée à une réduction du nombre d'infarctus du myocarde et de revascularisations non planifiées induites par l'ischémie.
Inflammation and cholesterol as predictors of cardiovascular events among patients receiving statin therapy: a collaborative analysis of three randomised trials.
Ridker PM, Bhatt DL, Pradhan AD, Glynn RJ, MacFadyen JG, Nissen SE; PROMINENT, REDUCE-IT, and STRENGTH Investigators. | Lancet. 2023 Apr 15;401(10384):1293-1301
Introduction : Inflammation and hyperlipidaemia jointly contribute to atherothrombotic disease. However, when people are treated with intensive statin therapy, the relative contributions of inflammation and hyperlipidaemia to the risk of future cardiovascular events might change, which has implications for the choice of adjunctive cardiovascular therapeutics. We aimed to evaluate the relative importance of high-sensitivity C-reactive protein (CRP) and low-density lipoprotein cholesterol (LDLC) as determinants of risk for major adverse cardiovascular events, cardiovascular death, and all-cause-death among patients receiving statins.
Méthode : We did a collaborative analysis of patients with-or at high risk of-atherosclerotic disease, who were receiving contemporary statins and were participants in the multinational PROMINENT (NCT03071692), REDUCE-IT (NCT01492361), or STRENGTH (NCT02104817) trials. Quartiles of increasing baseline high-sensitivity CRP (a biomarker of residual inflammatory risk) and of increasing baseline LDLC (a biomarker of residual cholesterol risk) were assessed as predictors of future major adverse cardiovascular events, cardiovascular death, and all-cause death. Hazard ratios (HRs) for cardiovascular events and deaths were calculated across quartiles of high-sensitivity CRP and LDLC in analyses adjusted for age, gender, BMI, smoking status, blood pressure, previous history of cardiovascular disease, and randomised treatment group assignment.
Résultats : 31 245 patients were included in the analysis from the PROMINENT (n=9988), REDUCE-IT (n=8179), and STRENGTH (n=13 078) trials. The observed ranges for baseline high-sensitivity CRP and LDLC, and the relationships of each biomarker to subsequent cardiovascular event rates, were almost identical in the three trials. Residual inflammatory risk was significantly associated with incident major adverse cardiovascular events (highest high-sensitivity CRP quartile vs lowest high-sensitivity CRP quartile, adjusted HR 1·31, 95% CI 1·20-1·43; p<0·0001), cardiovascular mortality (2·68, 2·22-3·23; p<0·0001), and all-cause mortality (2·42, 2·12-2·77; p<0·0001). By contrast, the relationship of residual cholesterol risk was neutral for major adverse cardiovascular events (highest LDLC quartile vs lowest LDLC quartile, adjusted HR 1·07, 95% CI 0·98-1·17; p=0·11), and of low magnitude for cardiovascular death (1·27, 1·07-1·50; p=0·0086) and all-cause death (1·16, 1·03-1·32; p=0·025).
Conclusion : Among patients receiving contemporary statins, inflammation assessed by high-sensitivity CRP was a stronger predictor for risk of future cardiovascular events and death than cholesterol assessed by LDLC. These data have implications for the selection of adjunctive treatments beyond statin therapy and suggest that combined use of aggressive lipid-lowering and inflammation-inhibiting therapies might be needed to further reduce atherosclerotic risk.
Conclusion (proposition de traduction) : Parmi les patients recevant des statines actuelles, l'inflammation évaluée par la CRP à haute sensibilité était un facteur prédictif du risque d'événements cardiovasculaires futurs et de décès plus important que le cholestérol évalué par le taux de cholestérol LDLC. Ces données ont des implications pour la sélection de traitements complémentaires à la prescription de statines et suggèrent que l'utilisation combinée de traitements hypolipidémiants agressifs et d'inhibiteurs de l'inflammation pourrait être nécessaire pour réduire davantage le risque d'athérosclérose.
Improving the approach to non-cardiac syncope in the emergency department observation unit.
Numeroso F, Casagranda I. | World J Emerg Med. 2023;14(2):128-132
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2023.017 | Télécharger l'article au format
Editorial : Syncope is a rather frequent condition, responsible for 1.0%–1.5% of emergency department (ED) visits. Even if the development of clinical guidelines has improved the ED management of syncope, the hospitalization rate is still very high (up to 50%), especially compared with the incidence of short-term adverse events, which is 11% globally, but decreases to less than 4% when events already diagnosed in the ED are excluded, meaning that most patients will not benefit from admission.
Conclusion : Recent advances in the management of non-cardiac syncope along with the contribution given to ED management by ESC GL, with a focus on the role of acute principal diseases underlying syncope, pathways and organizational issues and risk stratification based on causal and consequential risk, allow a further step along the road that leads to the ambitious target of zero admission for unexplained syncope. To combine this goal with patient safety, there is a strong need for organizational implementation, to ensure a widespread diffusion of the EDOU facilities with adequate equipment in the EDs and to further strengthen connections between these structures, syncope outpatient clinics or other hospital services.
Conclusion (proposition de traduction) : Les progrès récents dans la prise en charge des syncopes non cardiaques et la contribution apportée à la prise en charge des urgences par les lignes directrices de la Société européenne de cardiologie sur les syncopes, qui mettent l'accent sur le rôle des principales maladies aiguës à l'origine des syncopes, les parcours, les questions organisationnelles et la stratification des risques basée sur le risque étiologique et le risque induit, permettent de franchir une nouvelle étape sur la voie qui mène à l'objectif ambitieux de l'admission zéro pour syncope inexpliquée. Pour combiner cet objectif avec la sécurité des patients, il est absolument nécessaire de mettre en place une organisation, d'assurer une large diffusion des structures d'observation avec un équipement adéquat dans les services d'urgence et de renforcer les liens entre ces structures, les services de consultation externe pour les syncopes ou d'autres services hospitaliers. Traduit avec www.DeepL.com/Translator (version gratuite)