Intranasal ketamine for procedural sedation in children: An open-label multicenter clinical trial.
Rached-d'Astous S, Finkelstein Y, Bailey B, Marquis C, Lebel D, Desjardins MP, Trottier ED. | Am J Emerg Med. 2023 May;67:10-16
DOI: https://doi.org/10.1016/j.ajem.2023.01.046
Keywords: Intranasal; Pain; Pediatrics; Procedural sedation.

Research article

Introduction : There are limited options for pain and distress management in children undergoing minor procedures, without the burden of an intravenous line insertion. Prior to this study, we conducted a dose-escalation study and identified 6 mg/kg as a potentially optimal initial dose of intranasal ketamine.
Objective: To assess the efficacy and safety of intranasal ketamine at a dose of 6 mg/kg for procedural sedation to repair lacerations with sutures in children in the emergency department.

Méthode : We conducted a single-arm, open-label multicenter clinical trial for intranasal ketamine for laceration repair with sutures in children aged 1 to 12 years. A convenience sample of 30 patients received 6 mg/kg of intranasal ketamine for their procedural sedation. The primary outcome was the proportion (95% CI) of patients who achieved an effective procedural sedation.

Résultats : We recruited 30 patients from April 2018 to December 2019 in two pediatric emergency departments in Canada. Lacerations repaired were mostly facial in 21(70%) patients and longer than 2 cm in 20 (67%) patients. Sedation was effective in 18/30 (60% [95% CI 45, 80]) children and was suboptimal in 5 (17%) patients but procedure was completed in them with minimal difficulties. Sedation was poor in the remaining 7 (23%) patients, with 3 (10%) of them required additional sedative agents. No serious adverse events were reported.

Conclusion : Using a single dose of 6 mg/kg of intranasal Ketamine for laceration repair led to successful sedation in 60% of patients according to our a priori definition. An additional 17% of patients were considered suboptimal, but their procedure was still completed with minimal difficulty.

Conclusion (proposition de traduction) : L'utilisation d'une dose unique de 6 mg/kg de kétamine intranasale pour la suture de plaies a conduit à une sédation réussie chez 60 % des patients selon notre définition a priori. Dix-sept autres pour cent des patients ont été considérés comme sous-optimaux, mais l'intervention s'est tout de même déroulée avec un minimum de difficultés.

Respective Effects of Helmet Pressure Support, Continuous Positive Airway Pressure, and Nasal High-Flow in Hypoxemic Respiratory Failure: A Randomized Crossover Clinical Trial.
Menga LS, Delle Cese L, Rosà T, Cesarano M, Scarascia R, Michi T, Biasucci DG, Ruggiero E, Dell'Anna AM, Cutuli SL, Tanzarella ES, Pintaudi G, De Pascale G, Sandroni C, Maggiore SM, Grieco DL, Antonelli M. | Am J Respir Crit Care Med. 2023 May 15;207(10):1310-1323
DOI: https://doi.org/10.1164/rccm.202204-0629oc  | Télécharger l'article au format  
Keywords: acute hypoxemic respiratory failure; acute respiratory distress syndrome; helmet support; noninvasive ventilation.

Original article

Introduction : The respective effects of positive end-expiratory pressure (PEEP) and pressure support delivered through the helmet interface in patients with hypoxemia need to be better understood. Objectives: To assess the respective effects of helmet pressure support (noninvasive ventilation [NIV]) and continuous positive airway pressure (CPAP) compared with high-flow nasal oxygen (HFNO) on effort to breathe, lung inflation, and gas exchange in patients with hypoxemia (PaO2/FiO2 ⩽ 200).

Méthode : Fifteen patients underwent 1-hour phases (constant FiO2) of HFNO (60 L/min), helmet NIV (PEEP = 14 cm H2O, pressure support = 12 cm H2O), and CPAP (PEEP = 14 cm H2O) in randomized sequence.

Résultats : Inspiratory esophageal (ΔPES) and transpulmonary pressure (ΔPL) swings were used as surrogates for inspiratory effort and lung distension, respectively. Tidal Volume (Vt) and end-expiratory lung volume were assessed with electrical impedance tomography. ΔPES was lower during NIV versus CPAP and HFNO (median [interquartile range], 5 [3-9] cm H2O vs. 13 [10-19] cm H2O vs. 10 [8-13] cm H2O; P = 0.001 and P = 0.01). ΔPL was not statistically different between treatments. PaO2/FiO2 ratio was significantly higher during NIV and CPAP versus HFNO (166 [136-215] and 175 [158-281] vs. 120 [107-149]; P = 0.002 and P = 0.001). NIV and CPAP similarly increased Vt versus HFNO (mean change, 70% [95% confidence interval (CI), 17-122%], P = 0.02; 93% [95% CI, 30-155%], P = 0.002) and end-expiratory lung volume (mean change, 198% [95% CI, 67-330%], P = 0.001; 263% [95% CI, 121-407%], P = 0.001), mostly due to increased aeration/ventilation in dorsal lung regions. During HFNO, 14 of 15 patients had pendelluft involving >10% of Vt; pendelluft was mitigated by CPAP and further by NIV.

Conclusion : Compared with HFNO, helmet NIV, but not CPAP, reduced ΔPES. CPAP and NIV similarly increased oxygenation, end-expiratory lung volume, and Vt, without affecting ΔPL. NIV, and to a lesser extent CPAP, mitigated pendelluft.

Conclusion (proposition de traduction) : Par rapport à l'OHD, la VNI au casque de ventilation, mais pas la CPAPC, a réduit la pression oesophagienne inspiratoire. La CPAP et la VNI ont augmenté de façon similaire l'oxygénation, le volume pulmonaire en fin d'expiration et le Vt, sans affecter la pression transpulmonaire. La VNI et, dans une moindre mesure, la CPAP, ont atténué la pendelluft.

Commentaire : Pendelluft n.m. :
Asynchronisme des mouvements de l'air d'un poumon à l'autre à la suite d'une lésion de la paroi thoracique (volet thoracique) ou d'une paralysie d'un hémi-diaphragme.
Le passage de l'air alvéolaire d'un côté à l'autre au lieu de sortir normalement par la trachée vers l'extérieur entraîne une hypoxie-hypercapnie.
Dictionnaire médical de l'Académie de Médecine – version 2023

Oxygénothérapie nasale à haut débit (OHD) ; Oxygénothérapie à haut débit ; Oxygénothérapie à haut débit nasal ; Haut Débit Nasal (HDN) ; Haut débit par canule nasale (HFNC) ; high-flow nasal oxygen (HFNO) en anglais ; appelé couramment « optiflow », du nom commercial de l'appareil utilisé

The Management of Pregnant Trauma Patients: A Narrative Review.
Lopez CE, Salloum J, Varon AJ, Toledo P, Dudaryk R. | Anesth Analg. 2023 May 1;136(5):830-840
DOI: https://doi.org/10.1213/ane.0000000000006363
Keywords: Aucun

Narrative review article

Editorial : Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock.

Conclusion : The care of pregnant trauma patients involves special considerations both with regard to maternal physiological changes as well as the presence of a fetus. The most important message regarding the trauma management of these patients is that advanced trauma life support fundamentals should be applied to the mother without delay or distraction due to care provided to the fetus. Obstetric teams should be alerted to the presence of a pregnant trauma admission; however, any fetal assessment should not impede the initial assessment and stabilization of the mother by the trauma team. The most important physiologic changes in pregnancy include respiratory, cardiovascular, and hematological changes. Respiratory changes to be mindful include edematous airways, decreased functional residual capacity, and quicker oxygen desaturation during apnea. The most important cardiovascular changes include aortocaval compression of the gravid uterus, increased plasma volume, and increased cardiac output. The most relevant hematologic changes include anemia and relative hypercoagulability. During resuscitation, left uterine displacement must be performed to optimize cardiac output and end-organ perfusion. Intravenous lines should be placed above the level of the diaphragm. Resuscitation with a balanced ratio of blood products is essential during hemorrhagic shock and coagulopathy. Fetal assessment includes estimation of gestational ag/ viability and continuous fetal heart rate monitoring for at least 4 hours. Obstetric complications of trauma include placental abruption, uterine rupture, premature rupture of membranes, preterm labor, and need for cesarean delivery. Imaging studies for maternal trauma usually do not exceed radiation doses known to be harmful to fetal development and should not be avoided in pregnant trauma patients when indicated.

Conclusion (proposition de traduction) : La prise en charge des patientes enceintes victimes de traumatismes implique des considérations particulières, tant en ce qui concerne les changements physiologiques maternels que la présence d'un fœtus. Le message le plus important concernant la gestion des traumatismes de ces patientes est que les principes fondamentaux des soins avancés de réanimation traumatologique doivent être appliqués à la mère sans retard ni distraction dus aux soins prodigués au fœtus. Les équipes obstétricales doivent être alertées de la présence d'une femme enceinte admise pour un traumatisme ; cependant, l'évaluation du fœtus ne doit pas entraver l'évaluation initiale et la stabilisation de la mère par l'équipe de traumatologie. Les changements physiologiques les plus importants au cours de la grossesse sont les changements respiratoires, cardiovasculaires et hématologiques. Les changements respiratoires à prendre en compte sont l'œdème des voies respiratoires, la diminution de la capacité résiduelle fonctionnelle et la désaturation en oxygène plus rapide pendant l'apnée. Les modifications cardiovasculaires les plus importantes sont la compression aortocave de l'utérus gravide, l'augmentation du volume plasmatique et l'augmentation du débit cardiaque. Les changements hématologiques les plus importants sont l'anémie et une hypercoagulabilité relative. Pendant la réanimation, un déplacement de l'utérus gauche doit être effectué pour optimiser le débit cardiaque et la perfusion des organes terminaux. Les perfusions intraveineuses doivent être placées au-dessus du niveau du diaphragme. La réanimation avec un rapport équilibré de produits sanguins est essentielle en cas de choc hémorragique et de coagulopathie. L'évaluation fœtale comprend l'estimation de l'âge gestationnel/de la viabilité et la surveillance continue du rythme cardiaque fœtal pendant au moins 4 heures. Les complications obstétricales du traumatisme comprennent le décollement du placenta, la rupture utérine, la rupture prématurée des membranes, le travail prématuré et la nécessité d'un accouchement par césarienne. Les examens d'imagerie pour les traumatismes maternels ne dépassent généralement pas les doses de radiation connues pour être nocives pour le développement du fœtus et ne doivent pas être évités chez les patientes enceintes victimes de traumatismes lorsque cela est indiqué.

Commentaire :  Figure 1. Physiologic changes of pregnancy. Management of the obstetric trauma patient.png Figure 2. Management of the obstetric trauma patient. Figure 3. Manual left uterine displacement during advanced cardiac life support is routinely done for all parturients after 20 wk GA.

Comprehensive Management of the Patient With Traumatic Cardiac Injury.
Gupta B, Singh Y, Bagaria D, Nagarajappa A. | Anesth Analg. 2023 May 1;136(5):877-893
DOI: https://doi.org/10.1213/ane.0000000000006380
Keywords: Aucun

Narrative review article

Editorial : Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.

Conclusion : Cardiac injury is associated with high mortality. Expeditious transport to a trauma care facility and early surgical interventions are required for a better outcome. Focused assessment with sonography for trauma is one of the valuable examinations to diagnose pericardial effusion. Anesthetic management is extremely challenging, and a skillful anesthesiologist is required to establish appropriate interventions expeditiously. Each institute must have clear policies for emergency department thoracotomy, ready availability of operating room, airway management, and massive hemorrhage protocol. The postoperative period deals with hemodynamic stabilization, reversal of lethal triad if present, and managing complications. Figure 3 summarizes the workflow for the anesthetic management of penetrating cardiac injury patient with cardiac tamponade or severe hemorrhage, principles of management of these conditions with blunt mechanism remaining the same. Future research is required to elucidate the role of induced hypothermia in decreasing mortality and the use of vasopressors in hemorrhagic shock.

Conclusion (proposition de traduction) : Les lésions cardiaques sont associées à un taux de mortalité élevé. Un transport rapide vers un centre de traumatologie et des interventions chirurgicales précoces sont nécessaires pour obtenir un meilleur résultat. L'évaluation ciblée par échographie en cas de traumatisme est l'un des examens les plus utiles pour diagnostiquer un épanchement péricardique. La prise en charge anesthésique est extrêmement difficile et un anesthésiste compétent est nécessaire pour mettre en place rapidement les interventions appropriées. Chaque établissement doit disposer de politiques claires en matière de thoracotomie au service des urgences, de disponibilité de la salle d'opération, de gestion des voies respiratoires et de protocole en cas d'hémorragie massive. La période postopératoire est consacrée à la stabilisation hémodynamique, à l'inversion de la triade létale, le cas échéant, et à la gestion des complications. La figure 3 résume le processus de prise en charge anesthésique d'un patient souffrant d'un traumatisme cardiaque pénétrant avec tamponnade cardiaque ou hémorragie grave, les principes de prise en charge de ces conditions avec un mécanisme contondant restant les mêmes. De futures recherches sont nécessaires pour élucider le rôle de l'hypothermie induite dans la réduction de la mortalité et l'utilisation de vasopresseurs en cas de choc hémorragique.

Commentaire : 
Algorithme de prise en charge des lésions thoraciques contondantes avec bilan et diagnostic des lésions cardiaques contondantes.
CXR indique la radiographie thoracique ; ECG, électrocardiogramme ; FAST, évaluation ciblée par échographie pour les traumatismes ; ICU, unité de soins intensifs ; OR, salle d'opération ; TEE, échocardiographie transœsophagienne ; TTE, échocardiographie transthoracique.
Figure 3. Installation standard de la salle d'opération et rôles et responsabilités préétablis de l'équipe de traumatologie.
JR : sécurise la canule intraveineuse de gros calibre si elle n'a pas été obtenue avant l'arrivée au bloc opératoire, administre des médicaments, prélève des échantillons de sang, vérifie les produits sanguins et participe à la réanimation, SR1:gère les voies respiratoires, insère une sonde de température et sécurise la ligne artérielle, SR2 : sécurise l'accès veineux central guidé par ultrasons et pratique une compression thoracique en cas d'arrêt cardiaque avant l'ouverture du thorax par le chirurgien, NUR1 et NUR2 : assistent les chirurgiens, NUR3 : infirmière supplémentaire s'assure de la disponibilité de tout le matériel chirurgical, OTT1 : aide à la gestion des voies respiratoires et fixe le transfuseur rapide, les pompes à perfusion, OTT2 : OTT2 : aide à la pose du cathéter central, OTT3 : coordonne le protocole d'hémorragie massive et les tests de laboratoire et remplit la réserve de liquide chaud dans la salle d'opération, SUR1 : pratique la chirurgie, SUR2 : aide à la chirurgie, SUR3 : chirurgien supplémentaire, aide si nécessaire, TL : répartit les rôles et les responsabilités, coordonne et supervise les membres de l'équipe d'anesthésie, administre les médicaments vasoactifs, contrôle le dosage des médicaments, les liquides et la transfusion sanguine, et participe à la prise de décision, y compris l'arrêt des efforts de réanimation en cas d'arrêt cardiaque en dépit de toutes les tentatives. JR indique résident junior (anesthésie) ; NUR, infirmière ; OR, salle d'opération...

Association Between Profound Shock Signs and Peripheral Intravenous Access Success Rates in Trauma Patients in the Prehospital Scenario: A Retrospective Study.
Barsky D, Radomislensky I, Talmy T, Gendler S, Almog O, Avital G. | Anesth Analg. 2023 May 1;136(5):934-940
DOI: https://doi.org/10.1213/ane.0000000000006342
Keywords: Aucun

Original Clinical research report

Introduction : Hemorrhage is the leading cause of preventable death in trauma patients, and establishment of intravenous (IV) access is essential for volume resuscitation, a key component in the treatment of hemorrhagic shock. IV access among patients in shock is generally considered more challenging, although data to support this notion are lacking.

Méthode : In this retrospective registry-based study, data were collected from the Israeli Defense Forces Trauma Registry (IDF-TR) regarding all prehospital trauma patients treated by IDF medical forces between January 2020 and April 2022, for whom IV access was attempted. Patients younger than 16 years, nonurgent patients, and patients with no detectable heart rate or blood pressure were excluded. Profound shock was defined as a heart rate >130 or a systolic blood pressure <90 mm Hg, and comparisons were made between patients with profound shock and those not exhibiting such signs. The primary outcome was the number of attempts required for first IV access success, which was regarded as an ordinal categorical variable: 1, 2, 3 and higher and ultimate failure. A multivariable ordinal logistic regression was performed to adjust for potential confounders. Patients' sex, age, mechanism of injury and best consciousness level, as well as type of event (military/nonmilitary), and the presence of multiple patients were included in the ordinal logistic regression multivariable analysis model based on previous publications.

Résultats : Five hundred thirty-seven patients were included, 15.7% of whom were recorded as having signs of profound shock. Peripheral IV access establishment first attempt success rates were higher in the nonshock group, and there was a lower rate of unsuccessful attempts in this group (80.8% vs 67.8% for the first attempt, 9.4% vs 16.7% for the second attempt, 3.8% vs 5.6% for the third and further attempts, and 6% vs 10% unsuccessful attempts, P = .04). In the univariable analysis, profound shock was associated with requirement for an increased number of IV attempts (odds ratio [OR], 1.94; confidence interval [CI], 1.17-3.15). The ordinal logistic regression multivariable analysis demonstrated that profound shock was associated with worse results regarding primary outcome (adjusted odds ratio [AOR], 1.84; CI, 1.07-3.10).

Conclusion : The presence of profound shock in trauma patients in the prehospital scenario is associated with an increased number of attempts required for IV access establishment.

Conclusion (proposition de traduction) : La présence d'un état de choc grave chez les patients traumatisés en milieu préhospitalier est associée à un plus grand nombre de tentatives nécessaires à la pose d'une voie d'abord intraveineuse.

Managing Cardiac Arrest Using Ultrasound.
Gottlieb M, Alerhand S. | Ann Emerg Med. 2023 May;81(5):532-542
DOI: https://doi.org/10.1016/j.annemergmed.2022.09.016  | Télécharger l'article au format  
Keywords: Aucun

Cardiology

Editorial : The emergency department (ED) is the main receiving area for all out-of-hospital cardiac arrests and the setting for approximately 10% of all in-hospital cardiac arrests. The rate of survival-to-discharge among out-of-hospital cardiac arrests is approximately 9%, though it may be up to 35% in those experiencing cardiac arrest while in the ED. Patients in cardiac arrest require rapid, targeted interventions and resuscitative efforts, and those who have lost pulses in the ED have a greater likelihood of reversible causes. However, the cause can be challenging to diagnose by the inherently limited history and physical examination.
Several guidelines have suggested a role for point-of-care ultrasound (POCUS) in cardiac arrest. However, there have been concerns regarding prolonged interruptions in chest compressions when using this tool. Additionally, several unique POCUS protocols have been posited that vary in the diagnoses they evaluate for and the way they do so. Therefore, there is a need better to understand the optimal role of POCUS in cardiac arrest. This paper seeks to distill key facets of the application of POCUS in cardiac arrest based on the current literature and years of practice.

Conclusion : In conclusion, POCUS is a highly versatile tool for evaluating various potentially treatable etiologies in cardiac arrest. However, it is important to use proper technique and minimize delays in chest compressions. Nevertheless, in appropriately trained hands, POCUS can be integrated into cardiac arrest care and provide more targeted management for resuscitation in these critically ill patients.

Conclusion (proposition de traduction) : En conclusion, l'échographie au point d'intervention est un outil très polyvalent pour évaluer diverses étiologies potentiellement traitables dans le cas d'un arrêt cardiaque. Cependant, il est important d'utiliser une technique appropriée et de minimiser les interruptions des compressions thoraciques. Néanmoins, dans des mains correctement formées, l'échographie au point d'intervention peut être intégrée dans les soins de l'arrêt cardiaque et fournir une gestion plus ciblée de la réanimation chez ces patients gravement malades.

Managing Spontaneous Pneumothorax.
Gottlieb M, Long B. | Ann Emerg Med. 2023 May;81(5):568-576
DOI: https://doi.org/10.1016/j.annemergmed.2022.08.447
Keywords: Aucun

Pulmonary

Editorial : Pneumothorax is commonly cared for in the emergency department, with an incidence ranging from 6 to 66 per 100,000 per year and a 1-year recurrence rate of 29%. It is more common in men and has a biphasic distribution occurring more frequently in the 15 to 30-year-old and ≥ 65-year-old groups. Risk factors include chronic obstructive pulmonary disease, asthma, interstitial pneumonitis, cystic fibrosis, tuberculosis, lung cancer, and smoking history. Pneumothorax can be qualified as traumatic or spontaneous (ie, atraumatic). This paper will focus on spontaneous pneumothorax, as traumatic pneumothorax has a significantly different presentation and management. Spontaneous pneumothorax is typically divided into primary (occurring without a clear cause and in the absence of significant lung disease) and secondary (occurring in the presence of existing lung pathology). Primary spontaneous pneumothorax is the most common and is typically seen in younger patients with fewer comorbidities, whereas secondary spontaneous pneumothorax is more frequently seen in older patients with chronic obstructive pulmonary disease. This paper is not intended to be a comprehensive review of all the aspects of the evaluation and management of pneumothorax; instead, this paper seeks to distill key facets of management based on the current literature and years of practice.

Conclusion : When pneumothorax is suspected, we recommendpoint-of-care ultrasound as the first-line imaging modality.It is sensitive (91%) and highly specific (99%) amongtrained users. The absence of lung sliding,referred to as the barcode or stratosphere sign, is the mostsensitive finding, whereas a lung point (visualization of thepoint where the visceral pleura separates from the parietalpleura) is the most specific finding. Chest radiographs are poorly sensitive (44%) but highly specific(100%) for pneumothorax. In more subtlecases, expiratory chest radiographs may increase thesensitivity but can also artificially increase the sizeclassification. When pneumothorax is apparent onchest radiographs, there are several tools for classifying thesize of the pneumothorax. Although any of thecriteria can be used for size purposes, we recommend usingthe British Thoracic Society criteria because of the ease ofuse. Of note, because the American College of Chest Physicians criteria depends on apical measurements, it canovermeasure predominately apical pneumothoraxes. Computed tomography requires more radiation, time, andhealth care costs. Therefore, this should not be routinelyperformed to evaluate spontaneous pneumothorax. However, it may be considered when there is diagnostic uncertainty regarding a bulla versus pneumothorax.

Conclusion (proposition de traduction) : En cas de suspicion de pneumothorax, nous recommandons l'échographie au point d'intervention comme modalité d'imagerie de première intention. Elle est sensible (91 %) et hautement spécifique (99 %) chez les utilisateurs formés. L'absence de glissement pulmonaire, appelée signe du code-barres ou de la stratosphère, est le résultat le plus sensible, tandis qu'un point pulmonaire (visualisation du point où la plèvre viscérale se sépare de la plèvre pariétale) est le résultat le plus spécifique. Les radiographies thoraciques sont peu sensibles (44 %) mais très spécifiques (100 %) pour le pneumothorax. Dans les cas plus subtils, les radiographies thoraciques expiratoires peuvent augmenter la sensibilité mais peuvent également augmenter artificiellement la classification de la taille. Lorsque le pneumothorax est apparent sur les radiographies thoraciques, il existe plusieurs outils pour classer la taille du pneumothorax. Bien que tous les critères puissent être utilisés pour déterminer la taille, nous recommandons d'utiliser les critères de la British Thoracic Society en raison de leur facilité d'utilisation. Il convient de noter que les critères de l'American College of Chest Physicians reposant sur des mesures apicales, peuvent surdimensionner les pneumothorax essentiellement apicaux. La tomodensitométrie entraîne une augmentation des radiations, du temps et des coûts des soins de santé. C'est pourquoi elle ne doit pas être réalisée systématiquement pour évaluer un pneumothorax spontané. Cependant, elle peut être envisagée en cas d'incertitude diagnostique entre une bulle et un pneumothorax.

Ketamine versus etomidate for rapid sequence intubation in patients with trauma: a retrospective study in a level 1 trauma center in Korea.
Kim J, Jung K, Moon J, Kwon J, Kang BH, Yoo J, Song S, Bang E, Kim S, Huh Y. | BMC Emerg Med. 2023 May 29;23(1):57
DOI: https://doi.org/10.1186/s12873-023-00833-7  | Télécharger l'article au format  
Keywords: Etomidate; Ketamine; Rapid sequence intubation; Resuscitation; Trauma.

Research

Introduction : Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation.

Méthode : We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups.

Résultats : In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis.

Conclusion : In this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.

Conclusion (proposition de traduction) : Dans cette étude rétrospective sur la réanimation des traumatisés, les patients intubés avec de la kétamine présentaient une plus grande instabilité hémodynamique que ceux qui recevaient de l'étomidate. Cependant, il n'y avait pas de différence significative dans les résultats cliniques entre les patients sédatés à la kétamine et ceux traités à l'étomidate.

Comparative Effectiveness of Amiodarone and Lidocaine for the Treatment of In-Hospital Cardiac Arrest.
Wagner D, Kronick SL, Nawer H, Cranford JA, Bradley SM, Neumar RW. | Chest. 2023 May;163(5):1109-1119
DOI: https://doi.org/10.1016/j.chest.2022.10.024  | Télécharger l'article au format  
Keywords: cardiology; cardiopulmonary arrest; cardiopulmonary resuscitation; drugs; guidelines.

Research articleFull

Introduction : American Heart Association Advanced Cardiac Life Support (ACLS) guidelines support the use of either amiodarone or lidocaine for cardiac arrest caused by ventricular tachycardia or ventricular fibrillation (VT/VF) based on studies of out-of-hospital cardiac arrest. Studies comparing amiodarone and lidocaine in adult populations with in-hospital VT/VF arrest are lacking.
Research question: Does treatment with amiodarone vs lidocaine therapy have differential associations with outcomes among adult patients with in-hospital cardiac arrest from VT/VF?

Méthode : This retrospective cohort study of adult patients receiving amiodarone or lidocaine for VT/VF in-hospital cardiac arrest refractory to CPR and defibrillation between January 1, 2000, and December 31, 2014, was conducted within American Heart Association Get With the Guidelines-Resuscitation (GWTG-R) participating hospitals. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were 24 h survival, survival to hospital discharge, and favorable neurologic outcome.

Résultats : Among 14,630 patients with in-hospital VT/VF arrest, 68.7% (n = 10,058) were treated with amiodarone and 31.3% (n = 4,572) with lidocaine. When all covariates were statistically controlled, compared with amiodarone, lidocaine was associated with statistically significantly higher odds of the following: (1) ROSC (adjusted OR [AOR], 1.15, P = .01; average marginal effect [AME], 2.3; 95% CI, 0.5 to 4.2); (2) 24 h survival (AOR, 1.16; P = 004; AME, 3.0; 95% CI, 0.9 to 5.1); (3) survival to discharge (AOR, 1.19; P < .001; AME, 3.3; 95% CI, 1.5 to 5.2); and (4) favorable neurologic outcome at hospital discharge (AOR, 1.18; P < .001; AME, 3.1; 95% CI, 1.3 to 4.9). Results using propensity score methods were similar to those from multivariable logistic regression analyses.

Conclusion : Compared with amiodarone, lidocaine therapy among adult patients with in-hospital cardiac arrest from VT/VF was associated with statistically significantly higher rates of ROSC, 24 h survival, survival to hospital discharge, and favorable neurologic outcome.

Conclusion (proposition de traduction) : Comparé à l'amiodarone, le traitement par la lidocaïne chez les patients adultes ayant fait un arrêt cardiaque intra-hospitalier provoqué par une TV/FV a été associé à des taux statistiquement plus élevés de RACS, de survie à 24 heures, de survie jusqu'à la sortie de l'hôpital et d'issue neurologique favorable.

Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial.
Gopinath B, Mishra PR, Aggarwal P, Nayaka R, Naik SR, Kappagantu V, Shrimal P, Ramaswami A, Bhoi S, Jamshed N, Sinha TP, Ekka M, Kumar A. | Chest. 2023 May;163(5):1176-1184
DOI: https://doi.org/10.1016/j.chest.2022.11.021  | Télécharger l'article au format  
Keywords: ED; hemoptysis; nebulization; tranexamic acid.

Original Research

Introduction : Tranexamic acid (TA) is used to control bleeding in patients with hemoptysis. However, the effectiveness of the different routes of TA administration has not been studied.
Research question: Does the nebulized route of TA administration reduce the amount of hemoptysis compared with the IV route in patients presenting to the ED with hemoptysis?

Méthode : This was a pragmatic, open-label, randomized, parallel, single-center, pilot trial of nebulized TA (500 mg tid) vs IV TA (500 mg tid) in adult patients presenting to the ED with active hemoptysis. The primary outcome was cessation of bleeding at 30 min. Secondary outcomes included amount of hemoptysis at 6, 12, and 24 h; interventional procedures; and side effects of TA. Patients who were hemodynamically unstable or requiring immediate interventional procedure or mechanical ventilation were excluded from the study.

Résultats : Of the 55 patients in each arm, hemoptysis cessation at 30 min following TA administration was significantly higher in the nebulization arm (n = 40) compared with the IV arm (n = 28): χ2 (1, n = 110) = 5.55; P = .0019. Also, hemoptysis amount was reduced significantly in the nebulization arm at all time periods of observation (P value at 30 min = .011, at 6 h = .002, 12 h = .0008, and at 24 h = .005). Fewer patients in the nebulization arm required bronchial artery embolization (13 vs 21; P = .024) and thereby had higher discharge rates from the ED (67.92% vs 39.02%; P = .005). Two patients in the nebulization arm had asymptomatic bronchoconstriction that resolved after short-acting beta-agonist nebulization. No patient discharged from the ED underwent any interventional procedure or revisited the ED with rebleed during the 72 h follow-up period.

Conclusion : Nebulized TA may be more efficacious than IV TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared with IV TA in patients with mild hemoptysis.

Conclusion (proposition de traduction) : L'acide tranexamique nébulisé pourrait être plus efficace que l'acide tranexamique intraveineux pour réduire l'hémoptysie et la nécessité de recourir à des procédures d'intervention d'urgence. De futures études de plus grande envergure sont nécessaires pour explorer davantage le potentiel de l'acide tranexamique nébulisé par rapport à l'acide tranexamique IV chez les patients présentant une hémoptysie modérée.

Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies.
Oldrini I, Coventry L, Novak A, Gwilym S, Metcalfe D. | Emerg Med J. 2023 May;40(5):379-384
DOI: https://doi.org/10.1136/emermed-2022-212696  | Télécharger l'article au format  
Keywords: Systematic Review; clinical assessment; fractures and dislocations.

Systematic review

Introduction : Prereduction radiographs are conventionally used to exclude fracture before attempts to reduce a dislocated shoulder in the ED. However, this step increases cost, exposes patients to ionising radiation and may delay closed reduction. Some studies have suggested that prereduction imaging may be omitted for a subgroup of patients with shoulder dislocations.

Méthode : To determine whether clinical predictors can identify patients who may safely undergo closed reduction of a dislocated shoulder without prereduction radiographs.
Methods: A systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. The search was updated to 23 June 2022 and language limits were not applied. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were pooled and meta-analysed by fitting univariate random effects and multilevel mixed effects logistic regression models.

Résultats : Eight studies reported data on 2087 shoulder dislocations and 343 concomitant fractures. The most important potential sources of bias were unclear blinding of those undertaking the clinical (6/8 studies) and radiographic (3/8 studies) assessment. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (positive likelihood ratio (LR+) 1.8, 95% CI 1.5 to 2.1; negative likelihood ratio (LR-) 0.4, 95% CI 0.2 to 0.6), female sex (LR+ 2.0, 95% CI 1.6 to 2.4; LR- 0.7, 95% CI 0.6 to 0.8), first-time dislocation (LR+ 1.7, 95% CI 1.4 to 2.0; LR- 0.2, 95% CI 0.1 to 0.5) and presence of humeral ecchymosis (LR+ 3.0-5.7, LR- 0.8-1.1). The most important mechanisms of injury were high-energy mechanism fall (LR+ 2.0-9.8, LR- 0.4-0.8), fall >1 flight of stairs (LR+ 3.8, 95% CI 0.6 to 13.1; LR- 1.0, 95% CI 0.9 to 1.0) and motor vehicle collision (LR+ 2.3, 95% CI 0.5 to 4.0; LR- 0.9, 95% CI 0.9 to 1.0). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6% to 99.2%) and a specificity of 33.3% (95% CI 23.1% to 45.3%), but the Fresno-Quebec rule identified all clinically important fractures across two studies: sensitivity of 100% (95% CI 89% to 100%) in the derivation dataset and 100% (95% CI 90% to 100%) in the validation study. The specificity of the Fresno-Quebec rule ranged from 34% (95% CI 28% to 41%) in the derivation dataset to 24% (95% CI 16% to 33%) in the validation study.

Conclusion : Clinical prediction rules may have a role in supporting shared decision making after shoulder dislocation, particularly in the prehospital and remote environments when delay to imaging is anticipated.

Conclusion (proposition de traduction) : Les règles de diagnostic clinique peuvent jouer un certain rôle dans la prise de décision partagée après une luxation de l'épaule, en particulier dans les environnements préhospitaliers et éloignés, lorsqu'un délai d'imagerie est prévu.

Commentaire : La prévalence des fractures concomitantes était de 17,5 %.
Les critères cliniques prédictifs les plus pertinents étaient l'âge > 40 ans, le sexe féminin, une première luxation et la présence d'une ecchymose humérale.
Les mécanismes de blessure les plus importants étaient les chutes de mécanisme à haute énergie, les chutes de plus d'une marche d'escalier et les collisions de véhicules à moteur.

Association between prehospital end-tidal carbon dioxide levels and mortality in patients with suspected severe traumatic brain injury.
Bossers SM, Mansvelder F, Loer SA, Boer C, Bloemers FW, Van Lieshout EMM, Den Hartog D, Hoogerwerf N, van der Naalt J, Absalom AR, Schwarte LA, Twisk JWR, Schober P; BRAIN-PROTECT Collaborators. | Intensive Care Med. 2023 May;49(5):491-504
DOI: https://doi.org/10.1007/s00134-023-07012-z  | Télécharger l'article au format  
Keywords: Carbon dioxide; Critical care; Endotracheal intubation; Traumatic brain injury; Ventilation.

Original

Introduction : Severe traumatic brain injury is a leading cause of mortality and morbidity, and these patients are frequently intubated in the prehospital setting. Cerebral perfusion and intracranial pressure are influenced by the arterial partial pressure of CO₂ and derangements might induce further brain damage. We investigated which lower and upper limits of prehospital end-tidal CO₂ levels are associated with increased mortality in patients with severe traumatic brain injury.

Méthode : The BRAIN-PROTECT study is an observational multicenter study. Patients with severe traumatic brain injury, treated by Dutch Helicopter Emergency Medical Services between February 2012 and December 2017, were included. Follow-up continued for 1 year after inclusion. End-tidal CO₂ levels were measured during prehospital care and their association with 30-day mortality was analyzed with multivariable logistic regression.

Résultats : A total of 1776 patients were eligible for analysis. An L-shaped association between end-tidal CO₂ levels and 30-day mortality was observed (p = 0.01), with a sharp increase in mortality with values below 35 mmHg. End-tidal CO₂ values between 35 and 45 mmHg were associated with better survival rates compared to < 35 mmHg. No association between hypercapnia and mortality was observed. The odds ratio for the association between hypocapnia (< 35 mmHg) and mortality was 1.89 (95% CI 1.53-2.34, p < 0.001) and for hypercapnia (≥ 45 mmHg) 0.83 (0.62-1.11, p = 0.212).

Conclusion : A safe zone of 35-45 mmHg for end-tidal CO2 guidance seems reasonable during prehospital care. Particularly, end-tidal partial pressures of less than 35 mmHg were associated with a significantly increased mortality.

Conclusion (proposition de traduction) : Une zone de sécurité de 35-45 mmHg pour le contrôle de la capnie semble raisonnable pendant les interventions préhospitalières. En outre, des capnies inférieures à 35 mmHg ont été associées à une augmentation significative de la mortalité.

Management of the Pregnant Trauma Patient: A Systematic Literature Review.
Liggett MR, Amro A, Son M, Schwulst S. | J Surg Res. 2023 May;285:187-196
DOI: https://doi.org/10.1016/j.jss.2022.11.075
Keywords: Fetal monitoring; Kleihauer-Betke testing; Perimortem cesarean section; Pregnancy; Trauma.

Review

Introduction : Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates up to 5%-7% of pregnancies. This systematic review without meta-analysis explores the current literature regarding the assessment and management of pregnant trauma patients to provide evidence-based recommendations to guide the general surgeon regarding the prognostic value of laboratory testing including Kleihauer-Betke testing, duration of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic studies, and the utility of perimortem cesarean section to improve maternal and fetal mortality.

Méthode : A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier) was performed. The reference lists of included studies were reviewed for relevant citations.

Résultats : Of the 45 studies included in this review, there was reasonable evidence to suggest that the minimally injured pregnant trauma patient should be observed for a minimum of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean sections should be performed as soon as maternal cardiac arrest occurs.

Conclusion : We recommend delivery by perimortem cesarean section as soon as possible after maternal cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum of at least 4 h. Additional high-quality studies focusing on the prognostic potential of KB tests and other laboratory studies are needed.

Conclusion (proposition de traduction) : Nous recommandons d'accoucher par césarienne perimortem dès que possible après un arrêt cardiaque maternel, d'administrer de l'acide tranexanique à la patiente traumatisée enceinte qui présente une hémorragie, de réaliser des tomodensitométries traumatiques si nécessaire et d'observer la patiente enceinte blessée pendant au moins 4 heures. Des études supplémentaires de haute qualité portant sur le potentiel pronostique des tests de Kleihauer-Betke et d'autres études de laboratoire sont nécessaires.

Extracorporeal Cardiopulmonary Resuscitation for Cardiac Arrest.
Granfeldt A, Holmberg MJ, Andersen LW. | JAMA. 2023 May 16;329(19):1693-1694
DOI: https://doi.org/10.1001/jama.2023.5585
Keywords: Aucun

JAMA Insights

Editorial : Cardiac arrest affects approximately 600 000 people in the US yearly and is associated with a survival rate of 10% to 12% for out-of-hospital cardiac arrests and 25% to 30% for in-hospital cardiac arrests.1 Outcomes are particularly poor for people with cardiac arrests who are not responsive to initial treatment. Extracorporeal cardiopulmonary resuscitation (ECPR) is a newer treatment option for these patients.

Conclusion : ECPR may increase survival in patients with refractory cardiac arrest, who typically have mortality rates higher than 90%. However, ECPR is resource-intensive and additional research is needed to clarify the optimal timing of ECPR administration and to identify patients for ECPR who are most likely to benefit.

Conclusion (proposition de traduction) : La réanimation cardio-pulmonaire extracorporelle peut augmenter le taux de survie des patients ayant subi un arrêt cardiaque réfractaire, dont le taux de mortalité est généralement supérieur à 90 %. Cependant, la réanimation cardio-pulmonaire extracorporelle exige beaucoup de ressources et des recherches supplémentaires sont nécessaires pour clarifier le moment optimal d'administration de la réanimation cardio-pulmonaire extracorporelle et pour identifier les patients qui ont le plus de chances d'en bénéficier.

The Feasibility of Using Point-of-Care Ultrasound During Cardiac Arrest in Children: Rapid Apical Contractility Evaluation.
Leviter JI, Chen L, O'Marr J, Riera A. | Pediatr Emerg Care. 2023 May 1;39(5):347-350
DOI: https://doi.org/10.1097/pec.0000000000002741
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Resuscitation guidelines emphasize minimal interruption of compressions during cardiopulmonary resuscitation. Point-of-care ultrasound (POCUS) enables the clinician to visualize cardiac contractility and central artery pulsatility. The apical 4-chamber (A4), subxiphoid (SX), and femoral artery views may be used when defibrillator pads or active compressions preclude parasternal cardiac views. We hypothesized that clinicians can rapidly obtain interpretable POCUS views in healthy children from the A4, SX, and femoral positions.

Méthode : A prospective study of pediatric emergency medicine providers in an urban academic hospital was performed. Stable patients of 12 years or younger were scanned. Sonologists were each allotted 10 seconds to acquire A4, SX, and femoral views. Two attempts at each view were allowed. The primary outcome was whether cardiac and femoral artery scans were interpretable for contractility and pulsatility, respectively. The secondary outcome was whether cardiac scans were interpretable for effusion or right ventricular strain. A POCUS expert reviewed scans to confirm interpretability.

Résultats : Twenty-two sonologists performed a total of 50 scans on 22 patients. A view that was interpretable for contractility was obtained on the first attempt in 86% of A4 and 94% of SX scans. A femoral view that was interpretable for pulsatility was obtained on the first attempt in 74% of scans. Expert review was concordant with sonologist interpretation.

Conclusion : Pediatric emergency medicine physicians can obtain interpretable cardiac and central artery views within 10 seconds most of the time. Point-of-care ultrasound has the potential to enhance care during pediatric resuscitation. Future studies on the impact of POCUS pulse checks in actual pediatric resuscitations should be performed.

Conclusion (proposition de traduction) : Les urgentistes pédiatriques peuvent obtenir des images interprétables du cœur et de l'aorte en moins de 10 secondes la plupart du temps. L'échographie au point d'intervention a le potentiel d'améliorer les soins pendant la réanimation pédiatrique. De futures études sur l'impact des contrôles de pouls POCUS dans les réanimations pédiatriques réelles devraient être réalisées.

Prehospital Guidelines for the Management of Traumatic Brain Injury–3rdEdition.
Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. | Prehosp Emerg Care. 2023;27(5):507-538
DOI: https://doi.org/10.1080/10903127.2023.2187905  | Télécharger l'article au format  
Keywords: Aucun

BRAIN TRAUMA FOUNDATION TBI GUIDELINES

Editorial : Worldwide, 69 million people sustain traumatic brain injury(TBI) annually. The incidence of TBI in low- and mid-dle-income countries is three times greater than in high-income countries, with fatality rates ranging from as low as5.2/100,000/year in France to as high as 80.73/100,000/yearin South Africa.TBIs may range from mild, including concussions, tosevere, including coma and death. In general, a TBI is causedby a direct or indirect force to the brain that disrupts normalbrain function (3). The vast majority of TBIs are mild, butdistinguishing mild injury from more severe TBI in the pre-hospital setting may not be immediately apparent. Severe TBIis a leading cause of morbidity and mortality, resulting in2.87 million TBI-related emergency department visits, hospi-talizations, and deaths in the United States annually.Approximately one-third of these events occurred in child-ren. The likelihood of moderate-severe TBI is heightenedin any prehospital patient sustaining physical trauma withGlasgow Coma Scale (GCS) score<15, loss of consciousness,multisystem trauma requiring an advanced airway, or reportof post-traumatic seizure.

Conclusion : While this guideline informs best practices in care andhas identified important differences among pediatric andgeriatric populations, it did not evaluate the body of evi-dence pertaining to other demographical and medical differ-ences such as sex, specific region, race/ethnicity, insurerstatus, socioeconomical status, effect of other medical prob-lems on prehospital care determinants, and beyond. Theseimportant topics, along with those discussed in each topicalupdate’sFuture Interventionssection represent much workto be done to advance the quality of care provided topatients acutely following TBI. In general, the most mean-ingful effect to patient care occurs via high-quality con-trolled studies that include implementation plans.

Conclusion (proposition de traduction) : Bien que ce guide informe sur les meilleures pratiques en matière de soins et ait identifié des différences importantes entre les populations pédiatriques et gériatriques, il n'a pas évalué l'ensemble des données relatives à d'autres différences démographiques et médicales telles que le sexe, la région spécifique, la race/l'ethnie, le statut de l'assureur, le statut socio-économique, l'effet d'autres problèmes médicaux sur les déterminants des soins préhospitaliers, et au-delà. Ces sujets importants, ainsi que ceux discutés dans la section Interventions futures de chaque mise à jour, représentent beaucoup de travail à faire pour améliorer la qualité des soins fournis aux patients en phase aiguë après un traumatisme crânien. En général, l'effet le plus significatif sur les soins aux patients se produit par le biais d'études contrôlées de haute qualité qui incluent des plans de mise en œuvre.

Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement.
Berry C, Gallagher JM, Goodloe JM, Dorlac WC, Dodd J, Fischer PE. | Prehosp Emerg Care. 2023;27(5):544-551
DOI: https://doi.org/10.1080/10903127.2023.2195487  | Télécharger l'article au format  
Keywords: Aucun

POSITION STATEMENTS

Introduction : Exsanguination remains the leading cause of preventable death among victims of trauma. Foradult and pediatric trauma patients in the prehospital phase of care, methods to controlhemorrhage and hemostatic resuscitation are described in this joint consensus opinion by theAmerican College of Surgeons Committee on Trauma, the American College of EmergencyPhysicians, and the National Association of EMS Physicians.

Conclusion : Consensus-based guidance on prehospital hemorrhagecontrol and hemostatic resuscitation is described.
Where variations and differences of opinion are present,local protocols should be developed and followed.
Update local protocols based on a performance improve-ment process.
Ongoing continuing education to reinforce initial train-ing skills is strongly encouraged

Conclusion (proposition de traduction) : Des conseils consensuels sur le contrôle des hémorragies préhospitalières et la réanimation hémostatique sont décrits.
En cas de variations et de divergences d'opinion, des protocoles locaux doivent être élaborés et suivis.
Mettre à jour les protocoles locaux sur la base d'un processus d'amélioration des performances.
La formation continue pour renforcer les compétences de la formation initiale est fortement encouragée.

Prehospital Intubation of Patients with Severe Traumatic Brain Injury: A Dutch Nationwide Trauma Registry Analysis.
Bossers SM, Verheul R, van Zwet EW, Bloemers FW, Giannakopoulos GF, Loer SA, Schwarte LA, Schober P.. | Prehosp Emerg Care. 2023;27(5):662-668
DOI: https://doi.org/10.1080/10903127.2022.2119494  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Patients with severe traumatic brain injury (TBI) are commonly intubated during prehospital treatment despite a lack of evidence that this is beneficial. Accumulating evidence even suggests that prehospital intubation may be hazardous, in particular when performed by inexperienced EMS clinicians. To expand the limited knowledge base, we studied the relationship between prehospital intubation and hospital mortality in patients with severe TBI in a large Dutch trauma database. We specifically hypothesized that the relationship differs depending on whether a physician-based emergency medical service (EMS) was involved in the treatment, as opposed to intubation by paramedics.

Méthode : A retrospective analysis was performed using the Dutch Nationwide Trauma Registry that includes all trauma patients in the Netherlands who are admitted to any hospital with an emergency department. All patients treated for severe TBI (Head Abbreviated Injury Scale score ≥4) between January 2015 and December 2019 were selected. Multivariable logistic regression was used to assess the relationship between prehospital intubation and mortality while adjusting for potential confounders. An interaction term between prehospital intubation and the involvement of physician-based EMS was added to the model. Complete case analysis as well as multiple imputation were performed.

Résultats : 8946 patients (62% male, median age 63 years) were analyzed. The hospital mortality was 26.4%. Overall, a relationship between prehospital intubation and higher mortality was observed (complete case: OR 1.86, 95% CI 1.35-2.57, p < 0.001; multiple imputation: OR 1.92, 95% CI 1.56-2.36, p < 0.001). Adding the interaction revealed that the relationship of prehospital intubation may depend on whether physician-based EMS is involved in the treatment (complete case: p = 0.044; multiple imputation: p = 0.062). Physician-based EMS involvement attenuated but did not completely remove the detrimental association between prehospital intubation and mortality.

Conclusion : The data do not support the common practice of prehospital intubation. The effect of prehospital intubation on mortality might depend on EMS clinician experience, and it seems prudent to involve prehospital personnel well proficient in prehospital intubation whenever intubation is potentially required. The decision to perform prehospital intubation should not merely be based on the largely unsupported dogma that it is generally needed in severe TBI, but should rather individually weigh potential benefits and harms.

Conclusion (proposition de traduction) : Les données ne permettent pas de recommander la pratique courante de l'intubation préhospitalière. L'effet de l'intubation préhospitalière sur la mortalité pourrait dépendre de l'expérience du clinicien du SAMU, et il semble prudent d'impliquer le personnel préhospitalier qui maîtrise bien l'intubation préhospitalière chaque fois que l'intubation est potentiellement nécessaire. La décision de procéder à une intubation préhospitalière ne doit pas simplement se fonder sur le dogme largement non étayé selon lequel elle est généralement nécessaire en cas de lésion cérébrale traumatique grave, mais doit plutôt peser individuellement les avantages et les inconvénients potentiels.

Non-Invasive Ventilation in the Prehospital Emergency Setting: A Systematic Review and Meta-Analysis.
Scquizzato T, Imbriaco G, Moro F, Losiggio R, Cabrini L, Consolo F, Landoni G, Zangrillo A. | Prehosp Emerg Care. 2023;27(5):566-574
DOI: https://doi.org/10.1080/10903127.2022.2086331
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Noninvasive ventilation is a well-established treatment for acute respiratory failure, being increasingly applied in the prehospital setting. This systematic review and meta-analysis aims to investigate whether early prehospital initiation of noninvasive ventilation reduces mortality compared to standard oxygen therapy.

Méthode : We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 7^th, 2022, for studies comparing prehospital noninvasive ventilation performed by emergency medical services versus standard oxygen therapy in patients with acute respiratory failure. The primary outcome was mortality at the longest follow-up available.

Résultats : We included ten randomized studies and two quasi-randomized studies for a total of 1485 patients. Prehospital treatment with noninvasive ventilation compared with standard oxygen therapy did not significantly reduce mortality at the longest follow-up available (107/810 [13%] vs 114/772 [15%]; RR = 0.89; 95% CI, 0.70-1.13; P = 0.34; I²=24%). The endotracheal intubation rate was reduced when receiving prehospital noninvasive ventilation (38/776 [4.9%] vs 81/743 [11%]; RR = 0.44; 95% CI, 0.31-0.63; P < 0.001; I²=0%; number needed to treat 17). The intensive care admission rate (114/532 [21%] vs 129/507 [25%]; RR = 0.85; 95% CI, 0.69-1.04; P = 0.11; I²=0%) and length of hospital stay (mean difference=-1.29 days; 95% CI, -3.35-0.77; P = 0.21; I²=82%) were similar between groups.

Conclusion : Adults with acute respiratory failure treated in the prehospital setting with noninvasive ventilation had a lower risk of intubation than those managed with standard oxygen therapy, with similar risk of death, intensive care admission, and length of hospital stay.

Conclusion (proposition de traduction) : Les adultes souffrant d'insuffisance respiratoire aiguë traités en milieu préhospitalier par ventilation non invasive présentaient un risque d'intubation plus faible que ceux traités par oxygénothérapie standard, avec un risque similaire de décès, d'admission en soins intensifs et de durée de séjour à l'hôpital.

Impact of number of defibrillation attempts on neurologically favourable survival rate in patients with Out-of-Hospital cardiac arrest.
Tateishi K, Saito Y, Kitahara H, Shiko Y, Kawasaki Y, Nonogi H, Tahara Y, Yonemoto N, Nagao K, Ikeda T, Sato N, Kobayashi Y; Japanese Circulation Society Resuscitation Science Study JCS-ReSS Group. | Resuscitation. 2023 May;186:109779
DOI: https://doi.org/10.1016/j.resuscitation.2023.109779
Keywords: Defibrillation; Out-of-hospital cardiac arrest; Prehospital care; Survival.

CLINICAL PAPER

Introduction : Defibrillation plays a crucial role in early return of spontaneous circulation (ROSC) and survival of patients with out-of-hospital cardiac arrest (OHCA) and shockable rhythm. Prehospital adrenaline administration increases the probability of prehospital ROSC. However, little is known about the relationship between number of prehospital defibrillation attempts and neurologically favourable survival in patients treated with and without adrenaline.

Méthode : Using a nationwide Japanese OHCA registry database from 2006 to 2020, 1,802,084 patients with OHCA were retrospectively analysed, among whom 81,056 with witnessed OHCA and initial shockable rhythm were included. The relationship between the number of defibrillation attempts before hospital admission and neurologically favourable survival rate (cerebral performance category score of 1 or 2) at 1 month was evaluated with subgroup analysis for patients treated with and without adrenaline.

Résultats : At 1 month, 18,080 (22.3%) patients had a cerebral performance category score of 1 or 2. In the study population, the probability of prehospital ROSC and favourable neurological survival rate were inversely associated with number of defibrillation attempts. Similar trends were observed in patients treated without adrenaline, whereas a greater number of defibrillation attempts was counterintuitively associated with favourable neurological survival rate in patients treated with prehospital adrenaline.

Conclusion : Overall, a greater number of prehospital defibrillation attempts was associated with lower neurologically favourable survival at 1 month in patients with OHCA and shockable rhythm. However, an increasing number of shocks (up to the 4th shock) was associated with better neurological outcomes when considering only patients treated with adrenaline.

Conclusion (proposition de traduction) : Dans l'ensemble, un plus grand nombre de tentatives de défibrillation préhospitalière a été associé à une survie neurologique moins favorable à un mois chez les patients ayant subi un arrêt cardiaque en dehors de l'hôpital et présentant un rythme choquable. Cependant, un nombre croissant de chocs (jusqu'au 4ème choc) était associé à de meilleurs résultats neurologiques si l'on considère uniquement les patients traités à l'adrénaline.

Traumatic hemorrhage and chain of survival.
Latif RK, Clifford SP, Baker JA, Lenhardt R, Haq MZ, Huang J, Farah I, Businger JR. | Scand J Trauma Resusc Emerg Med. 2023 May 24;31(1):25
DOI: https://doi.org/10.1186/s13049-023-01088-8  | Télécharger l'article au format  
Keywords: Chain of survival algorithm in trauma; Damage control resuscitation; Damage control surgery; Diagnostic imaging in trauma; Traumatic hemorrhage.

REVIEW

Editorial : Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.

Conclusion : Traumatic hemorrhagic represents a serious therapeutic problem that results in high patient mortality when not managed properly. The time from injury to hospital admission, diagnosis, resuscitation, and definite hemo- stasis should be as abbreviated as possible. The patho-physiology of traumatic hemorrhage is complex, and imaging modalities are important to identify the source of bleeding. The application of damage control resuscitation (DCR), definitive hemostasis, and damage control surgery (DCS) have shown promising results in trauma patients. The guidelines for endpoints of resuscitation are developed but too limited in their scope to show clear outcome benefit at this point. Significant work remains in reducing the morbidity and mortality associated with traumatic hemorrhagic in areas of primary prevention, early recognition and accurate diagnosis, resuscitation therapy with hemostasis, and determination of resuscitation endpoints.

Conclusion (proposition de traduction) : L'hémorragie traumatique représente un problème thérapeutique majeur qui entraîne une mortalité élevée chez les patients lorsqu'elle n'est pas prise en charge correctement. Le temps écoulé entre la blessure et l'admission à l'hôpital, le diagnostic, la réanimation et l'hémostase définitive doit être aussi court que possible. La physiopathologie de l'hémorragie traumatique est complexe et les modalités d'imagerie sont importantes pour identifier la source du saignement. L'application de la réanimation de contrôle des dommages, de l'hémostase définitive et de la chirurgie de contrôle des dommages a donné des résultats prometteurs chez les patients traumatisés. Les lignes directrices relatives aux critères d'évaluation de la réanimation sont élaborées, mais leur champ d'application est trop limité pour que l'on puisse en tirer des avantages clairs à l'heure actuelle. Il reste encore beaucoup à faire pour réduire la morbidité et la mortalité associées à l'hémorragie traumatique dans les domaines de la prévention primaire, de la reconnaissance précoce et du diagnostic précis, de la thérapie de réanimation avec hémostase et de la détermination des critères d'évaluation de la réanimation.

Commentaire : 

Intranasal ketamine for procedural sedation in children: An open-label multicenter clinical trial.
Rached-d'Astous S, Finkelstein Y, Bailey B, Marquis C, Lebel D, Desjardins MP, Trottier ED. | Am J Emerg Med. 2023 May;67:10-16
DOI: https://doi.org/10.1016/j.ajem.2023.01.046
Keywords: Intranasal; Pain; Pediatrics; Procedural sedation.

Original contribution

Introduction : There are limited options for pain and distress management in children undergoing minor procedures, without the burden of an intravenous line insertion. Prior to this study, we conducted a dose-escalation study and identified 6 mg/kg as a potentially optimal initial dose of intranasal ketamine.
Objective: To assess the efficacy and safety of intranasal ketamine at a dose of 6 mg/kg for procedural sedation to repair lacerations with sutures in children in the emergency department.

Méthode : We conducted a single-arm, open-label multicenter clinical trial for intranasal ketamine for laceration repair with sutures in children aged 1 to 12 years. A convenience sample of 30 patients received 6 mg/kg of intranasal ketamine for their procedural sedation. The primary outcome was the proportion (95% CI) of patients who achieved an effective procedural sedation.

Résultats : We recruited 30 patients from April 2018 to December 2019 in two pediatric emergency departments in Canada. Lacerations repaired were mostly facial in 21(70%) patients and longer than 2 cm in 20 (67%) patients. Sedation was effective in 18/30 (60% [95% CI 45, 80]) children and was suboptimal in 5 (17%) patients but procedure was completed in them with minimal difficulties. Sedation was poor in the remaining 7 (23%) patients, with 3 (10%) of them required additional sedative agents. No serious adverse events were reported.

Conclusion : Using a single dose of 6 mg/kg of intranasal Ketamine for laceration repair led to successful sedation in 60% of patients according to our a priori definition. An additional 17% of patients were considered suboptimal, but their procedure was still completed with minimal difficulty.

Conclusion (proposition de traduction) : L'utilisation d'une dose unique de 6 mg/kg de kétamine intranasale pour la prise en charge de plaies a permis d'obtenir une sédation réussie chez 60 % des patients selon notre définition a priori. Dix-sept pour cent de patients supplémentaires ont été considérés comme sous-optimaux, mais l'intervention s'est tout de même déroulée avec un minimum de difficultés.

Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route.
Yang SC, Hsu YH, Chang YH, Chien LT, Chen IC, Chiang WC. | Am J Emerg Med. 2023 May;67:63-69
DOI: https://doi.org/10.1016/j.ajem.2023.02.003
Keywords: Advanced life support (ALS); Epinephrine; Intraosseous (IO); Intravenous (IV); Out-of-hospital cardiac arrest (OHCA).

Original contribution

Introduction : The benefits and risks of the intraosseous (IO) route for vascular access in patients with out-of-hospital cardiac arrest (OHCA) remain controversial. This study compares the success rates of establishing the access route, epinephrine administration rates, and time-to-epinephrine between adult patients with OHCA with IO access and those with intravenous (IV) access established by paramedics in the prehospital setting.

Méthode : This was a retrospective study conducted by the San-Min station of Taoyuan Fire Department. Data for IV access were collected between January 1, 2020, and December 31, 2020. Data for IO access were collected between January 1, 2021, and March 10, 2021. Inclusion criteria were adult patients with OHCA who received on-scene resuscitation attempts and in whom either IV or IO route access was established by paramedics. Exclusion criteria were missing data, return of spontaneous circulation before establishing vascular access, cardiac arrest en route to hospital, patients not resuscitated, and OHCA unidentified by the dispatcher. Exposure was defined as IV route vs. IO route (EZ-IO®). The outcome measurements were per-patient based success rates of route establishment (successes/attempts), administration rates of epinephrine (epinephrine administered per case/enrolled OHCAs), and odds ratios of IV versus IO on epinephrine administration. We used nonparametric Mann-Whitney rank sum tests for the analysis in continuous variables and Fisher's exact tests for the analysis of categorical variables and the outcomes. Firth logistic regression method was used for sparse data. Factors associated with epinephrine administration other than vascular access were also analyzed. Time-to-epinephrine (defined as time from paramedic arrival to epinephrine injection) was reviewed and calculated by two independent observers and the Kaplan-Meier method was used to compare the two access routes.

Résultats : A total of 112 adult patients were enrolled in the analysis, including 71 men and 41 women, with an average age of 67 years. There were 90 IV access cases and 22 IO access cases. The groups were compared for median success rates of route establishment (33% vs. 100%, P < 0.001) and administration rates of epinephrine (52% vs. 100%, P < 0.001). The adjusted odds ratio of IO versus IV was 32.445, 95% confidence interval (CI) of 1.844-570.861. Time-to-epinephrine was significantly shorter in the cumulative time-event analysis by the Kaplan-Meier method (P < 0.001).

Conclusion : The IO route was significantly associated with higher success rates of route establishment, epinephrine administration, and shorter time-to-epinephrine in the prehospital resuscitation of adult patients with OHCA.

Conclusion (proposition de traduction) : La voie IO a été associée de manière significative à des taux de réussite plus élevés pour l'établissement de la voie, l'administration d'adrénaline et un délai plus court pour l'administration d'adrénaline lors de la réanimation préhospitalière de patients adultes victimes d'un arrêt cardiaque extrahospitalier.

Peri-Intubation Arrest in High Risk vs. Standard Risk Pediatric Trauma Patients Undergoing Endotracheal Intubation.
VanDeWall A, Harris-Kober S, Farooqi A, Kannikeswaran N. | Am J Emerg Med. 2023 May;67:79-83
DOI: https://doi.org/10.1016/j.ajem.2023.02.014
Keywords: Cardiac arrest; Intubation; Pediatric; Trauma.

Original contribution

Introduction : While the anatomically difficult airway has been studied in pediatric trauma patients, physiologic risk factors are poorly understood. Our objective was to evaluate if previously published high risk physiologic criteria for difficult airway in medical patients is associated with adverse outcomes in pediatric trauma patients.

Méthode : This was a retrospective chart review of patients ≤18 years with traumatic injuries who underwent endotracheal intubation (EI) in a pediatric emergency department (PED) between 2016 and 2021. High risk criteria evaluated included 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation. Our primary outcome was peri-intubation cardiac arrest, defined as cardiac arrest within 10 minutes of EI. Secondary outcomes included in-hospital cardiac arrest and mortality and first pass EI success.

Résultats : One third (n = 32; 36.4%) of the 88 patients analyzed had at least one high risk criteria. When compared to the standard risk group, those in the high risk group had a higher incidence of peri-intubation arrest (28.1% vs. 0%, difference: 28.1%, 95% CI: 10.1-46.2), PED/in-hospital arrest (43.8% vs. 3.4%, difference: 38.4%, 95% CI: 17.8-59.0) and in-hospital mortality (33.4% vs. 3.6%, difference: 29.8%, 95% CI: 8.4-46.9). Having multiple high risk criteria progressively increased the odds of post-intubation PED/in-hospital cardiac arrest (1 risk factor: OR = 6.7, 95% CI: 1.5-30.2; 2 risk factors: OR = 12.5, 95% CI: 2.3-70.0; ≥ 3 risk factors: OR = 56.1, 95% CI: 6.0-523.8).

Conclusion : The presence of high risk physiologic criteria is associated with increased incidence of peri-intubation, in-hospital arrest, and death in pediatric trauma patients. Children with multiple risk factors are at an incremental risk of cardiac arrest.

Conclusion (proposition de traduction) : La présence de critères de risque élevé est associée à des incidents plus fréquents au cours de l'intubation, d'arrêt cardiaque à l'hôpital et de décès chez les enfants victimes de traumatismes. Les enfants présentant plusieurs facteurs de risque sont exposés à un risque accru d'arrêt cardiaque.

Commentaire : Les critères à haut risque évalués comprenaient :
1) l'hypotension :
2) la possibilité d'un dysfonctionnement cardiaque :
3) l'hypoxémie persistante :
4) l'acidose métabolique sévère (pH < 7,1) :
5) le rétablissement de la circulation spontanée après l'intubation.

Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity.
Ota S, Takeuchi I, Hamada M, Fujita W, Muramatsu KI, Nagasawa H, Jitsuiki K, Ohsaka H, Ishikawa K, Mogami A, Yanagawa Y. | Am J Emerg Med. 2023 May;67:108-111
DOI: https://doi.org/10.1016/j.ajem.2023.02.029
Keywords: Bladder shape; Pelvic fracture; Shock.

Original contribution

Introduction : That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF.

Méthode : From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups.

Résultats : During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group.

Conclusion : The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF.

Conclusion (proposition de traduction) : La présente étude a montré que la déformation de la vessie induite par une fracture du bassin tendait à être un signe de mauvais état physiologique associé à une anomalie anatomique grave, à une instabilité de la circulation sanguine nécessitant une transfusion et à une longue hospitalisation. Par conséquent, les médecins devraient évaluer la forme de la vessie lors du traitement d'une fracture du bassin.

Agreement of Oscillometric and Auscultatory blood pressure measurement methods: An ambulance noise simulation study.
Tatliparmak AC, Yilmaz S. | Am J Emerg Med. 2023 May;67:120-125
DOI: https://doi.org/10.1016/j.ajem.2023.02.022
Keywords: Ambulance noise; Auscultatory blood pressure measurement; Blood pressure measurement method; Oscillometric blood pressure measurement.

Original contribution

Introduction : Although noise is known to negatively affect blood pressure (BP) measurements, its impact on different BP measurement methods remains unclear. The aim of this study is to compare the agreement of oscillometric and auscultatory BP measurement methods under in-ambulance noise levels.

Méthode : This method-comparison study was conducted on 50 healthy volunteers in a tertiary emergency department (ED). Participants were divided into two groups of 25, and BP was measured using auscultatory and oscillometric methods in noisy and ambient environments by 2 emergency medicine technicians (EMT). The primary object of the study was to compare the agreement of auscultatory mercury sphygmomanometers and automated auscillometric BP measurements in ambient and noisy environments.

Résultats : We examined the agreement between auscultative and oscillometric measurements of BP conducted in an ambient environment (46.75 [IQR (41.2--55.18)] dB) and found that both systolic and diastolic BP were within the level of agreement (LoA) established before the study (systolic BP [-13.96 to 8.48 mmHG], diastolic BP [-7.44 to 8.08 mmHg]); whereas, in noisy environment (92.35 [IQR 88-96.55] dB) both systolic and diastolic BP were outside the range of LoA (systolic BP [-37.77 to 9.94 mmHg], diastolic BP [-21.73 to 16.37 mmHg]). Additionally, we found that in ambient environments, concordance correlation coefficients were higher than in noisy environments (0.943 [0.906-0.966], 0.957 [0.93-0.974]; 0.574 [0.419-0.697], 0.544 [0.326-0.707]; systolic and diastolic BP, respectively).

Conclusion : The results of this study demonstrate that noise significantly affects the agreement between oscillometric and auscultatory blood pressure measurement methods.

Conclusion (proposition de traduction) : Les résultats de cette étude démontrent que le bruit affecte de manière significative la concordance entre les méthodes de mesure de la pression sanguine oscillométrique et auscultatoire.

Acute rate control with metoprolol versus diltiazem in atrial fibrillation with heart failure with reduced ejection fraction.
Kapustova K, Phan B, Allison-Aipa T, Choi M. | Am J Emerg Med. 2023 May;67:126-129
DOI: https://doi.org/10.1016/j.ajem.2023.02.019
Keywords: Atrial fibrillation; Heart failure with reduced ejection fraction.

Original contribution

Introduction : Compare heart rate control between parenteral metoprolol and diltiazem and identify safety outcomes in the acute management of atrial fibrillation (AFib) with rapid ventricular response (RVR) in patients with heart failure with reduced ejection fraction (HFrEF).

Méthode : This retrospective, single-center, cohort study included adult patients with HFrEF who received intravenous (IV) metoprolol or diltiazem for AFib RVR in the emergency department (ED). The primary outcome was rate control defined as HR <100 bpm or a HR reduction ≥20% within 30 min of first dose administration. The secondary outcomes included rate control within 60 min and 120 min from first dose, need for repeat dosing, and disposition. Safety outcomes included hypotensive and bradycardic events.

Résultats : Out of 552 patients, 45 patients met the inclusion criteria with 15 in the metoprolol group and 30 in the diltiazem group. Using bootstrapping method, patients treated with metoprolol were equally able to reach the primary outcome as those treated with diltiazem (BCa 95% CI: 0.14, 4.31). Hypotensive and bradycardia events remained zero in both groups.

Conclusion : Our study provides further evidence that short term use of diltiazem is likely as safe and effective as metoprolol in the acute management of HFrEF patients with AFib RVR and provides support for the use of non-dihydropyridine calcium channel blockers (non-DHP CCBs) in this patient population.

Conclusion (proposition de traduction) : Notre étude apporte des preuves supplémentaires que l'utilisation à court terme du diltiazem est probablement aussi sûre et efficace que le métoprolol dans le traitement aigu des patients souffrant d'insuffisance cardiaque avec fraction d'éjection altérée et de la fibrillation atriale avec réponse ventriculaire rapide, et confirme l'utilisation d'inhibiteurs calciques non-dihydropyridiniques (ndlr : inhibiteurs calciques comme le vérapamil et le diltiazem) dans cette population de patients.

Bystander basic life support and survival after out-of-hospital cardiac arrest: A propensity score matching analysis.
Lafrance M, Recher M, Javaudin F, Chouihed T, Wiel E, Helft G, Hubert H, Canon V; GR-RéAC. | Am J Emerg Med. 2023 May;67:135-143
DOI: https://doi.org/10.1016/j.ajem.2023.02.028  | Télécharger l'article au format  
Keywords: Basic life support; Bystander; Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest; Propensity score.

Original contribution

Introduction : In out-of-hospital cardiac arrest, early recognition, calling for emergency medical assistance, and early cardiopulmonary resuscitation are acknowledged to be the three most important components in the chain of survival. However, bystander basic life support (BLS) initiation rates remain low. The objective of the present study was to evaluate the association between bystander BLS and survival after an out-of-hospital cardiac arrest (OHCA).

Méthode : We conducted a retrospective cohort study of all patients with OHCA with a medical etiology treated by a mobile intensive care unit (MICU) in France from July 2011 to September 2021, as recorded in the French National OHCA Registry (RéAC). Cases in which the bystander was an on-duty fire fighter, paramedic, or emergency physician were excluded. We assessed the characteristics of patients who received bystander BLS vs. those who did not. The two classes of patient were then matched 1:1, using a propensity score. Conditional logistic regression was then used to probe the putative association between bystander BLS and survival.

Résultats : During the study, 52,303 patients were included; BLS was provided by a bystander in 29,412 of these cases (56.2%). The 30-day survival rates were 7.6% in the BLS group and 2.5% in the no-BLS group (p < 0.001). After matching, bystander BLS was associated with a greater 30-day survival rate (odds ratio (OR) [95% confidence interval (CI)] = 1.77 [1.58-1.98]). Bystander BLS was also associated with greater short-term survival (alive on hospital admission; OR [95%CI] = 1.29 [1.23-1.36]).

Conclusion : The provision of bystander BLS was associated with a 77% greater likelihood of 30-day survival after OHCA. Given than only one in two OHCA bystanders provides BLS, a greater focus on life saving training for laypeople is essential.

Conclusion (proposition de traduction) : La mise en œuvre d'une réanimation par un témoin a été associée à une probabilité accrue de 77 % de survie à 30 jours après un arrêt cardiaque extrahospitalier. Étant donné que seule une personne sur deux ayant assisté à un arrêt cardiaque en dehors de l'hôpital a prodigué des soins d'urgence, il est essentiel de mettre davantage l'accent sur la formation des citoyens ordinaires en matière de secourisme.

High risk and low prevalence diseases: Toxic alcohol ingestion..
Inman B, Maddry JK, Ng PC, Koyfman A, Long B. | Am J Emerg Med. 2023 May;67:29-36
DOI: https://doi.org/10.1016/j.ajem.2023.01.048
Keywords: Diethylene glycol; Ethylene glycol; Isopropyl alcohol; Methanol; Propylene glycol; Toxic alcohol; Toxicology.

Review

Introduction : Toxic alcohol ingestion is a rare but serious condition that carries with it a high rate of morbidity and mortality.

Méthode : This review highlights the pearls and pitfalls of toxic alcohol ingestion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion : Toxic alcohols include ethylene glycol, methanol, isopropyl alcohol, propylene glycol, and diethylene glycol. These substances can be found in several settings including hospitals, hardware stores, and the household, and ingestion can be accidental or intentional. Toxic alcohol ingestion presents with various degrees of inebriation, acidemia, and end-organ damage depending on the substance. Timely diagnosis is critical to prevent irreversible organ damage or death and is based primarily on clinical history and consideration of this entity. Laboratory evidence of toxic alcohol ingestion includes worsening osmolar gap or anion-gap acidemia and end organ injury. Treatment depends on the ingestion and severity of illness but includes alcohol dehydrogenase blockade with fomepizole or ethanol and special considerations for the initiation of hemodialysis.

Conclusion : An understanding of toxic alcohol ingestion can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Conclusion (proposition de traduction) : Il existe plusieurs types d'alcools similaires, dont le méthanol, l'éthylène glycol, le diéthylène glycol, le propylène glycol et l'alcool isopropylique. Les patients peuvent présenter divers signes et symptômes, mais l'ingestion peut entraîner des complications graves. L'ingestion de ces alcools toxiques peut entraîner une intoxication, un coma, une acidémie métabolique, une insuffisance rénale (éthylène glycol et diéthylène glycol), une cécité (méthanol), des lésions neurologiques et la mort. Le traitement de l'intoxication par l'éthylène glycol et le méthanol consiste à bloquer l'enzyme alcool déshydrogénase à l'aide de l'antidote fomépizole ou d'éthanol. En cas de toxicité importante, l'hémodialyse peut être indiquée. En cas d'intoxication au diéthylène glycol, l'hémodialyse est indiquée après l'administration de fomépizole.

Ondansetron Safety Regarding Prolong QTc for Children with Head Trauma.
Assaad R, Pratt RE, Wrotniak BH, Qiao H, Territo HM. | J Emerg Med. 2023 May;64(5):647-651
DOI: https://doi.org/10.1016/j.jemermed.2023.03.052
Keywords: Zofran; children; head trauma; ondansetron; prolong QTc.

Pharmacology in Emergency Medicine

Introduction : There have been recent reports of increased QT interval after head trauma in concussed athletes and adult patients. Ondansetron, which is widely used in treatment of nausea and vomiting symptoms in head injuries, was issued a safety warning from the U.S. Food and Drug Administration regarding QT prolongation and risk of fatal dysrhythmias. Objective: The purpose of this study was to evaluate the safety of ondansetron regarding QT prolongation for patients experiencing nausea or vomiting after head trauma.

Méthode : Patients aged 1-20 years presenting to a pediatric emergency department with head trauma and who required a dose of ondansetron for nausea or vomiting were enrolled in the study. Patients received a baseline 12-lead electrocardiogram (ECG) prior to administration of either oral or IV ondansetron. A second post-ondansetron 12-lead ECG was performed after administration of ondansetron. All ECGs were reviewed and the QTc calculated manually by a board-certified pediatric cardiologist.

Résultats : Forty-two patients met enrollment criteria. Five patients received IV ondansetron and 37 received oral ondansetron. Mean QTc pre ondansetron was 387.5 ms and mean QTc post ondansetron was 400.9 ms (p = 0.120). We found no statistically significant difference in other ECG parameters pre and post ondansetron.

Conclusion : Ondansetron is safe in regard to QTc prolongation in patients with head trauma. Based on this research, ondansetron should continue to be used for the treatment of nausea and vomiting in emergency department patients who present with head injury.

Conclusion (proposition de traduction) : L'ondansétron est sûr en ce qui concerne l'allongement de l'intervalle QTc chez les patients ayant subi un traumatisme crânien. Sur la base de cette recherche, l'ondansétron devrait continuer à être utilisé pour le traitement des nausées et des vomissements chez les patients des services d'urgence qui présentent un traumatisme crânien.

Novel equation successfully calculates tidal volumes for lung protective ventilation.
Self M, Mun C, Goodrich A, Schmidt U. | J Emerg Med. 2023 Jul;65(1):e1-e8
DOI: https://doi.org/10.1016/j.jemermed.2023.04.007  | Télécharger l'article au format  
Keywords: ARDS; critical care; lung protective ventilation; mechanical ventilation.

Original Contribution

Introduction : Early application of low-tidal-volume ventilation (LTVV) has been associated with improved outcomes in the emergency department (ED) and intensive care unit (ICU), but is not consistently applied. The perceived complexity of calculating an ideal body weight (IBW)-based tidal volume (Vt) may contribute to this disparity. We hypothesized that a simplified equation could successfully predict LTVV.
Objective: To create a memorable, single-step, sex-independent equation to estimate LTVV based on height.

Méthode : We conducted a retrospective observational cohort study of patients who received mechanical ventilation (MV) at 2 EDs from January 2016 to June 2019. Data were abstracted by automatic query. Patients < 18 years old, < 60 inches in height, and with implausible or incomplete data were excluded. LTVV was defined as ≤ 8 mL/kg IBW. We created a formula predicting a 6-8-mL/kg IBW Vt. We applied this formula to a population of ICU patients in the same health care system who received MV from January 2017 to December 2019 using the same exclusion criteria. The outcome was whether the equation predicted a 6-8-mL/kg IBW Vt.

Résultats : A total of 982 ED patients were included; 753 (76.7%) had an initial Vt < 8 mL/kg IBW. The equation Vt = 20*(Ht-60) + 300 was derived. A total of 3720 ICU patients were included. The Vt equation successfully predicted a Vt of 6-8 mL/kg IBW in 3720 (100%) of ICU patients.

Conclusion : A novel equation successfully predicted a 6-8-mL/kg IBW Vt in a cohort of patients with height ≥ 60 inches.

Conclusion (proposition de traduction) : La nouvelle équation a permis de prédire avec succès un Vt de 6-8 ml/kg de poids corporel idéal dans une cohorte de patients d'une taille ≥ 152 cm.

Hydrocortisone in Severe Community-Acquired Pneumonia.
Dequin PF, Meziani F, Quenot JP, Kamel T, Ricard JD, Badie J, Reignier J, Heming N, Plantefève G, Souweine B, Voiriot G, Colin G, Frat JP, Mira JP, Barbarot N, François B, Louis G, Gibot S, Guitton C, Giacardi C, Hraiech S, Vimeux S, L'Her E, Faure H, Herbrecht JE, Bouisse C, Joret A, Terzi N, Gacouin A, Quentin C, Jourdain M, Leclerc M, Coffre C, Bourgoin H, Lengellé C, Caille-Fénérol C, Giraudeau B, Le Gouge A; CRICS-TriGGERSep Network. | N Engl J Med. 2023 May 25;388(21):1931-1941
DOI: https://doi.org/10.1056/nejmoa2215145  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Whether the antiinflammatory and immunomodulatory effects of glucocorticoids may decrease mortality among patients with severe community-acquired pneumonia is unclear.

Méthode : In this phase 3, multicenter, double-blind, randomized, controlled trial, we assigned adults who had been admitted to the intensive care unit (ICU) for severe community-acquired pneumonia to receive intravenous hydrocortisone (200 mg daily for either 4 or 7 days as determined by clinical improvement, followed by tapering for a total of 8 or 14 days) or to receive placebo. All the patients received standard therapy, including antibiotics and supportive care. The primary outcome was death at 28 days.

Résultats : A total of 800 patients had undergone randomization when the trial was stopped after the second planned interim analysis. Data from 795 patients were analyzed. By day 28, death had occurred in 25 of 400 patients (6.2%; 95% confidence interval [CI], 3.9 to 8.6) in the hydrocortisone group and in 47 of 395 patients (11.9%; 95% CI, 8.7 to 15.1) in the placebo group (absolute difference, -5.6 percentage points; 95% CI, -9.6 to -1.7; P = 0.006). Among the patients who were not undergoing mechanical ventilation at baseline, endotracheal intubation was performed in 40 of 222 (18.0%) in the hydrocortisone group and in 65 of 220 (29.5%) in the placebo group (hazard ratio, 0.59; 95% CI, 0.40 to 0.86). Among the patients who were not receiving vasopressors at baseline, such therapy was initiated by day 28 in 55 of 359 (15.3%) of the hydrocortisone group and in 86 of 344 (25.0%) in the placebo group (hazard ratio, 0.59; 95% CI, 0.43 to 0.82). The frequencies of hospital-acquired infections and gastrointestinal bleeding were similar in the two groups; patients in the hydrocortisone group received higher daily doses of insulin during the first week of treatment.

Conclusion : Among patients with severe community-acquired pneumonia being treated in the ICU, those who received hydrocortisone had a lower risk of death by day 28 than those who received placebo.

Conclusion (proposition de traduction) : Parmi les patients présentant une pneumonie sévère acquise communautaire et traités en soins intensifs, ceux qui ont reçu de l'hydrocortisone avaient un risque de décès plus faible au 28e jour que ceux qui ont reçu un placebo.