Head computed tomography findings in geriatric emergency department patients with delirium, altered mental status, and confusion: A systematic review.
Liu SW, Lee S, Hayes JM, Khoujah D, Lo AX, Doering M, de Wit K; Geriatric Emergency Department Delirium Guidelines Group. | Acad Emerg Med. 2023 Jun;30(6):616-625
DOI: https://doi.org/10.1111/acem.14622
Keywords: Aucun

SYSTEMATIC REVIEWS (WITH OR WITHOUT META-ANALYSES)

Introduction : Delirium, altered mental status (AMS), or confusion among older adults are common presentations to the emergency department (ED). We aimed to report the proportion of older ED patients presenting with delirium who have acute abnormal findings on head imaging. We also assessed whether anticoagulation, neurological deficits, trauma, or headache were associated with head imaging abnormalities in these patients.

Méthode : A systematic review was performed using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8, 2021. Citations were included if they described patients aged 65 years or older who received neuroimaging at the time of ED assessment for delirium, confusion, or AMS. Screening, data extraction, and bias assessment were performed in duplicate. The estimated proportion of patients with abnormal neuroimaging and odds ratios (ORs) for each predictor were calculated.

Résultats : The search strategy identified 3014 unique citations, of which six studies reporting on 909 patients with confusion or AMS were included. None of the studies formally diagnosed delirium. Overall, the proportions of older ED patients with AMS or confusion were found to have an abnormal head computed tomography (CT) was 15.6% (95% confidence interval [CI] 7.3%-26.2%). The prevalence of focal neurologic findings was 13.0% (66/506) and for anticoagulation was 9.8% (33/337) among the studies who reported them. The presence of a focal neurological deficit was associated with abnormal head CT (OR 101.8, 95% CI 30.5-340.1). Anticoagulation was not associated with abnormal head CT (OR 1.2, 95% CI 0.4-3.3). No studies reported on the association between headache or trauma and abnormal neuroimaging.

Conclusion : The proportion of abnormal findings on CT neuroimaging in older ED patients with AMS or confusion was 15.6%. The presence of a focal neurological deficit was a strong predictor for the presence of acute abnormality, whereas anticoagulation was not.

Conclusion (proposition de traduction) : La proportion de résultats anormaux à la tomodensitométrie cérébrale chez les patients âgés des services d'urgence présentant une altération de l'état mental ou une confusion était de 15,6 %. La présence d'un déficit neurologique focal était un facteur prédictif important de la présence d'une anomalie aiguë, alors que l'anticoagulation ne l'était pas.

Thoracic point-of-care ultrasound is an accurate diagnostic modality for clinically significant traumatic pneumothorax.
DeMasi S, Parker MS, Joyce M, Mulligan K, Feeser S, Balderston JR. | Acad Emerg Med. 2023 Jun;30(6):653-661
DOI: https://doi.org/10.1111/acem.14663  | Télécharger l'article au format  
Keywords: emergency department; point-of-care ultrasound; thoracic ultrasound; traumatic pneumothorax.

ORIGINAL ARTICLE

Introduction : There are conflicting data regarding the accuracy of thoracic point-of-care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by emergency physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients.

Méthode : We conducted a retrospective institutional review board-approved study of trauma patients 15 years or older presenting to our urban Level I academic trauma center from December 2021 to June 2022. All study patients were imaged with single-view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound (US) with tube thoracostomy placement.

Résultats : A total of 846 patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant PTXs (defined as ≥35 mm of pleural separation on a blinded overread or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% confidence interval [CI] 58-97), specificity of 100% (95% CI 99-100), positive predictive value of 81% (95% CI 54%-95%), and negative predictive value of 100% (95% CI 99%-100%). The positive likelihood ratio was 484 and the negative likelihood ratio was 0.1. CXR identified eight (53%) clinically significant PTXs, with a sensitivity of 53% (95% CI 27%-78%) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert-blinded overread was failure to recognize a lung point sign that was present on US.

Conclusion : Thoracic POCUS accurately identifies the majority of clinically significant PTXs in both blunt and penetrating trauma patients. Common themes for false-negative thoracic US in the expert-blinded overread process identified key gaps in training to inspire US education and medical education research.

Conclusion (proposition de traduction) : L'échographie thoracique au point d'intervention permet d'identifier avec précision la majorité des pneumothorax cliniquement significatifs chez les patients présentant un traumatisme contondant ou pénétrant. Les points communs de l'échographie thoracique faussement négative dans le processus de relecture à l'insu des experts ont permis d'identifier les principales carences en matière de formation, ce qui devrait servir de base à l'enseignement de l'échographie thoracique et à la recherche dans le domaine de l'enseignement médical.

Diagnostic testing for evaluation of brief resolved unexplained events.
Mittal MK, Tieder JS, Westphal K, Sullivan E, Hall M, Bochner R, Cohen A, Colgan JY, Delaney AC, DeLaroche AM, Graf T, Harper B, Kaplan RL, Neubauer HC, Neuman MI, Shastri N, Wilkins V, Stephans A. | Acad Emerg Med. 2023 Jun;30(6):662-670
DOI: https://doi.org/10.1111/acem.14666
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Since the publication of the American Academy of Pediatrics (AAP) clinical practice guideline for brief resolved unexplained events (BRUEs), a few small, single-center studies have suggested low yield of diagnostic testing in infants presenting with such an event. We conducted this large retrospective multicenter study to determine the role of diagnostic testing in leading to a confirmatory diagnosis in BRUE patients.

Méthode : Secondary analysis from a large multicenter cohort derived from 15 hospitals participating in the BRUE Quality Improvement and Research Collaborative. The study subjects were infants < 1 year of age presenting with a BRUE to the emergency departments (EDs) of these hospitals between October 1, 2015, and September 30, 2018. Potential BRUE cases were identified using a validated algorithm that relies on administrative data. Chart review was conducted to confirm study inclusion/exclusion, AAP risk criteria, final diagnosis, and contribution of test results. Findings were stratified by ED or hospital discharge and AAP risk criteria. For each patient, we identified whether any diagnostic test contributed to the final diagnosis. We distinguished true (contributory) results from false-positive results.

Résultats : Of 2036 patients meeting study criteria, 63.2% were hospitalized, 87.1% qualified as AAP higher risk, and 45.3% received an explanatory diagnosis. Overall, a laboratory test, imaging, or an ancillary test supported the final diagnosis in 3.2% (65/2036, 95% confidence interval [CI] 2.7%-4.4%) of patients. Out of 5163 diagnostic tests overall, 1.1% (33/2897, 95% CI 0.8%-1.5%) laboratory tests and 1.5% (33/2266, 95% CI 1.0%-1.9%) of imaging and ancillary studies contributed to a diagnosis. Although 861 electrocardiograms were performed, no new cardiac diagnoses were identified during the index visit.

Conclusion : Diagnostic testing to explain BRUE including for those with AAP higher risk criteria is low yield and rarely contributes to an explanation. Future research is needed to evaluate the role of testing in more specific, at-risk populations.

Conclusion (proposition de traduction) : Les tests diagnostiques visant à analyser les événements inexpliqués de courte durée, y compris chez les personnes présentant des critères de risque plus élevés selon l'American Academy of Pediatrics, ont un faible rendement et contribuent rarement à l'élaboration d'une explication. De futures recherches sont nécessaires pour évaluer le rôle des examens dans des populations à risque plus spécifiques.

Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial.
Marx T, Joly LM, Parmentier AL, Pretalli JB, Puyraveau M, Meurice JC, Schmidt J, Tiffet O, Ferretti G, Lauque D, Honnart D, Al Freijat F, Dubart AE, Grandpierre RG, Viallon A, Perdu D, Roy PM, El Cadi T, Bronet N, Duncan G, Cardot G, Lestavel P, Mauny F, Desmettre T. | Am J Respir Crit Care Med. 2023 Jun 1;207(11):1475-1485
DOI: https://doi.org/10.1164/rccm.202110-2409oc
Keywords: first-line strategy; primary spontaneous pneumothorax; simple aspiration.

Original article

Introduction : Management of first episodes of primary spontaneous pneumothorax remains the subject of debate.
Objectives: To determine whether first-line simple aspiration is noninferior to first-line chest tube drainage for lung expansion in patients with complete primary spontaneous pneumothorax.

Méthode : We conducted a prospective, open-label, randomized noninferiority trial. Adults aged 18-50 years with complete primary spontaneous pneumothorax (total separation of the lung from the chest wall), recruited at 31 French hospitals from 2009 to 2015, received simple aspiration (n = 200) or chest tube drainage (n = 202) as first-line treatment. The primary outcome was pulmonary expansion 24 hours after the procedure. Secondary outcomes were tolerance of treatment, occurrence of adverse events, and recurrence of pneumothorax within 1 year. Substantial discordance in the numerical inputs used for trial planning and the actual trial rates of the primary outcome resulted in a reevaluation of the trial analysis plan.

Résultats : Treatment failure occurred in 29% in the aspiration group and 18% in the chest tube drainage group (difference in failure rate, 0.113; 95% confidence interval [CI], 0.026-0.200). The aspiration group experienced less pain overall (mean difference, -1.4; 95% CI, -1.89, -0.91), less pain limiting breathing (frequency difference, -0.18; 95% CI, -0.27, -0.09), and less kinking of the device (frequency difference, -0.05; 95% CI, -0.09, -0.01). Recurrence of pneumothorax was 20% in this group versus 27% in the drainage group (frequency difference, -0.07; 95% CI, -0.16, +0.02).

Conclusion : First-line management of complete primary spontaneous pneumothorax with simple aspiration had a higher failure rate than chest tube drainage but was better tolerated with fewer adverse events.

Conclusion (proposition de traduction) : La prise en charge en première intention d'un pneumothorax spontané primitif complet par aspiration simple présente un taux d'échec plus élevé que le drainage du drain thoracique, mais est mieux tolérée avec moins d'effets indésirables.

Changes in Practice of Controlled Hypothermia after Cardiac Arrest in the Past 20 Years: A Critical Care Perspective.
Nielsen N, Friberg H. | Am J Respir Crit Care Med. 2023 Jun 15;207(12):1558-1564
DOI: https://doi.org/10.1164/rccm.202211-2142cp
Keywords: cardiac arrest; functional outcome; heart arrest; hypothermia; targeted temperature management.

Critical Care Perspective

Editorial : For 20 years, induced hypothermia and targeted temperature management have been recommended to mitigate brain injury and increase survival after cardiac arrest. On the basis of animal research and small clinical trials, the International Liaison Committee on Resuscitation strongly advocated hypothermia at 32-34 °C for 12-24 hours for comatose patients with out-of-hospital cardiac arrest with initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia. The intervention was implemented worldwide. In the past decade, hypothermia and targeted temperature management have been investigated in larger clinical randomized trials focusing on target temperature depth, target temperature duration, prehospital versus in-hospital initiation, nonshockable rhythms, and in-hospital cardiac arrest. Systematic reviews suggest little or no effect of delivering the intervention on the basis of the summary of evidence, and the International Liaison Committee on Resuscitation today recommends only to treat fever and keep body temperature below 37.5 °C (weak recommendation, low-certainty evidence). Here we describe the evolution of temperature management for patients with cardiac arrest during the past 20 years and how the accrued evidence has influenced not only the recommendations but also the guideline process. We also discuss possible paths forward in this field, bringing up both whether fever management is at all beneficial for patients with cardiac arrest and which knowledge gaps future clinical trials in temperature management should address.

Conclusion : Our conclusion on the basis of the trajectory of hypothermia and targeted temperature management during the past 20 years is that we are at a node at which we ought to try to explore in detail whether the promising signals from earlier animal research, case reports, and small clinical trials are real, while we simultaneously explore the realms of fever and fever treatment, which are so far uncharted waters. One could argue that we could have come to this node earlier if we had worked more systematically, in larger research networks guided by strategies for sound research methodology and focusing on the hard facts. We believe that one valid consideration is to not act prematurely on early promising findings but to demand continued methodological research until firm evidence is established and uncertainties have been limited as much as possible. However, the increased interest in the cardiac arrest population overall over these 20 years, to a certain extent triggered by hypothermia and targeted temperature management, has most likely saved many lives because of improved prehospital care, prolonged care in the ICU, and better long-term follow-up. More cardiac arrest victims are brought to hospitals with return of spontaneous circulation, and more survivors are offered emergency cardiac interventions and modern coronary care. In addition, the introduction of controlled hypothermia and mandatory sedation has prolonged the observation time in the ICU and allowed more time for comatose survivors to recover cerebral function. In addition, refined methods to assess hypoxic-ischemic encephalopathy have contributed to amore cautious strategy and more conservative prognostication algorithms and made premature withdrawal of intensive care less common. These important aspects in the chain of survival after cardiac arrest should be continuously refined, independently of the destiny of temperature management.

Conclusion (proposition de traduction) : Notre conclusion sur la base de la progression de l'hypothermie et de la gestion ciblée de la température au cours des 20 dernières années est que nous nous trouvons à un point clé où nous devrions essayer d'explorer en détail si les signes prometteurs des recherches animales antérieures, des rapports de cas et des petits essais cliniques sont réels, tout en explorant simultanément les domaines de la fièvre et du traitement de la fièvre, qui sont jusqu'à présent des domaines inexplorés. On pourrait dire que nous aurions pu parvenir à ce stade plus tôt si nous avions travaillé de manière plus systématique, dans le cadre de réseaux de recherche plus vastes, en nous appuyant sur des stratégies de méthodologie de recherche solides et en nous concentrant sur les faits concrets. Nous pensons qu'une considération valable est de ne pas agir prématurément sur les premiers résultats prometteurs, mais d'exiger la poursuite de la recherche méthodologique jusqu'à ce que des preuves solides soient établies et que les incertitudes aient été limitées autant que possible. Cependant, l'intérêt accru pour la population des victimes d'arrêts cardiaques au cours de ces 20 dernières années, déclenché dans une certaine mesure par l'hypothermie et la gestion ciblée de la température, a très probablement sauvé de nombreuses vies grâce à l'amélioration des soins préhospitaliers, à la prolongation des soins en USI et à l'amélioration du suivi à long terme. Davantage de victimes d'arrêts cardiaques sont amenées à l'hôpital avec un retour de la circulation spontanée, et davantage de survivants bénéficient d'interventions cardiaques d'urgence et de soins coronariens modernes. En outre, l'introduction de l'hypothermie contrôlée et de la sédation obligatoire a prolongé la durée d'observation dans les services de soins intensifs et a donné plus de temps aux survivants comateux pour récupérer leur fonction cérébrale. En outre, l'affinement des méthodes d'évaluation de l'encéphalopathie hypoxique-ischémique a contribué à une stratégie plus prudente et à des algorithmes de pronostic plus conservateurs, et a rendu moins fréquent l'arrêt prématuré des soins intensifs. Ces aspects importants de la chaîne de survie après un arrêt cardiaque doivent être continuellement améliorés, indépendamment du devenir de la gestion de la température.

Lung Ultrasound Prediction Model for Acute Respiratory Distress Syndrome: A Multicenter Prospective Observational Study.
Smit MR, Hagens LA, Heijnen NFL, Pisani L, Cherpanath TGV, Dongelmans DA, de Grooth HS, Pierrakos C, Tuinman PR, Zimatore C, Paulus F, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ; DARTS Consortium members. | Am J Respir Crit Care Med. 2023 Jun 15;207(12):1591-1601
DOI: https://doi.org/10.1164/rccm.202210-1882oc  | Télécharger l'article au format  
Keywords: ARDS; LUS; diagnosis; intensive care.

Original article

Introduction : Lung ultrasound (LUS) is a promising tool for diagnosis of acute respiratory distress syndrome (ARDS), but adequately sized studies with external validation are lacking. Objectives: To develop and validate a data-driven LUS score for diagnosis of ARDS and compare its performance with that of chest radiography (CXR).

Méthode : This multicenter prospective observational study included invasively ventilated ICU patients who were divided into a derivation cohort and a validation cohort. Three raters scored ARDS according to the Berlin criteria, resulting in a classification of "certain no ARDS," or "certain ARDS" when experts agreed or "uncertain ARDS" when evaluations conflicted. Uncertain cases were classified in a consensus meeting. Results of a 12-region LUS exam were used in a logistic regression model to develop the LUS-ARDS score.

Résultats : Three hundred twenty-four (16% certain ARDS) and 129 (34% certain ARDS) patients were included in the derivation cohort and the validation cohort, respectively. With an ARDS diagnosis by the expert panel as the reference test, the LUS-ARDS score, including the left and right LUS aeration scores and anterolateral pleural line abnormalities, had an area under the receiver operating characteristic (ROC) curve of 0.90 (95% confidence interval [CI], 0.85-0.95) in certain patients of the derivation cohort and 0.80 (95% CI, 0.72-0.87) in all patients of the validation cohort. Within patients who had imaging-gold standard chest computed tomography available, diagnostic accuracy of eight independent CXR readers followed the ROC curve of the LUS-ARDS score.

Conclusion : The LUS-ARDS score can be used to accurately diagnose ARDS also after external validation. The LUS-ARDS score may be a useful adjunct to a diagnosis of ARDS after further validation, as it showed performance comparable with that of the current practice with experienced CXR readers but more objectifiable diagnostic accuracy at each cutoff.

Conclusion (proposition de traduction) : Le modèle de diagnostic du syndrome de détresse respiratoire aiguë par échographie pulmonaire peut être utilisé pour diagnostiquer avec précision le syndrome de détresse respiratoire aiguë, y compris après validation externe. Le score du modèle de diagnostic du syndrome de détresse respiratoire aiguë par échographie pulmonaire peut être un complément utile au diagnostic du syndrome de détresse respiratoire aiguë après une validation plus poussée, car il a montré des performances comparables à celles de la pratique actuelle avec des professionnels expérimentés de la radiographie thoracique, mais une précision diagnostique plus objectivable pour chaque seuil d'évaluation.

Individualized Treatment Effects of Bougie versus Stylet for Tracheal Intubation in Critical Illness.
Seitz KP, Spicer AB, Casey JD, Buell KG, Qian ET, Graham Linck EJ, Driver BE, Self WH, Ginde AA, Trent SA, Gandotra S, Smith LM, Page DB, Vonderhaar DJ, West JR, Joffe AM, Doerschug KC, Hughes CG, Whitson MR, Prekker ME, Rice TW, Sinha P, Semler MW, Churpek MM. | Am J Respir Crit Care Med. 2023 Jun 15;207(12):1602-1611
DOI: https://doi.org/10.1164/rccm.202209-1799oc
Keywords: critical illness; intubation; machine learning; prediction models.

Original article

Introduction : A recent randomized trial found that using a bougie did not increase the incidence of successful intubation on first attempt in critically ill adults. The average effect of treatment in a trial population, however, may differ from effects for individuals. Objective: We hypothesized that application of a machine learning model to data from a clinical trial could estimate the effect of treatment (bougie vs. stylet) for individual patients based on their baseline characteristics ("individualized treatment effects").

Méthode : This was a secondary analysis of the BOUGIE (Bougie or Stylet in Patients Undergoing Intubation Emergently) trial. A causal forest algorithm was used to model differences in outcome probabilities by randomized group assignment (bougie vs. stylet) for each patient in the first half of the trial (training cohort). This model was used to predict individualized treatment effects for each patient in the second half (validation cohort).

Résultats : Of 1,102 patients in the BOUGIE trial, 558 (50.6%) were the training cohort, and 544 (49.4%) were the validation cohort. In the validation cohort, individualized treatment effects predicted by the model significantly modified the effect of trial group assignment on the primary outcome (P value for interaction = 0.02; adjusted qini coefficient, 2.46). The most important model variables were difficult airway characteristics, body mass index, and Acute Physiology and Chronic Health Evaluation II score.

Conclusion : In this hypothesis-generating secondary analysis of a randomized trial with no average treatment effect and no treatment effect in any prespecified subgroups, a causal forest machine learning algorithm identified patients who appeared to benefit from the use of a bougie over a stylet and from the use of a stylet over a bougie using complex interactions between baseline patient and operator characteristics.

Conclusion (proposition de traduction) : Dans cette analyse secondaire génératrice d'hypothèses d'un essai randomisé sans effet de traitement moyen et sans effet de traitement dans les sous-groupes préspécifiés, un algorithme d'apprentissage automatique de forêt d'arbre de décision causale a identifié les patients qui semblaient bénéficier de l'utilisation d'un mandrin long béquillé plutôt que d'un mandrin souple malléable et de l'utilisation d'un mandrin souple malléable plutôt que d'une mandrin long béquillé en utilisant des interactions complexes entre les caractéristiques de base du patient et de l'opérateur.

Commentaire : Le random forest est un algorithme incontournable en machine learning. Random forest signifie « forêt aléatoire ». C’est un algorithme qui se base sur l’assemblage d’arbres de décision qui produit des résultats généralisables.

Mandrin court malléable
Il est inséré dans la sonde d’intubation et permet de lui donner une forme en « crosse de hockey », ce qui facilite le passage de la sonde entre les cordes vocales, notamment lorsque celles-ci sont situées antérieurement.


Long mandrin béquillé malléable
Il existe de nombreux mandrins longs béquillés dont le principe d’utilisation est identique : une laryngoscopie directe est réalisée puis le mandrin est directement mis en place à travers la glotte. La sonde d’intubation est ensuite glissée sur le mandrin.

First-Attempt Intubation Success Among Emergency Medicine Trainees by Laryngoscopic Device and Training Year: A National Emergency Airway Registry Study.
Garcia SI, Sandefur BJ, Campbell RL, Driver BE, April MD, Carlson JN, Walls RM, Brown CA 3rd. | Ann Emerg Med. 2023 Jun;81(6):649-657.
DOI: https://doi.org/10.1016/j.annemergmed.2022.10.019  | Télécharger l'article au format  
Keywords: Aucun

Airway

Introduction : We compare intubation first-attempt success with the direct laryngoscope, hyperangulated video laryngoscope, and standard geometry video laryngoscope among emergency medicine residents at various postgraduate years (PGY) of training.

Méthode : We analyzed prospective data from emergency department (ED) patients enrolled in the National Emergency Airway Registry from January 1, 2016 to December 31, 2018 using mixed-effects logistic regression to assess the association between PGY of training and first-attempt success by the device.

Résultats : Among 15,204 intubations performed by emergency medicine trainees, first-attempt success for PGY-1, PGY-2, and PGY3+ residents, respectively were: 78.8% (95% CI, 75.0 to 82.2%), 81.3% (79.4 to 83.0), and 83.6% (95% CI, 82.1 to 85.1) for direct laryngoscope; 87.2% (95% CI, 84.2 to 89.7), 90.4% (95% CI, 88.8 to 91.9%), and 91.2% (95% CI, 89.8 to 92.5%) for hyperangulated video laryngoscope; and 88.7% (95% CI, 86.1 to 90.9), 90.2% (95% CI, 88.7 to 91.5%), and 94.6% (95% CI 93.9 to 95.3%) for standard geometry video laryngoscope. Direct laryngoscope first-attempt success improved for PGY-2 (adjusted odds ratio [aOR],1.41; 95% CI, 1.09 to 1.82) and PGY-3+ (aOR, 1.76; 1.36 to 2.27) trainees compared to PGY-1. Hyperangulated video laryngoscope success also improved for PGY-2 (aOR, 1.51; 1.1 to 2.05) and PGY-3+ (aOR, 1.56; 1.15 to 2.13) trainees compared to PGY-1. For the standard geometry video laryngoscope, only PGY-3+ (aOR, 1.72; 1.25 to 2.36) was associated with improved first-attempt success compared to PGY-1.

Conclusion : Each laryngoscopy device class was associated with improvement in first-attempt success as training progressed. The video laryngoscope outperformed the direct laryngoscope for all operator groups, and PGY-1 trainees achieved higher first-attempt success using a standard geometry video laryngoscope than PGY-3+ trainees using a direct laryngoscope. These findings support the conjecture that in adult patients, a direct laryngoscope should not be routinely used for the first intubation attempt unless clinical circumstances, such as the presence of a soiled airway, would favor its success. These findings need to be validated with prospective randomized clinical trials.

Conclusion (proposition de traduction) : Chaque classe de dispositif de laryngoscopie a été associée à une amélioration de la réussite à la première tentative au fur et à mesure de la formation. Le vidéo-laryngoscope a été plus performant que le laryngoscope direct pour tous les groupes d'opérateurs, et les stagiaires de la première année d'études supérieures ont obtenu de meilleurs résultats lors de la première tentative en utilisant un vidéo-laryngoscope à géométrie standard que les stagiaires de la troisième année d'études supérieures et plus en utilisant un laryngoscope direct. Ces résultats confirment l'hypothèse selon laquelle, pour les patients adultes, la première tentative d'intubation ne devrait pas être systématiquement effectuée à l'aide d'un laryngoscope direct, à moins que des circonstances cliniques, telles que la présence d'une voie aérienne obstruée, n'en favorisent la réussite. Ces résultats doivent être validés par des essais cliniques prospectifs randomisés.

Effectiveness of Lay Bystander Hands-Only Cardiopulmonary Resuscitation on a Mattress versus the Floor: A Randomized Cross-Over Trial.
Missel AL, Donnelly JP, Tsutsui J, Wilson N, Friedman C, Rooney DM, Neumar RW, Cooke JM. | Ann Emerg Med. 2023 Jun;81(6):691-698
DOI: https://doi.org/10.1016/j.annemergmed.2023.01.012  | Télécharger l'article au format  
Keywords: Aucun

Emergency Medical Services

Introduction : Bystander cardiopulmonary resuscitation increases the likelihood of out-of-hospital cardiac arrest survival by more than two-fold. A common barrier to the prompt initiation of compressions is moving victims to the floor, but compression quality on a "floor" versus a "mattress" has not been tested among lay bystanders.

Méthode : We conducted a prospective, randomized, cross-over trial comparing lay bystander compression quality using a manikin on a bed versus the floor. Participants included adults without professional health care training. We randomized participants to the order of manikin placement, either on a mattress or on the floor. For both, participants were instructed to perform 2 minutes of chest compressions on a cardiopulmonary resuscitation Simon manikin Gaumard (Gaumard Scientific, Miami, FL). The primary outcome was mean compression depth (cm) over 2 minutes. We fit a linear regression model adjusted for scenario order, age, sex, and body mass index with robust standard errors to account for repeated measures and reported mean differences with 95% confidence intervals (CIs).

Résultats : Our sample of 80 adults was 66% female with a mean age of 50.5 years (SD 18.2). The mean compression depth on the mattress was 2.9 cm (SD 2.3) and 3.5 cm (SD 2.2) on the floor, a mean difference of 0.58 cm (95% CI 0.18, 0.98). Compression depth fell below the 5 to 6 cm depth recommended by the American Heart Association on both surfaces. In the adjusted model, the mean depth was greater when the manikin was on the floor than the mattress (adjusted mean difference 0.62 cm; 95% CI 0.23 to 1.01), and mean depth was less for females than males (adjusted mean difference -1.42 cm, 95% CI -2.59, -0.25). In addition, the difference in compression depth was larger for female participants (mean difference 0.94 cm; 95% CI 0.54, 1.34) than for male participants (mean difference -0.01 cm; 95% CI -0.80, 0.78), and the interaction was statistically significant (P = .04).

Conclusion : The mean compression depth was significantly smaller on the mattress and with female bystanders. Further research is needed to understand the benefit of moving out-of-hospital cardiac arrest victims to the floor relative to the detrimental effect of delaying chest compressions.

Conclusion (proposition de traduction) : La profondeur moyenne de compression était significativement plus faible sur un matelas et avec des intervenants de sexe féminin. Des recherches supplémentaires sont nécessaires pour comprendre l'avantage de déplacer les victimes d'arrêts cardiaques extrahospitaliers sur le sol par rapport à l'effet défavorable de retarder les compressions thoraciques.

Pre-hospital peripheral intravenous catheter insertion practice: An integrative review.
Golling E, van de Mortel T, Barr N, Zimmerman PA. | Australas Emerg Care. 2023 Jun;26(2):105-112
DOI: https://doi.org/10.1016/j.auec.2022.08.006
Keywords: Ambulance; Emergency medical technicians; Paramedic; Peripheral intravenous catheter; Vascular access device.

Systematic Review

Introduction : Peripheral intravenous catheters (PIVCs) are widely used within healthcare settings. There is substantial hospital-based research, particularly in Emergency Departments, supporting the need to reduce inappropriate PIVCs due to associated risks. However, there is limited research into pre-hospital practice. This review aims to determine the rates of pre-hospital PIVC insertions, how many remain unused, and to explore paramedic PIVC decision-making.

Méthode : A systematic search of research databases was undertaken using an integrative review methodology. Articles published between 2011 and April 2022 were included. The Mixed Methods Appraisal Tool was used to assess the quality of the studies.

Résultats : Fifteen studies were included. Rates of PIVC insertions ranged from 21% to 58%. Up to 72% of PIVCs remained unused in the pre-hospital setting. Paramedic decision-making was not well reported, though erring of the side of caution and inserting a "just in case" PIVC was identified.

Conclusion : There are limited articles on pre-hospital PIVC practice, particularly in Australian settings. Research is required to understand factors influencing practice and provide contemporary evidence to inform the development of guidance specific to the pre-hospital setting to reduce the numbers of inappropriate PIVCs.

Conclusion (proposition de traduction) : Il existe peu d'articles sur la pratique de la pose de cathéters intraveineux périphériques en milieu préhospitalier, en particulier dans le contexte australien. Des recherches sont nécessaires pour comprendre les facteurs qui influencent la pratique et fournir des preuves actualisées pour guider l'élaboration de recommandations spécifiques au milieu préhospitalier afin de réduire le nombre de cathéters intraveineux périphériques inutiles.

Use of point of care ultrasound (POCUS) by intensive care paramedics to achieve peripheral intravenous access in patients predicted to be difficult: An out-of-hospital pilot study.
Burton SO, Donovan JK, Jones SL, Phillips LM, Anderson DJ, Meadley BN. | Australas Emerg Care. 2023 Jun;26(2):164-168
DOI: https://doi.org/10.1016/j.auec.2022.10.003
Keywords: Adults; Allied health personnel; Catheterisation, Peripheral; Critical care; Out-of-hospital; POCUS; Paramedic; Ultrasonography, Interventional.

Research paper

Introduction : Intravenous cannulation is a common procedure for paramedics. Difficulty is often encountered and may result in escalation of care to an intensive care paramedic (ICP). Ultrasound-guided peripheral intravenous access (USGPIVA) is used in-hospital as an alternative approach. Historically limited to physicians, it is increasingly embraced by non-physicians, with point of care ultrasound (POCUS) devices more affordable, portable, and suited to the out of hospital environment.

Méthode : To explore the utility of ICP-performed USGPIVA for patients who are predicted to be difficult according to a difficult intravenous access scoring tool.
Methods: This was a prospective observational pilot study of ICPs who used the adult difficult intravenous access (A-DIVA) scale to predict difficulty and perform USGPIVA using a contemporary POCUS device.

Résultats : For the 32 patients enroled, the overall success rate was 50% of which 87% were successful on the first attempt. Mean A-DIVA score was 4.1/5, and paradoxically, success improved with A-DIVA-predicted difficulty.

Conclusion : ICPs can perform USGPIVA with moderate success. The A-DIVA score could be useful for paramedics to predict difficult cannulation. Future research should focus on increasing exposure, training time and enhancing feedback to paramedics performing USGPIVA.

Conclusion (proposition de traduction) : Le personnel paramédical des soins intensifs peut réaliser un accès intraveineux périphérique guidé par échographie avec un succès modéré. Le score de difficulté de pose d'intraveineuse chez l'adulte pourrait être utile au personnel paramédical pour prédire les difficultés de pose d'intraveineuse. Les recherches futures devraient se concentrer sur une meilleure exposition, un temps de formation plus long et un meilleur retour d'information pour les auxiliaires médicaux pratiquant l'accès intraveineux périphérique guidé par ultrasons.

Pre-hospital predictors of long-term survival from out-of-hospital cardiac arrest.
Pemberton K, Franklin RC, Bosley E, Watt K. | Australas Emerg Care. 2023 Jun;26(2):184-192
DOI: https://doi.org/10.1016/j.auec.2022.10.006  | Télécharger l'article au format  
Keywords: Emergency medical services; Epidemiology; Out-of-hospital cardiac arrest.

Research paper

Introduction : To identify predictors of longer-term outcomes from adult out-of-hospital cardiac arrest of presumed cardiac aetiology.

Méthode : In this retrospective cohort study, three large routinely collected databases were linked: 1)QAS Out-of-Hospital Cardiac (OHCA) Registry; 2)Queensland Hospital Admitted Patient Data Collection; and 3)Queensland Registrar General Death Registry. Participants were adult (18years+) residents of Queensland, who suffered an OHCA of presumed cardiac aetiology and had resuscitation attempted by QAS paramedics between 2002 and 2014. Four mutually exclusive outcomes were analysed: 1) No pre-hospital return of spontaneous circulation (ROSC) sustained to the Emergency Department (ED) or ROSC in ED; 2) Survival< 30 days (Pre-hospital ROSC sustained to ED or ROSC in ED but death within 30 days; 3) survival between 30 and 364 days; and 4) survival to 365 + days. Multinomial logistic regression was used to calculate odds ratios and 95 % confidence intervals.

Résultats : Variables significantly predictive of survival to 365 + days after adjusting for all measured confounders are: an initial shockable rhythm; bystander witnessed events with bystander CPR; paramedic witnessed events; intubation placement; time of day (midday-2.59 pm); and attendance by Critical Care Paramedic (CCP).

Conclusion : From a service provision perspective, attendance of a CCP at an OHCA may be an important factor to achieve preferred long-term outcomes. Enhanced experience, exposure and expertise, together with extended clinical practice, may explain this finding.

Conclusion (proposition de traduction) : Du point de vue de la dispensation des soins, la présence d'un paramédical en soins intensifs lors d'un arrêt cardiaque extrahospitalier peut être un facteur important pour obtenir les meilleurs résultats à long terme. L'expérience, l'exposition et l'expertise accrues, ainsi qu'une pratique clinique étendue, peuvent expliquer ce résultat.

A pilot, prospective trial of IntuBrite® versus Macintosh direct laryngoscopy for paramedic endotracheal intubation in out of hospital cardiac arrest.
Kluj P, Fedorczak M, Gaszyński T, Ratajczyk P. | BMC Emerg Med. 2023 Jun 23;23(1):70
DOI: https://doi.org/10.1186/s12873-023-00845-3  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : Intubation in the case of out-of-hospital cardiac arrest (OHCA) is one of the most difficult procedures for Emergency Medical Services (EMS). The use of a laryngoscope with a dual light source is an interesting alternative to classic laryngoscopes. However, there are as yet no prospective data concerning the use of double light direct laryngoscopy (DL) by paramedics in traditional ground ambulance agencies in OHCA.

Méthode : We performed a non-blinded trial in a single EMS in Poland within ambulances crews, comparing time and first pass success (FPS) for endotracheal intubation (ETI) in DL using the IntuBrite® (INT) and Macintosh laryngoscope (MCL) during cardiopulmonary resuscitation (CPR). We collected both patient and provider demographic information along with intubation details. The time and success rates were compared using an intention-to-treat analysis.

Résultats : Over a period of 40 months, a total of 86 intubations were performed using 42 INT and 44 MCL based on an intention-to-treat analysis. The FPS time of the ETI attempt (13.49 vs. 15.55 s) using an INT which was shorter than MCL was used (p < 0.05). First attempt success (34/42, 80.9% vs. 29/44, 64.4%) was comparable for INT and MCL with no statistical significance.

Conclusion : We found a statistically significant difference in intubation attempt time when the INT laryngoscope was used. Intubation first attempt success rates with INT and MCL were comparable with no statistical significance during CPR performed by paramedics.

Conclusion (proposition de traduction) : Dans notre étude, le temps de tentative d'intubation endotrachéale avec IntuBrite était plus court qu'avec le laryngoscope avec lame de Macintosh. La différence observée était statistiquement significative. Nous n'avons pas trouvé de différence dans la réussite du premier essai entre les laryngoscopes IntuBrite et Macintosh au cours de la réanimation cardio-pulmonaire par le personnel paramédical.

Commentaire : 

Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis.
Poonai N, Creene C, Dobrowlanski A, Geda R, Hartling L, Ali S, Bhatt M, Trottier ED, Sabhaney V, O'Hearn K, Jain R, Osmond MH. | CJEM. 2023 Jun;25(6):508-528
DOI: https://doi.org/10.1007/s43678-023-00507-0
Keywords: Distress; Nitrous oxide; Pain; Pediatrics.

Original Research

Introduction : Synthétiser les données probantes fondées sur l'indication pour le N2O pour la détresse et la douleur chez les enfants.

Méthode : Nous avons inclus des essais de N2O chez des participants âgés de 0 à 21 ans, signalant une détresse ou une douleur pour les procédures des services d’urgence. Le critère de jugement principal était la détresse procédurale. Lorsqu'une méta-analyse n'était pas possible, nous avons utilisé la classification de Tricco et al. "neutre" (p>0,05), "favorable" ou "défavorable" (p<0,05, en faveur de la N2O ou du comparateur, respectivement). Nous avons utilisé l'outil risque de biais de la Collaboration Cochrane et le système Grading of Recommendations Assessment, Development, and Evaluation pour évaluer respectivement le risque de biais et la qualité des preuves.

Résultats : Nous avons inclus 30 essais. Pour la douleur sur l'échelle visuelle analogique (0-100 mm) pendant l'insertion IV, 70 % de N2O (delta : -16,5 ; IC à 95% : -28,6 à -4,4 ; p = 0,008 ; trois essais ; I2 = 0 %) et 50 % de N2O plus un mélange eutectique d'anesthésiques locaux (EMLA) (delta : -1,2 ; IC à 95 % : -2,1 à -0,3 ; p = 0,007 ; deux essais ; I2 = 43 %) étaient supérieurs à l'EMLA. La N2O à 50 % n'était pas supérieure à l'EMLA (delta : -0,4 ; IC à 95 % : -1,2 à 0,3 ; p = 0,26 ; deux essais ; I2 = 15 %). En ce qui concerne la détresse et la douleur pendant la réparation des lacérations, le N2O était "favorable" par rapport à la lidocaïne SC, à l'oxygène et au midazolam oral, mais "neutre" par rapport à la kétamine IV (cinq essais). Pour la détresse et la douleur pendant la réduction des fractures (trois essais), le N2O était « neutre » par rapport à la mépéridine IM plus prométhazine, l'anesthésie régionale et la kétamine IV plus midazolam. Pour la détresse et la douleur lors de la ponction lombaire (un essai), le N2O était "favorable" par rapport à l'oxygène. Pour la détresse et la douleur pendant le cathétérisme urétral (un essai), N2O était "neutre" par rapport au midazolam oral. Pour la douleur pendant l'injection intramusculaire (un essai), le N2O plus EMLA était « favorable » par rapport au N2O et à l'EMLA seuls. Les effets indésirables les plus fréquents de la N2O étaient les nausées (4,4 %), l'agitation (3,7 %) et les vomissements (3,6 %). Les EI étaient moins fréquents avec la N2O seule (278/1147 (24,2 %)) par rapport au N2O plus midazolam (48/52 (92,3 %)) et le N2O plus fentanyl (123/201 (61,2 %)).

Conclusion (proposition de traduction) : Les preuves sont suffisantes pour recommander l'utilisation de N2O en association avec un anesthésique local pour la pose d'une perfusion intraveineuse et la réparation d'une plaie. Les effets indésirables sont plus importants lorsqu'il est associé à d'autres agents sédatifs.

Direct Oral Anticoagulants Versus Warfarin Across the Spectrum of Kidney Function: Patient-Level Network Meta-Analyses From COMBINE AF.
Harrington J, Carnicelli AP, Hua K, Wallentin L, Patel MR, Hohnloser SH, Giugliano RP, Fox KAA, Hijazi Z, Lopes RD, Pokorney SD, Hong H, Granger CB. | Circulation. 2023 Jun 6;147(23):1748-1757
DOI: https://doi.org/10.1161/circulationaha.122.062752  | Télécharger l'article au format  
Keywords: anticoagulants; atrial fibrillation; kidney

ORIGINAL RESEARCH ARTICLE

Introduction : There is uncertainty surrounding the use of direct oral anticoagulants (DOACs) in patients with kidney dysfunction.

Méthode : Using the COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) database (data from RE-LY [Randomized Evaluation of Long-term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation], ARISTOTLE [Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation], and ENGAGE AF-TIMI 48 [Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48]), we performed an individual patient-level network meta-analysis to evaluate the safety and efficacy of DOACs versus warfarin across continuous creatinine clearance (CrCl). A multivariable Cox model including treatment-by-CrCl interaction with random effects was fitted to estimate hazard ratios for paired treatment strategies (standard-dose DOAC, lower-dose DOAC, and warfarin). Outcomes included stroke and systemic embolism (S/SE), major bleeding, intracranial hemorrhage (ICH), and death.

Résultats : Among 71 683 patients (mean age, 70.6±9.4 years; 37.3% female; median follow-up, 23.1 months), the mean CrCl was 75.5±30.5 mL/min. The incidence of S/SE, major bleeding, ICH, and death increased significantly with worsening kidney function. Across continuous CrCl values down to 25 mL/min, the hazard of major bleeding did not change for patients randomized to standard-dose DOACs compared with those randomized to warfarin (Pinteraction=0.61). Compared with warfarin, standard-dose DOAC use resulted in a significantly lower hazard of ICH at CrCl values <122 mL/min, with a trend for increased safety with DOAC as CrCl decreased (6.2% decrease in hazard ratio per 10-mL/min decrease in CrCl; Pinteraction=0.08). Compared with warfarin, standard-dose DOAC use resulted in a significantly lower hazard of S/SE with CrCl <87 mL/min, with a significant treatment-by-CrCl effect (4.8% decrease in hazard ratio per 10-mL/min decrease in CrCl; Pinteraction=0.01). The hazard of death was significantly lower with standard-dose DOACs for patients with CrCl <77 mL/min, with a trend toward increasing benefit with lower CrCl (2.1% decrease in hazard ratio per 10-mL/min decrease in CrCl; Pinteraction=0.08). Use of lower-dose rather than standard-dose DOACs was not associated with a significant difference in incident bleeding or ICH in patients with reduced kidney function but was associated with a higher incidence4 of death and S/SE.

Conclusion : Standard-dose DOACs are safer and more effective than warfarin down to a CrCl of at least 25 mL/min. Lower-dose DOACs do not significantly lower the incidence of bleeding or ICH compared with standard-dose DOACs but are associated with a higher incidence of S/SE and death. These findings support the use of standard-dose DOACs over warfarin in patients with kidney dysfunction.

Conclusion (proposition de traduction) : Les AOD à dose normale sont plus sûrs et plus efficaces que la warfarine jusqu'à une clairance de la créatinine continue d'au moins 25 ml/min. Les AOD à faible dose ne réduisent pas de manière significative l'incidence des saignements ou des hémorragies intracrâniennes par rapport aux AOD à dose normale, mais sont associés à une incidence plus élevée d'accidents vasculaires cérébraux et d'embolies systémiques, ainsi que de décès. Ces résultats soutiennent l'utilisation des AOD à dose standard plutôt que de la warfarine chez les patients souffrant d'une insuffisance rénale.

KIDS SAVE LIVES: Basic Life Support Education for Schoolchildren: A Narrative Review and Scientific Statement From the International Liaison Committee on Resuscitation.
Schroeder DC, Semeraro F, Greif R, Bray J, Morley P, Parr M, Kondo Nakagawa N, Iwami T, Finke SR, Malta Hansen C, Lockey A, Del Rios M, Bhanji F, Sasson C, Schexnayder SM, Scquizzato T, Wetsch WA, Böttiger BW; International Liaison Committee on Resuscitation. | Circulation. 2023 Jun 13;147(24):1854-1868
DOI: https://doi.org/10.1161/cir.0000000000001128  | Télécharger l'article au format  
Keywords: ILCOR Scientific Statements; cardiopulmonary resuscitation; out-of-hospital cardiac arrest; retrospective studies; students; sudden cardiac death

ILCOR SCIENTIFIC STATEMENT

Introduction : Basic life support education for schoolchildren has become a key initiative to increase bystander cardiopulmonary resuscitation rates. Our objective was to review the existing literature on teaching schoolchildren basic life support to identify the best practices to provide basic life support training in schoolchildren.

Méthode : After topics and subgroups were defined, a comprehensive literature search was conducted. Systematic reviews and controlled and uncontrolled prospective and retrospective studies containing data on students <20 years of age were included.

Résultats : Schoolchildren are highly motivated to learn basic life support. The CHECK-CALL-COMPRESS algorithm is recommended for all schoolchildren. Regular training in basic life support regardless of age consolidates long-term skills. Young children from 4 years of age are able to assess the first links in the chain of survival. By 10 to 12 years of age, effective chest compression depths and ventilation volumes can be achieved on training manikins. A combination of theoretical and practical training is recommended. Schoolteachers serve as effective basic life support instructors. Schoolchildren also serve as multipliers by passing on basic life support skills to others. The use of age-appropriate social media tools for teaching is a promising approach for schoolchildren of all ages.

Conclusion : Schoolchildren basic life support training has the potential to educate whole generations to respond to cardiac arrest and to increase survival after out-of-hospital cardiac arrest. Comprehensive legislation, curricula, and scientific assessment are crucial to further develop the education of schoolchildren in basic life support.

Conclusion (proposition de traduction) : La formation des écoliers aux gestes élémentaires de survie a le potentiel d'apprendre à des générations entières à réagir en cas d'arrêt cardiaque et d'augmenter le taux de survie après un arrêt cardiaque extrahospitalier. Une législation complète, des programmes d'études et une évaluation scientifique sont essentiels pour développer la formation des écoliers aux gestes élémentaires de survie.

Teaching suturing skill to emergency physicians: the experience of a hands-on practical training in a laboratory simulation-based setting.
Manno A, Santoro MC, Pascale MM, Saviano A, Benicchi A, Gabrielli M, Covino M, Franceschi F. | Emerg Care J. 2023 June;19:11417
DOI: https://doi.org/10.4081/ecj.2023.11417  | Télécharger l'article au format  
Keywords: suturing skill teaching, traumatic wound care, emergency medicine, medical education.

ORIGINAL ARTICLE

Editorial : Both specialists and trainees in emergency medicine are often unaware of the principles of good suturing. Hands-on training course was proposed to both members of the staff (group A) and trainees (group B) of the emergency department of our hospital. Familiarity with all aspects of the operation, pre-course 0%, postcourse 79% (group A) and 85.71% (group B) - p<0.000); clear economy of movement and maximum efficiency, pre-course 0%, post-course 73.8% (group A) and 89.80% (group B) - p<0.000; fluid moves with instruments and no awkwardness, pre-course 0%, post-course 73.8% (group A) and 89.80% (group B) - p<0.000; obviously planned course of operation with effortless flow from one move to the next, pre-course 0%, post-course 79% (group A) and 89,80% (group B) - p<0.000; strategically used assistants to the best advantage of all time, pre-course 0%, post-course 73,8% (group A) and 89,80% (group B) - p<0.000; improvement in dexterity, 79.5% of students post-course). The course was judged very useful by 94.8% of students. Attending suturing skill courses could be very useful for both trainees and specialists in emergency medicine.

Conclusion : To the best of our knowledge, this is the first study aimed at evaluating the results of a suturing skill acquisition program dedicated to specialist and trainees in EM, with the aim of filling a widespread educational gap. The course was very successful among both ED staff members and trainees and extremely satisfying in terms of self-perceived confidence in suturing technique. Two members of the ED staff with consolidated surgical experience acted as tutors, enabling students to develop their skills in a non-intimidating environment, but this goal can easily be also achieved by entrusting this role giving this role to senior students, according to a peer-to-peer approach. The course resulted low resource consuming, both in terms of budget, 359 euro for materials and no faculty pay as tutors act on a voluntary basis, and time necessary to dedicate to it, as both didactic sessions and practice on patients could be easily integrated with daily activity of both students and tutors. We suggest including this type of course in the official training program of the post-graduate schools in EM and in a scheduled update plan for ED physicians with no surgical background could be advisable.

Conclusion (proposition de traduction) : À notre connaissance, il s'agit de la première étude visant à évaluer les résultats d'un programme d'acquisition de compétences en matière de suture destiné aux spécialistes et aux stagiaires en médecine d'urgence, dans le but de combler une lacune éducative répandue. Le cours a remporté un vif succès auprès des membres du personnel de l'urgence et des stagiaires et s'est révélé extrêmement satisfaisant en termes de confiance auto-perçue dans la technique de suture. Deux membres du personnel des urgences ayant une expérience chirurgicale consolidée ont joué le rôle de tuteurs, permettant aux étudiants de développer leurs compétences dans un environnement non intimidant, mais cet objectif peut facilement être atteint en confiant ce rôle à des étudiants plus expérimentés, selon une approche de pair à pair. Le cours s'est avéré peu consommateur de ressources, tant en termes de budget (359 euros pour le matériel et aucun salaire pour la faculté, les tuteurs agissant à titre bénévole) que de temps à y consacrer, les sessions didactiques et la pratique sur les patients pouvant être facilement intégrées à l'activité quotidienne des étudiants et des tuteurs. Nous suggérons d'inclure ce type de cours dans le programme officiel de formation des écoles de médecine d'urgence et dans un plan de mise à jour programmé pour les médecins urgentistes n'ayant pas de formation chirurgicale.

Accuracy of bedside sonographic measurement of optic nerve sheath diameter for intracranial hypertension diagnosis in the emergency department.
Busti C, Marcosignori M, Marchetti F, Batori G, Giovenali L, Corea F, Calabrò G, Monti M, Germini F. | Emerg. Care J. 2023 June;19:11333
DOI: https://doi.org/10.4081/ecj.2023.11333  | Télécharger l'article au format  
Keywords: optic nerve, ultrasound optic nerve sheet diameter (US ONSD), ultrasound, intracranial hypertension, traumatic brain injury, non traumatic brain injury.

Original article

Editorial : Ultrasound measurement of the optic nerve sheath diameter (US ONSD) has been proposed as a method to diagnose elevated intracranial pressure (EICP), but the optimal threshold is unclear. The aim of this study was to assess the accuracy of US ONSD, as compared to head computed tomography (CT), in detecting EICP of both traumatic and non-traumatic origin. We conducted a prospective, cross-sectional, multicenter study. Patients presenting to the emergency department with a suspect of traumatic or non-traumatic brain injury, referred for an urgent head CT, underwent US ONSD measurement. A US ONSD ≥5.5 mm was considered positive. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for three ONSD cut-offs: 5.5 (primary outcome), 5.0, and 6.0 mm. A receiver operating characteristic (ROC) curve was also generated and the area under the ROC curve calculated. Ninetynine patients were enrolled. The CT was positive in 15% of cases and the US ONSD was positive in all of these, achieving a sensitivity of 100% [95% confidence interval (CI) 78; 100] and a negative predictive value of 100% (95% CI 79; 100). The CT was negative in 85% of cases, while the US ONSD was positive in 69% of these, achieving a specificity of 19% (95% CI 11; 29) and a positive predictive value of 18% (95% CI 11; 28). The US ONSD, with a 5.5 mm cut-off, might safely be used to rule out EICP in patients with traumatic and non-traumatic brain injury in the ED. In limited-resources contexts, a negative US ONSD could allow emergency physicians to rule out EICP in low-risk patients, deferring the head CT.

Conclusion : The Ultrasound measurement of the optic nerve sheath diameter measurement, with a 5.5 mm cut-off, might safely be used to rule out elevated intracranial pressure in patients with traumatic and nontraumatic brain injury in the ED. This information may be particularly valuable when the time to CT must be prioritized, such as during mass casualty events, or in settings without readily access to CT.

Conclusion (proposition de traduction) : La mesure échographique du diamètre de la gaine du nerf optique, avec un seuil de 5,5 mm, pourrait être utilisée en toute sécurité pour exclure une pression intracrânienne élevée chez les patients souffrant de lésions cérébrales traumatiques et non traumatiques aux urgences. Cette information peut s'avérer particulièrement précieuse lorsqu'il faut donner la priorité à la tomodensitométrie, par exemple lors d'événements impliquant un grand nombre de blessés, ou dans des contextes où l'accès à la tomodensitométrie n'est pas facile.

Accuracy of bedside sonographic measurement of optic nerve sheath diameter for intracranial hypertension diagnosis in the emergency department.
Busti C, Marcosignori M, Marchetti F, Batori G, Giovenali L, Corea F, Calabrò G, Monti M, Germini F. | Emerg. Care J. 2023 June;19:11333
DOI: https://doi.org/10.4081/ecj.2023.11333  | Télécharger l'article au format  
Keywords: optic nerve, ultrasound optic nerve sheet diameter (US ONSD), ultrasound, intracranial hypertension, traumatic brain injury, non traumatic brain injury.

Original article

Editorial : Ultrasound measurement of the optic nerve sheath diameter (US ONSD) has been proposed as a method to diagnose elevated intracranial pressure (EICP), but the optimal threshold is unclear. The aim of this study was to assess the accuracy of US ONSD, as compared to head computed tomography (CT), in detecting EICP of both traumatic and non-traumatic origin. We conducted a prospective, cross-sectional, multicenter study. Patients presenting to the emergency department with a suspect of traumatic or non-traumatic brain injury, referred for an urgent head CT, underwent US ONSD measurement. A US ONSD ≥5.5 mm was considered positive. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for three ONSD cut-offs: 5.5 (primary outcome), 5.0, and 6.0 mm. A receiver operating characteristic (ROC) curve was also generated and the area under the ROC curve calculated. Ninetynine patients were enrolled. The CT was positive in 15% of cases and the US ONSD was positive in all of these, achieving a sensitivity of 100% [95% confidence interval (CI) 78; 100] and a negative predictive value of 100% (95% CI 79; 100). The CT was negative in 85% of cases, while the US ONSD was positive in 69% of these, achieving a specificity of 19% (95% CI 11; 29) and a positive predictive value of 18% (95% CI 11; 28). The US ONSD, with a 5.5 mm cut-off, might safely be used to rule out EICP in patients with traumatic and non-traumatic brain injury in the ED. In limited-resources contexts, a negative US ONSD could allow emergency physicians to rule out EICP in low-risk patients, deferring the head CT.

Conclusion : The Ultrasound measurement of the optic nerve sheath diameter measurement, with a 5.5 mm cut-off, might safely be used to rule out elevated intracranial pressure in patients with traumatic and nontraumatic brain injury in the ED. This information may be particularly valuable when the time to CT must be prioritized, such as during mass casualty events, or in settings without readily access to CT.

Conclusion (proposition de traduction) : La mesure échographique du diamètre de la gaine du nerf optique, avec un seuil de 5,5 mm, pourrait être utilisée en toute sécurité pour exclure une pression intracrânienne élevée chez les patients souffrant de lésions cérébrales traumatiques et non traumatiques aux urgences. Cette information peut s'avérer particulièrement précieuse lorsqu'il faut donner la priorité à la tomodensitométrie, par exemple lors d'événements impliquant un grand nombre de blessés, ou dans des contextes où l'accès à la tomodensitométrie n'est pas facile.

External validation of Glasgow-Blatchford, modified Glasgow-Blatchford and CANUKA scores to identify low-risk patients with upper gastrointestinal bleeding in emergency departments: a retrospective cohort study.
Pognonec C, Dirhoussi Z, Cury N, Moreau M, Billard C, Yordanov Y, Thiebaud PC. | Emerg Med J. 2023 Jun;40(6):451-457
DOI: https://doi.org/10.1136/emermed-2022-213052
Keywords: emergency department; gastro-intestinal.

Original research

Introduction : Upper gastrointestinal bleeding (UGIB) is a medical emergency with an approximate mortality of 10%, which results in a high hospitalisation rate. The Glasgow-Blatchford score (GBS) is recommended to identify low-risk patients who can be discharged from the emergency department (ED). A modified GBS (mGBS) and CANUKA score have recently been proposed but have not been well studied. The aim of this study was to assess whether the use of GBS, mGBS or CANUKA score could identify patients at low risk of death or need for intervention.

Méthode : A single-centre retrospective study was performed including patients with suspected UGIB visiting the ED of Saint-Antoine hospital (Paris, France) from January 2016 to December 2018. Demographic and medical data needed to calculate GBS and CANUKA were collected, as well as outcomes data. Need for intervention was defined as the need for blood transfusion, endoscopic haemostasis or rebleeding within 7 days. In-hospital mortality was also collected. Sensitivity, specificity and predictive values were measured for the score thresholds of interest.

Résultats : A total of 386 patients were included. Median age was 60 years (38-78), 65.3% (n=252) were male and 60% (n=233) were hospitalised. A GBS≤1, mGBS=0 and CANUKA≤2 categorised 24.9%, 18.2% and 18.9% of patients as low risk, respectively. There was a need for intervention in 2.2%, 4.6% and 0% of those patients categorised as low risk by GBS, mGBS and CANUKA, respectively. No deaths occurred in the patients identified as low risk, regardless of the score used. All scores had a high sensitivity and negative predictive value.

Conclusion : In patients with UGIB, the use of a GBS≤1 or CANUKA score ≤2 appears to be safe for identifying patients at low risk of death or need for intervention.

Conclusion (proposition de traduction) : Chez les patients présentant une hémorragie gastro-intestinale haute, l'utilisation d'un score GBS ≤ 1 ou CANUKA ≤ 2 semble être sûre pour identifier les patients à faible risque de décès ou de nécessité d'intervention.

Upper cervical spine fracture patterns and blunt cerebrovascular injuries.
Tran NA, Pawar JP, Tobert D, Harris MB, Khurana B. | Emerg Radiol. 2023 Jun;30(3):315-323
DOI: https://doi.org/10.1007/s10140-023-02129-6
Keywords: Blunt cerebrovascular injury; Cervical spine; Fractures; Trauma.

Original Article

Introduction : To determine patterns of C1 and C2 vertebral fractures that are associated with blunt cerebrovascular injury (BCVI).

Méthode : Retrospective chart review of clinical and imaging reports at a level 1 trauma center over 10 consecutive years was conducted in patients with C1 and C2 fractures. Student t-test and chi-squared analyses were used to determine associations between fracture levels and fracture types with the presence of BCVI on CTA and/or MRI or stroke on CT and/or MRI.

Résultats : Multilevel fractures were associated with higher incidence of BCVI compared to isolated C1 or C2 fractures (p < 0.01), but not with stroke (p = 0.16). There was no difference in incidence of BCVI or stroke between isolated C1 and isolated C2 fractures (p = 0.46, p = 0.25). Involvement of the transverse foramen (TF) alone was not associated with BCVI or stroke (p = 0.10-0.40, p = 0.34-0.43). However, TF fractures that were comminuted or contained fracture fragment(s) were associated with increased BCVI (p < 0.01, p = 0.02), though not with stroke (p = 0.11, p = 0.09). In addition, high-energy mechanism of injury was also associated with BCVI (p < 0.01) and stroke (p < 0.01).

Conclusion : C1 and C2 fractures are associated with BCVI in the presence of high-energy mechanism of injury, concomitant fractures of other cervical vertebral body levels, comminuted TF fractures, or TF fractures with internal fragments. Attention to these fracture parameters is important in evaluating C1 and C2 fractures for BCVI.

Conclusion (proposition de traduction) : Les fractures de C1 et C2 sont associées à des lésions vasculaires cérébrales traumatiques en présence d'un mécanisme de lésion à haute énergie, de fractures concomitantes à d'autres niveaux du corps vertébral cervical, de fractures comminutives du foramen transverse ou de fractures du foramen transverse avec des fragments internes. Il est important de prêter attention à ces paramètres de fracture lors de l'évaluation des fractures C1 et C2 en cas de lésions vasculaires cérébrales traumatiques.

Factors associated with tracheal intubation-related complications in the prehospital setting: a prospective multicentric cohort study.
Le Bastard Q, Pès P, Leroux P, Penverne Y, Jenvrin J, Montassier E. | Eur J Emerg Med. 2023 Jun 1;30(3):163-170
DOI: https://doi.org/10.1097/mej.0000000000001010
Keywords: airway management, complications, difficult intubation, prehospital field, tracheal intubation

Original article

Introduction : Emergency tracheal intubation is routinely performed in the prehospital setting. Airway management in the prehospital setting has substantial challenges. Objective The aim of the present study was to determine risk factors predicting tracheal intubation-related complications on the prehospital field.
Setting A prospective, multicentric, cohort study which was conducted in three mobile ICUs (MICUs; service mobile d'urgence et de réanimation).

Méthode : Tracheal intubation-related complications were defined as the occurrence of at least one of the following events: oxygen desaturation (SpO2 < 90%) during tracheal intubation, aspiration (regurgitation visualized during laryngoscopy), and vomiting. Difficult intubation was defined as more than two failed direct laryngoscopic attempts, or the need for any alternative tracheal intubation method. Multivariate logistic regressions were used.

Résultats : During the 5-year study period, 1915 consecutive patients were intubated in the MICUs participating in the study. Overall, 1287 (70%) patients were successfully intubated after the first laryngoscopic attempt, with rates of 90, 74, 42, and 30% for Cormack-Lehane grade 1, 2, 3, and 4, respectively. Tracheal intubation was difficult in 663 cases (36%). Tracheal intubation-related complications occurred in 267 (14%) patients. In the multivariate analysis, we found that the leading risk factors for tracheal intubation-related complications were Cormack and Lehane grade 3 and 4 [odds ratio (OR) = 1.65; 95% confidence interval (CI), 1.05-2.61; and OR = 2.79; 95% CI, 1.56-4.98, respectively], a BMI of more than 30 (OR = 1.61; 95% CI, 1.13-2.28), when intubation was difficult (OR = 1.72; 95% CI, 1.15-2.57), and when tracheal intubation required more than one operator (OR = 2.30; 95% CI, 1.50-3.49).

Conclusion : In this prospective study, we found that Cormack and Lehane more than grade 2, BMI >30, difficult intubation, and tracheal intubation requiring more than one operator were all independent predictors of tracheal intubation-related complications in the prehospital setting. When these risk factors are identified on scene, adapted algorithms that anticipate the use of a bougie should be generalized to reduce morbidity on the prehospital field.

Conclusion (proposition de traduction) : Dans cette étude prospective, nous avons constaté qu'un Cormack et Lehane supérieur au grade 2, un IMC > 30, une intubation difficile et une intubation trachéale nécessitant plus d'un opérateur étaient tous des facteurs prédictifs indépendants de complications liées à l'intubation trachéale dans le cadre préhospitalier. Lorsque ces facteurs de risque sont identifiés sur place, des algorithmes adaptés qui anticipent l'utilisation d'un mandrin long béquillé devraient être généralisés pour réduire la morbidité sur le terrain préhospitalier.

Commentaire : Dans cette étude, le taux de réussite global de l'intubation trachéale était de 99 %, avec 70 % de réussite lors de la première tentative. Globalement, dans les systèmes d'urgence extrahospitaliers assurés par des médecins, le taux de réussite de la première tentative d'intubation varie entre 70 et 85 %
L'utilisation d'un mandrin élastique en gomme dès la première tentative augmentait de manière significative le taux de réussite de l'intubation. Cette information est importante, car le risque de complications liées à l'intubation trachéale est plus élevé lorsque plusieurs tentatives sont nécessaires pour réussir l'intubation trachéale. Il est donc hautement souhaitable de réussir la première tentative d'intubation pour éviter les événements indésirables liés à l'intubation, par l'utilisation d'une technique alternative, telle que le mandrin long béquillé, dès la première tentative et ce même chez les patients ne présentant pas de facteurs prédictifs d'une intubation difficile.

Résultats à comparer avec les deux études suivantes :
• Driver BE et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189  .
• Driver BE et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. Published online December 08, 2021  .

Et l'article de Trent sur la définition de la première tentative d'intubation :
• Trent SA et al. Defining Successful Intubation on the First Attempt Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Ann Emerg Med [Internet]. 2023  .

Performances of HEART score to predict 6-month prognostic of emergency department patients with chest pain: a retrospective cohort analysis.
Fiore G, Pinto G, Preda A, Rampa L, Gaspardone C, Oppizzi M, Slavich M, Di Napoli D, Bianchi G, Etteri M, Margonato A, Fragasso G. | Eur J Emerg Med. 2023 Jun 1;30(3):179-185
DOI: https://doi.org/10.1097/mej.0000000000001022
Keywords: Aucun

Original article

Introduction : Chest pain is a frequent cause of patient admissions in emergency departments (EDs). Clinical scores can help in the management of chest pain patients with an undefined impact on the appropriateness of hospitalization or discharge when compared to usual care.
Objectives: The aim of this study was to assess the performances of the HEART score to predict the 6-month prognostic of patients presenting to the ED of a tertiary referral university hospital with non-traumatic chest pain.

Méthode : From 7040 patients presenting with chest pain from 1 January 2015 to 31 December 2017, after applying exclusion criteria (ST-segment elevation >1 mm, shock, absence of telephone number) we selected a sample of 20% chosen randomly. We retrospectively assessed the clinical course, definitive diagnosis, and HEART score according to ED final report. Follow-up was made by telephone interview with discharged patients. In hospitalized patients, clinical records were analyzed to evaluate major adverse cardiac events (MACE) incidence.
Outcome measure and analysis: The primary endpoint was MACE, comprising cardiovascular death, myocardial infarction, or unscheduled revascularization at 6 months. We assessed the diagnostic performance of the HEART score in ruling out MACE at 6 months. We also assessed the performance of ED usual care in the management of chest pain patients.

Résultats : Of 1119 screened, 1099 were included for analysis after excluding patients lost to follow-up; 788 patients (71.70%) had been discharged and 311 (28.30%) were hospitalized. Incident MACE was 18.3% ( n = 205). The HEART score was retrospectively calculated in 1047 patients showing increasing MACE incidence according to risk category (0.98% for low risk, 38.02% for intermediate risk, and 62.21% for high risk). Low-risk category allowed to safely exclude MACE at 6 months with a negative predictive value (NPV) of 99%. Usual care diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% positive predictive value, and 99% NPV, with an overall accuracy of 98.00%.

Conclusion : In ED patients with chest pain, a low HEART score is associated with a very low risk of MACE at 6 months.

Conclusion (proposition de traduction) : Chez les patients des urgences souffrant de douleurs thoraciques, un score HEART faible est associé à un risque très faible d'événements cardiovasculaires indésirables majeurs à 6 mois.

Association between out-of-hospital cardiac arrest and survival in paediatric traumatic population: results from the French national registry.
Lockhart-Bouron M, Baert V, Leteurtre S, Hubert H, Recher M. | Eur J Emerg Med. 2023 Jun 1;30(3):186-192
DOI: https://doi.org/10.1097/mej.0000000000001024
Keywords: Aucun

Original article

Introduction : Trauma is an important cause of paediatric out-of-hospital cardiac arrest (OHCA) with a high mortality rate.
Objectives: The first aim of this study was to compare the survival rate at day 30 and at hospital discharge following paediatric traumatic and medical OHCA. The second aim was to compare the rates of return of spontaneous circulation and survival rates at hospital admission (Day 0).

Méthode : This multicentre comparative post-hoc study was conducted between July 2011 and February 2022 based on the French National Cardiac Arrest Registry data. All patients aged <18 years with OHCA were included in the study.
Outcome measures and analysis: Patients with traumatic aetiology were matched with those with medical aetiology using propensity score matching. Endpoint was the survival rate at day 30.

Résultats : There were 398 traumatic and 1061 medical OHCAs. Matching yielded 227 pairs. In non-adjusted comparisons, days 0 and 30 survival rates were lower in the traumatic aetiology group than in the medical aetiology group [19.1% vs. 24.0%, odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, and 2.0% vs. 4.5%, OR 0.43, 95% CI, 0.20-0.92, respectively]. In adjusted comparisons, day 30 survival rate was lower in the traumatic aetiology group than in the medical aetiology group (2.2% vs. 6.2%, OR 0.36, 95% CI, 0.13-0.99).

Conclusion : In this post-hoc analysis, paediatric traumatic OHCA was associated with a lower survival rate than medical cardiac arrest.

Conclusion (proposition de traduction) : Dans cette analyse post-hoc, l'arrêt cardiaque pédiatrique traumatique extra-hospitalier est associé à un taux de survie plus faible que l'arrêt cardiaque médical.

A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation.
Radhakrishnan A, McCahill C, Atwal RS, Lahiri S. | Eur J Trauma Emerg Surg. 2023 Jun;49(3):1199-1215
DOI: https://doi.org/10.1007/s00068-022-02048-0
Keywords: Endotracheal intubation; Head injury; Pre-hospital intubation; Traumatic brain injury.

Original Article

Introduction : The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries.

Méthode : We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation.

Résultats : Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months.

Conclusion : The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.

Conclusion (proposition de traduction) : Les données existantes ne plaident pas en faveur d'une intubation préhospitalière généralisée chez tous les patients victimes d'un traumatisme crânien. Cela ne contredit toutefois pas la nécessité d'une intervention en cas d'obstruction grave des voies respiratoires ; en revanche, il convient que le personnel expérimenté évalue si un transfert à l'hôpital à un moment critique est plus profitable. Les résultats neurologiques favorables mis en évidence par l'essai contrôlé randomisé sont en faveur de l'intubation préhospitalière, mais des recherches supplémentaires sont nécessaires dans ce domaine.

Commentaire : Une récente méta-analyse comparant différents prestataires préhospitaliers pratiquant l'intubation préhospitalière a montré une différence entre les taux de réussite. Bien que cela ne soit pas statistiquement significatif, le taux de réussite médian des médecins était de 98,8 %, contre 91,7 % pour les non-médecins.
Crewdson K and al. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care. 2017 Feb 14;21(1):31  .

Indications for prehospital intubation among severely injured children and the prevalence of significant traumatic brain injury among those intubated due to impaired level of consciousness.
Samuel N, Hoffmann Y, Rakedzon S, Lipsky AM, Raz A, Ben Lulu H, Bahouth H, Epstein D. | Eur J Trauma Emerg Surg. 2023 Jun;49(3):1217-1225
DOI: https://doi.org/10.1007/s00068-022-01983-2
Keywords: Airway; Pediatric trauma; Prehospital endotracheal intubation; Prehospital trauma care; Traumatic brain injury.

Original Article

Introduction : Prehospital endotracheal intubation (PEI) of head injured children with impaired level of consciousness (LOC) aims to minimize secondary brain injury. However, PEI is controversial in otherwise stable children. We aimed to investigate the indications for PEI among pediatric trauma patients and the prevalence of clinically significant traumatic brain injury (csTBI) among those intubated solely due to impaired consciousness.

Méthode : This is a multicenter retrospective cohort study of children who underwent PEI in northern Israel between January 2014 and December 2020 by six EMS agencies and were transported to two trauma centers in the area. We extracted data from EMS records and trauma registries.

Résultats : PEI was attempted in 179/986 (18.2%) patients and was successful in 92.2% of cases. Common indications for PEI were hypoxemia not corrected by supplemental oxygen (n = 30), traumatic cardiac arrest (n = 16), and facial injury compromising the airway (n = 13). 112 patients (62.6%) were intubated solely due to impaired or deteriorating LOC. Among these patients, 68 (62.4%) suffered csTBI. The prevalence of csTBI among those with field Glasgow Coma Scale (GCS) of 3, 4-8, and > 8 was 81.4%, 55.8%, and 28.6%, respectively (p < 0.001). Among children ≤ 10 years old intubated due to impaired LOC, 50% had csTBI.

Conclusion : Impaired LOC is a major indication for PEI. However, a significant proportion of these patients do not suffer csTBI. Older age and lower pre-intubation GCS are associated with more accurate field classification. Our data indicate that further investigation and better characterization of patients who may benefit from PEI is necessary.

Conclusion (proposition de traduction) : L'altération de l'état de conscience est une indication majeure de l'intubation endotrachéale préhospitalière. Cependant, une proportion significative de ces patients ne souffre pas de lésion cérébrale traumatique. Un âge plus avancé et un Glasgow plus bas avant l'intubation sont associés à une évaluation plus précise de la situation sur le terrain. Nos données indiquent qu'il est nécessaire de poursuivre les recherches et de mieux caractériser les patients susceptibles de bénéficier d'une intubation endotrachéale préhospitalière.

Effects of reduction technique for acute anterior shoulder dislocation without sedation or intra-articular pain management: a systematic review and meta-analysis.
Baden DN, Visser MFL, Roetman MH, Smeeing DPJ, Houwert RM, Groenwold RHH, van der Meijden OAJ. | Eur J Trauma Emerg Surg. 2023 Jun;49(3):1383-1392
DOI: https://doi.org/10.1007/s00068-023-02242-8  | Télécharger l'article au format  
Keywords: Biomechanical reduction techniques; Leverage technique; Reduction success; Shoulder dislocation; Systematic review; Traction–countertraction technique.

Review Article

Introduction : Anterior shoulder dislocations are commonly seen in the emergency department for which several closed reduction techniques exist. The aim of this systematic review is to identify the most successful principle of closed reduction techniques for an acute anterior shoulder dislocation in the emergency department without the use of sedation or intra-articular lidocaine injection.

Méthode : A literature search was conducted up to 15-08-2022 in the electronic databases of PubMed, Embase and CENTRAL for randomized and observational studies comparing two or more closed reduction techniques for anterior shoulder dislocations. Included techniques were grouped based on their main operating mechanism resulting in a traction-countertraction (TCT), leverage and biomechanical reduction technique (BRT) group. The primary outcome was success rate and secondary outcomes were reduction time and endured pain scores. Meta-analyses were conducted between reduction groups and for the primary outcome a network meta-analysis was performed.

Résultats : A total of 3118 articles were screened on title and abstract, of which 9 were included, with a total of 987 patients. Success rates were 0.80 (95% CI 0.74; 0.85), 0.81 (95% CI 0.63; 0.92) and 0.80 (95% CI 0.56; 0.93) for BRT, leverage and TCT, respectively. No differences in success rates were observed between the three separate reduction groups. In the network meta-analysis, similar yet more precise effect estimates were found. However, in a post hoc analysis the BRT group was more successful than the combined leverage and TCT group with a relative risk of 1.33 (95% CI 1.19, 1.48).

Conclusion : All included techniques showed good results with regard to success of reduction. The BRT might be the preferred technique for the reduction of an anterior shoulder dislocation, as patients experience the least pain and it results in the fastest reduction.

Conclusion (proposition de traduction) : Toutes les techniques utilisées ont donné de bons résultats en ce qui concerne la réussite de la réduction. La technique de réduction biomécanique pourrait être la technique préférée pour la réduction d'une luxation antérieure de l'épaule, car les patients ressentent le moins de douleur et la réduction est la plus rapide.

Acute kidney injury.
Joannidis M, Meersch-Dini M, Forni LG. | Intensive Care Med. 2023 Jun;49(6):665-668
DOI: https://doi.org/10.1007/s00134-023-07061-4  | Télécharger l'article au format  
Keywords: Aucun

Recent Advances in ICU

Editorial : The introduction by the KDIGO group (Kidney Disease: Improving Global Outcomes) of an accepted definition of acute kidney injury (AKI) has highlighted that AKI is commonly encountered in the critically ill and influences outcomes [1, 2]. Hence, in recent years, much attention has focussed on not only prevention of AKI but also optimising treatment.

Conclusion : Despite a degree of nihilism from some that given the syndromic nature of AKI, no “cure” exists we are making small but significant steps. Biomarkers aid our diagnosis and shed insights into the longevity of an AKI episode. We have more knowledge with regard to fluid prescription, haemodynamic monitoring where appropriate, and where RRT is considered, we have a better idea as to when not to start. Some may be persuaded that other tools may help identify AKI early, including artificial intelligence (AI). The role of AI will undoubtedly influence the practice of medicine significantly in the future and recent meta-analyses of currently published models showed promising performance for early prediction of postoperative AKI [15]. However, a word of caution. External validation for many models is lacking and often shows a reduced accuracy when performed. Also few, if any, have been shown to have clinical effects when used, either improving clinical decision-making or not. There is also the concern that physicians may await instruction from an AI system rather than use their clinical skills to take action promptly.

Conclusion (proposition de traduction) : Malgré un certain nihilisme de la part de certains, qui estiment qu'étant donné la nature syndromique de l'insuffisance rénale aiguë, il n'existe pas de "remède", nous avançons à petits pas, mais de manière significative. Les biomarqueurs facilitent notre diagnostic et nous éclairent sur la longévité d'un épisode d'insuffisance rénale aiguë. Nous disposons de plus de connaissances en ce qui concerne la prescription de liquides, la surveillance hémodynamique le cas échéant, et lorsqu'une thérapie de remplacement rénal est envisagée, nous avons une meilleure idée du moment où il ne faut pas commencer. Certains seront peut-être persuadés que d'autres outils peuvent aider à identifier précocement les lésions rénales aiguës, notamment l'intelligence artificielle (IA). Le rôle de l'IA influencera sans aucun doute la pratique de la médecine de manière significative à l'avenir et des méta-analyses récentes des modèles actuellement publiés ont montré des performances prometteuses pour la prédiction précoce de l'insuffisance rénale aiguë postopératoire. Une mise en garde s'impose toutefois. La validation externe de nombreux modèles fait défaut et, lorsqu'elle est effectuée, elle montre souvent une précision réduite. En outre, peu de modèles, voire aucun, se sont avérés avoir des effets cliniques lorsqu'ils sont utilisés, qu'ils améliorent ou non la prise de décision clinique. On peut également craindre que les médecins attendent les instructions d'un système d'IA au lieu d'utiliser leurs compétences cliniques pour agir rapidement.

Commentaire :  Vers une meilleure prise en charge de l'insuffisance rénale aiguë.
CKD chronic kidney disease; KDIGO kidney disease: improving global outcomes; MAKE major adverse kidney events; RRT renal replacement therapy.

Invasive mechanical ventilation.
Wong IMJ, Ferguson ND, Urner M. | Intensive Care Med. 2023 Jun;49(6):669-672
DOI: https://doi.org/10.1007/s00134-023-07079-8  | Télécharger l'article au format  
Keywords: Aucun

Recent Advances in ICU

Editorial : Mechanical ventilation is provided to up to 20 million patients annually in intensive care units (ICUs) worldwide. Despite lung-protective mechanical ventilation strategies, the mortality of mechanically ventilated patients remains high, especially in patients with acute respiratory distress syndrome (ARDS). Current lung-protective mechanical ventilation strategies include lower tidal volume (TV) ventilation of 4–6 ml/kg predicted body weight (PBW), the potential use of higher positive end-expiratory pressure (PEEP) without routine stepwise recruitment maneuvers for moderate-to-severe ARDS, early prone positioning, the use of extracorporeal life support (ECLS), and the practice of spontaneous breathing trials [1]. This article outlines recent advances in mechanical ventilation and discusses innovative concepts that after further investigation have the potential to change future practice.

Conclusion : As summarized in Fig. 1, recent advances in invasive mechanical ventilation are characterized by the growing awareness that ARDS is a highly heterogeneous syndrome, and interventions to improve clinical outcomes need to be tailored to specific patient subgroups that share distinct clinical and possibly molecular phenotypes. Many of the concepts described above are very innovative and have a solid physiological rationale but have yet to be tested in large clinical studies. Ongoing research efforts, therefore, continue to investigate treatment strategies that optimally support the patient during recovery from the underlying illness, while mitigating the risk of additional harm associated with mechanical ventilation.

Conclusion (proposition de traduction) : Comme le résume la figure 1, les récentes avancées en matière de ventilation mécanique invasive se caractérisent par une prise de conscience croissante du fait que le SDRA est un syndrome très hétérogène et que les interventions visant à améliorer les résultats cliniques doivent être adaptées à des sous-groupes de patients spécifiques qui partagent des phénotypes cliniques et éventuellement moléculaires distincts. Bon nombre des concepts décrits ci-dessus sont très novateurs et reposent sur une justification physiologique solide, mais ils n'ont pas encore été testés dans le cadre d'études cliniques de grande envergure. Les efforts de la recherche se poursuivent donc pour étudier des stratégies de traitement qui permettent de soutenir au mieux le patient pendant sa convalescence, tout en réduisant le risque de dommages supplémentaires associés à la ventilation mécanique.

Commentaire :  Fig. 1. Concepts novateurs en cours d'étude qui pourraient modifier la pratique future de la ventilation mécanique.
ECCO2R extracorporeal carbon dioxide removal, PEEP positive end-expiratory pressure

The use of high-flow nasal oxygen.
Maggiore SM, Grieco DL, Lemiale V. | Intensive Care Med. 2023 Jun;49(6):673-676
DOI: https://doi.org/10.1007/s00134-023-07067-y  | Télécharger l'article au format  
Keywords: Aucun

Recent Advances in ICU

Editorial : In the last decade, the use of high-flow nasal oxygen (HFNO), a technique of noninvasive respiratory support, has become widespread in critically ill patients.

Conclusion : With HFNO, up to 60 L/min of fresh gas flow generated by an air/oxygen blender or a turbine is conditioned by a heated humidifier (temperature 31–37°C, absolute humidity 30–44 mgH2O/L) and administered to the patient through large-bore nasal cannulas. HFNO has several beneficial physiological effects including the accurate delivery of the set FiO2, the washout of anatomical deadspace and the reduction of breathing effort, the increase in positive airway pressure with improvement in lung aeration, in oxygenation and in respiratory mechanics, and the optimization in patients’ comfort. As many of the effects of HFNO are flow-dependent, maximum tolerated flows should be delivered to maximize the respiratory support, while temperature should be set according to patient’s comfort and FiO2 should be tailored on the target SpO2.
More recently, HFNO delivered through asymmetric nasal cannulas has been proposed with the aim of further enhancing carbon dioxide washout and increasing the airway pressure generation. The physiological effects of this design are currently under investigation.
We hereby summarize the most recent evidence regarding HFNO use in the intensive care unit.

Conclusion (proposition de traduction) : Avec l'OHD, jusqu'à 60 L/min de débit de gaz frais généré par un mélangeur air/oxygène ou une turbine sont humidifiés par un humidificateur chauffé (température 31-37°C, humidité absolue 30-44 mgH2O/L) et administrés au patient par l'intermédiaire de canules nasales de grand diamètre. L'OHD a plusieurs effets physiologiques bénéfiques, notamment l'administration précise d'une FiO2 programmée, l'élimination de l'espace mort anatomique et la réduction de l'effort respiratoire, l'augmentation de la pression positive des voies aériennes avec une amélioration de la ventilation des poumons, de l'oxygénation et de la mécanique respiratoire, ainsi que l'optimisation du confort des patients (Fig. 1). Comme de nombreux effets de l'OHD dépendent du débit, les débits maximaux tolérés doivent être délivrés pour maximiser l'assistance respiratoire, tandis que la température doit être réglée en fonction du confort du patient et que la FiO2 doit être adaptée à la SpO2 cible. Plus récemment, il a été proposé d'administrer de l'OHD au moyen de canules nasales asymétriques afin d'améliorer encore l'élimination du dioxyde de carbone et d'augmenter la pression générée dans les voies respiratoires. Les effets physiologiques de cette conception sont actuellement à l'étude. Nous résumons ici les données les plus récentes concernant l'utilisation de l'OHD dans les unités de soins intensifs.

Commentaire :  Fig. 1 Effets physiologiques/cliniques et indications de l'oxygène à haut débit.
PANNEAU SUPÉRIEUR : les principaux effets physiologiques de l'oxygène nasal à haut débit sont illustrés. Par exemple, la pression générée dans les voies respiratoires peut influencer l'élimination du dioxyde de carbone (par exemple, plus la pression est élevée, plus l'élimination du dioxyde de carbone est importante). De même, la génération d'une pression positive dans les voies aériennes et l'élimination du dioxyde de carbone fournie par le système pourraient toutes deux influencer l'effort inspiratoire.
TABLEAU DU BAS : les effets physiologiques et cliniques de l'oxygène nasal à haut débit sont détaillés, ainsi que ses indications dans différents scénarios cliniques.
FiO2: inspired fraction of oxygen, CO2 carbon dioxide, ARF acute respiratory failure, PEEP positive end-expiratory pressure, P-SILI patient self-inflicted lung injury

Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin and Recurrent VTE in Patients With Cancer: A Randomized Clinical Trial.
Schrag D, Uno H, Rosovsky R, Rutherford C, Sanfilippo K, Villano JL, Drescher M, Jayaram N, Holmes C, Feldman L, Zattra O, Farrar-Muir H, Cronin C, Basch E, Weiss A, Connors JM; CANVAS Investigators. | JAMA. 2023 Jun 13;329(22):1924-1933
DOI: https://doi.org/10.1001/jama.2023.7843
Keywords: Aucun

Original Investigation

Introduction : In patients with cancer who have venous thromboembolism (VTE) events, long-term anticoagulation with low-molecular-weight heparin (LMWH) is recommended to prevent recurrent VTE. The effectiveness of a direct oral anticoagulant (DOAC) compared with LMWH for preventing recurrent VTE in patients with cancer is uncertain.
Objective

Méthode : Unblinded, comparative effectiveness, noninferiority randomized clinical trial conducted at 67 oncology practices in the US that enrolled 671 patients with cancer (any invasive solid tumor, lymphoma, multiple myeloma, or chronic lymphocytic leukemia) who had a new clinical or radiological diagnosis of VTE. Enrollment occurred from December 2016 to April 2020. Final follow-up was in November 2020.
Intervention: Participants were randomized in a 1:1 ratio to either a DOAC (n = 335) or LMWH (n = 336) and were followed up for 6 months or until death. Physicians and patients selected any DOAC or any LMWH (or fondaparinux) and physicians selected drug doses.
Main outcomes and measures: The primary outcome was the recurrent VTE rate at 6 months. Noninferiority of anticoagulation with a DOAC vs LMWH was defined by the upper limit of the 1-sided 95% CI for the difference of a DOAC relative to LMWH of less than 3% in the randomized cohort that received at least 1 dose of assigned treatment. The 6 prespecified secondary outcomes included major bleeding, which was assessed using a 2.5% noninferiority margin.

Résultats : Between December 2016 and April 2020, 671 participants were randomized and 638 (95%) completed the trial (median age, 64 years; 353 women [55%]). Among those randomized to a DOAC, 330 received at least 1 dose. Among those randomized to LMWH, 308 received at least 1 dose. Rates of recurrent VTE were 6.1% in the DOAC group and 8.8% in the LMWH group (difference, -2.7%; 1-sided 95% CI, -100% to 0.7%) consistent with the prespecified noninferiority criterion. Of 6 prespecified secondary outcomes, none were statistically significant. Major bleeding occurred in 5.2% of participants in the DOAC group and 5.6% in the LMWH group (difference, -0.4%; 1-sided 95% CI, -100% to 2.5%) and did not meet the noninferiority criterion. Severe adverse events occurred in 33.8% of participants in the DOAC group and 35.1% in the LMWH group. The most common serious adverse events were anemia and death.

Conclusion : Among adults with cancer and VTE, DOACs were noninferior to LMWH for preventing recurrent VTE over 6-month follow-up. These findings support use of a DOAC to prevent recurrent VTE in patients with cancer.

Conclusion (proposition de traduction) : Chez les adultes présentant un cancer et une thrombose veineuse, les anticoagulants oraux directs n'étaient pas inférieurs à l'héparine de faible poids moléculaire pour la prévention de la thrombose veineuse récidivante au cours d'un suivi de six mois. Ces résultats sont favorables à l'utilisation d'un anticoagulant oral direct pour prévenir les thromboemboses veineuses récurrentes chez les patients atteints d'un cancer.

Fluid Therapy for Critically Ill Adults With Sepsis: A Review.
Zampieri FG, Bagshaw SM, Semler MW. | JAMA. 2023 Jun 13;329(22):1967-1980
DOI: https://doi.org/10.1001/jama.2023.7560
Keywords: Aucun

Review

Introduction : Approximately 20% to 30% of patients admitted to an intensive care unit have sepsis. While fluid therapy typically begins in the emergency department, intravenous fluids in the intensive care unit are an essential component of therapy for sepsis.

Résultats : For patients with sepsis, intravenous fluid can increase cardiac output and blood pressure, maintain or increase intravascular fluid volume, and deliver medications. Fluid therapy can be conceptualized as 4 overlapping phases from early illness through resolution of sepsis: resuscitation (rapid fluid administered to restore perfusion); optimization (the risks and benefits of additional fluids to treat shock and ensure organ perfusion are evaluated); stabilization (fluid therapy is used only when there is a signal of fluid responsiveness); and evacuation (excess fluid accumulated during treatment of critical illness is eliminated). Among 3723 patients with sepsis who received 1 to 2 L of fluid, 3 randomized clinical trials (RCTs) reported that goal-directed therapy administering fluid boluses to attain a central venous pressure of 8 to 12 mm Hg, vasopressors to attain a mean arterial blood pressure of 65 to 90 mm Hg, and red blood cell transfusions or inotropes to attain a central venous oxygen saturation of at least 70% did not decrease mortality compared with unstructured clinical care (24.9% vs 25.4%; P = .68). Among 1563 patients with sepsis and hypotension who received 1 L of fluid, an RCT reported that favoring vasopressor treatment did not improve mortality compared with further fluid administration (14.0% vs 14.9%; P = .61). Another RCT reported that among 1554 patients in the intensive care unit with septic shock treated with at least 1 L of fluid compared with more liberal fluid administration, restricting fluid administration in the absence of severe hypoperfusion did not reduce mortality (42.3% vs 42.1%; P = .96). An RCT of 1000 patients with acute respiratory distress during the evacuation phase reported that limiting fluid administration and administering diuretics improved the number of days alive without mechanical ventilation compared with fluid treatment to attain higher intracardiac pressure (14.6 vs 12.1 days; P < .001), and it reported that hydroxyethyl starch significantly increased the incidence of kidney replacement therapy compared with saline (7.0% vs 5.8%; P = .04), Ringer lactate, or Ringer acetate.

Conclusion : Fluids are an important component of treating patients who are critically ill with sepsis. Although optimal fluid management in patients with sepsis remains uncertain, clinicians should consider the risks and benefits of fluid administration in each phase of critical illness, avoid use of hydroxyethyl starch, and facilitate fluid removal for patients recovering from acute respiratory distress syndrome.

Conclusion (proposition de traduction) : Le remplissage vasculaire est un élément important du traitement des patients de réanimation présentant un septis. Bien que la gestion optimale dru remplissage vasculaire chez les patients présentant un sepsis reste incertaine, les praticiens doivent prendre en compte les risques et les avantages de l'administration de liquides à chaque phase de la réanimation, éviter l'utilisation d'hydroxyéthylamidon et faciliter l'élimination des liquides chez les patients se sortant d'un syndrome de détresse respiratoire aigüe.

Normative Echocardiographic Left Ventricular Parameters and Reference Intervals in Infants.
Vøgg ROB, Sillesen AS, Wohlfahrt J, Pihl C, Raja AA, Vejlstrup N, Norsk JB, Elia E, Sleeper LA, Colan SD, Iversen KK, Boyd HA, Bundgaard H. | J Am Coll Cardiol. 2023 Jun 6;81(22):2175-2185
DOI: https://doi.org/10.1016/j.jacc.2023.03.423
Keywords: cardiovascular growth; echocardiography; normative reference intervals; pediatric; z-scores.

Research article

Introduction : In pediatric echocardiography, reference intervals are required to distinguish normal variation from pathology. Left ventricular (LV) parameters are particularly important predictors of clinical outcome. However, data from healthy newborns are limited, and current reference intervals provide an inadequate approximation of normal reference ranges.
Objectives: Normative reference intervals and z-scores for 2-dimensional echocardiographic measurements of LV structure and function based on a large group of healthy newborns were developed.

Méthode : The study population included 13,454 healthy newborns from the Copenhagen Baby Heart Study who were born at term to healthy mothers, had an echocardiogram performed within 30 days of birth, and did not have congenital heart disease. To develop normative reference intervals, this study modeled 10 LV parameters as a function of body surface area through joint modeling of 4 statistical components.

Résultats : Infants in the study population (48.5% were female) had a median body surface area of 0.23 m² (IQR: 0.22-0.25 m²) and median age of 12.0 days (IQR: 8.0-15.0 days) at examination. All normative reference intervals performed well in both sexes without stratification on infant sex. In contrast, creation of separate reference models for infants examined at <7 days of age and those examined at 7-30 days of age was necessary to optimize the performance of the reference intervals.

Conclusion : This study provides normative reference intervals and z-scores for 10 clinical, widely used echocardiographic measures of LV structure and function based on a large cohort of newborns. These results provide highly needed reference material for clinical application by pediatric cardiologists.

Conclusion (proposition de traduction) : Cette étude fournit des intervalles de référence normatifs et des z-scores pour 10 mesures échocardiographiques cliniques, largement utilisées, de la structure et de la fonction du ventricule gauche, sur la base d'une large cohorte de nouveau-nés. Ces résultats fournissent un matériel de référence hautement utile pour l'application clinique par les cardiologues pédiatriques.

Association of Beta-Blocker Therapy With Cardiovascular Outcomes in Patients With Stable Ischemic Heart Disease.
Godoy LC, Farkouh ME, Austin PC, Shah BR, Qiu F, Jackevicius CA, Wijeysundera HC, Krumholz HM, Ko DT. | J Am Coll Cardiol. 2023 Jun 20;81(24):2299-2311
DOI: https://doi.org/10.1016/j.jacc.2023.04.021
Keywords: beta-blocker; cardiovascular outcomes; stable coronary artery disease.

Research article

Introduction : Previous studies have failed to show a cardioprotective benefit of beta-blockers in patients with stable coronary artery disease (CAD).
Objectives: This study sought to determine the association between beta-blockers and cardiovascular events in patients with stable CAD using a new user design.

Méthode : All patients aged >66 years undergoing elective coronary angiography in Ontario, Canada, from 2009 to 2019 with diagnosed obstructive CAD were included. Exclusion criteria included heart failure or a recent myocardial infarction, as well as having a beta-blocker prescription claim in the previous year. Beta-blocker use was defined as having at least 1 beta-blocker prescription claim in the 90 days preceding or after the index coronary angiography. The main outcome was a composite of all-cause mortality and hospitalization for heart failure or myocardial infarction. Inverse probability of treatment weighting using the propensity score was used to account for confounding.

Résultats : This study included 28,039 patients (mean age: 73.0 ± 5.6 years; 66.2% male), and 12,695 of those (45.3%) were newly prescribed beta-blockers. The 5-year risks of the primary outcome were 14.3% in the beta-blocker group and 16.1% in the no beta-blocker group (absolute risk reduction: -1.8%; 95% CI: -2.8 to -0.8; HR: 0.92; 95% CI: 0.86-0.98; P = 0.006). This result was driven by reductions in myocardial infarction hospitalization (cause-specific HR: 0.87; 95% CI: 0.77-0.99; P = 0.031), whereas no differences were observed in all-cause death or heart failure hospitalization.

Conclusion : In patients with angiographically documented stable CAD without heart failure or a recent myocardial infarction, beta-blockers were associated with a small but significant reduction in cardiovascular events at 5 years.

Conclusion (proposition de traduction) : Chez les patients présentant une cardiopathie ischémique stable documentée par angiographie, sans insuffisance cardiaque ni infarctus du myocarde récent, les bêta-bloquants ont été associés à une réduction faible mais significative des événements cardiovasculaires à 5 ans.

The Pediatric Rigid Stylet Improves First-Pass Success Compared With the Standard Malleable Stylet and Tracheal Tube Introducer in a Simulated Pediatric Emergency Intubation.
Pacheco GS, Leetch AN, Patanwala AE, Hurst NB, Mendelson JS, Sakles JC. | Pediatr Emerg Care. 2023 Jun 1;39(6):423-427
DOI: https://doi.org/10.1097/pec.0000000000002802
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI.

Méthode : This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct.

Résultats : Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm).

Conclusion : Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children

Conclusion (proposition de traduction) : L'utilisation du stylet rigide pédiatrique par les résidents en médecine d'urgence et en médecine d'urgence et de soins intensifs sur un simulateur de nourrisson a été associée à une meilleure réussite du premier essai et à un temps d'intubation plus court. Des études cliniques sont justifiées pour comparer ces aides à l'intubation chez les enfants.

Use of a novel smartphone-based application tool for enrolment and randomisation in pre-hospital clinical trials.
Bloom JE, Partovi A, Bernard S, Okyere D, Heritier S, Mahony E, Eliakundu AL, Dawson LP, Voskoboinik A, Anderson D, Ball J, Chan W, Kaye DM, Nehme Z, Stub D. | Resuscitation. 2023 Jun;187:109787
DOI: https://doi.org/10.1016/j.resuscitation.2023.109787
Keywords: Methods; Randomised controlled trial; Smartphone; Trial design.

Commentary and concepts

Editorial : The effective recruitment and randomisation of patients in pre-hospital clinical trials presents unique challenges. Owing to the time critical nature of many pre-hospital emergencies and limited resourcing, the use of traditional methods of randomisation that may include centralised telephone or web-based systems are often not practicable or feasible. Previous technological limitations have necessitated that pre-hospital trialists strike a compromise between implementing pragmatic, deliverable study designs, with robust enrolment and randomisation methodologies. In this commentary piece, we present a novel smartphone-based solution that has the potential to align pre-hospital clinical trial recruitment processes to that of best-in-practice in-hospital and ambulatory care based studies.

Conclusion : Enrolment and randomisation of patients in the pre-hospital setting is challenging and existing methodologies to facilitate this process have the potential to introduce significant biases to any study outcomes. The use of a novel smartphone-based enrolment and randomisation application has the capacity to streamline patient recruitment and introduce methodological rigour that is comparable to that of high- quality in-hospital studies. The use of this technology should be con- sidered a viable alternate recruitment methodology in the conduct of pre-hospital clinical trials.

Conclusion (proposition de traduction) : Le recrutement et la randomisation des patients en milieu préhospitalier sont difficiles et les méthodologies existantes pour faciliter ce processus sont susceptibles d'introduire des biais importants dans les résultats de l'étude. L'utilisation d'une nouvelle application de recrutement et de randomisation basée sur un smartphone a la capacité de simplifier le recrutement des patients et d'introduire une rigueur méthodologique comparable à celle des études hospitalières de haute qualité. L'utilisation de cette technologie devrait être considérée comme une méthode de recrutement alternative viable dans la conduite d'essais cliniques pré-hospitaliers.

Commentaire :  Proposition de processus utilisant la randomisation par smartphone

Determinants of survival in sudden cardiac arrest manifesting with pulseless electrical activity.
Holmstrom L, Chugh H, Uy-Evanado A, Salvucci A, Jui J, Reinier K, Chugh SS. | Resuscitation. 2023 Jun;187:109798
DOI: https://doi.org/10.1016/j.resuscitation.2023.109798  | Télécharger l'article au format  
Keywords: Asthma: copd; General population; Hypoxia; Pulseless Electrical Activity; Sudden Cardiac Arrest; Survival.

Clinical paper

Introduction : The proportion of sudden cardiac arrests (SCA) manifesting with pulseless electrical activity (PEA) has increased significantly, and the survival rate remains lower than ventricular fibrillation (VF). However, a subgroup of PEA-SCA cases does survive and may yield key predictors of improved outcomes when compared to non-survivors. We aimed to identify key predictors of survival from PEA-SCA.

Méthode : Our study sample is drawn from two ongoing community-based, prospective studies of out-of-hospital SCA: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; 2002-2017) and Ventura PRESTO from Ventura County, CA (Pop. approx. 850,000, 2015-2021). For the present sub-study, we included SCA cases with PEA as the presenting rhythm where emergency medical services (EMS) personnel attempted resuscitation.

Résultats : We identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) non-survivors. Patients whose PEA-SCA occurred in a healthcare unit (16.9%) or public location (18.1%) had higher survival than those whose PEA-SCA occurred at home (9.3%) or in a care facility (5.7%). Young age, witness status, PEA-SCA location and pre-existing COPD/asthma were independent predictors of survival. Among witnessed cases the survival rate was 10% even if EMS response time was >10 minutes.

Conclusion : Key determinants for survival from PEA-SCA were young age, witnessed status, public location and pre-existing COPD/asthma. Survival outcomes in witnessed PEA cases were better than expected, even with delayed EMS response.

Conclusion (proposition de traduction) : Les principaux déterminants de la survie dans les cas d'arrêts cardiaques soudains se manifestant par une activité électrique sans pouls sont le jeune âge, le statut de témoin, le lieu public et la présence d'une BPCO ou d'un asthme préexistant. Les résultats en matière de survie dans les cas d'activité électrique sans pouls chez les témoins ont été meilleurs que prévu, même en cas d'intervention retardée des services médicaux d'urgence.

Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: A randomised controlled trial.
Prause G, Zoidl P, Eichinger M, Eichlseder M, Orlob S, Ruhdorfer F, Honnef G, Metnitz PGH, Zajic P. | Resuscitation. 2023 Jun;187:109765
DOI: https://doi.org/10.1016/j.resuscitation.2023.109765  | Télécharger l'article au format  
Keywords: Aucun

Short paper

Introduction : This study sought to assess the effects of increasing the ventilatory rate from 10 min^-1 to 20 min^-1 using a mechanical ventilator during cardio-pulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) on ventilation, acid-base-status, and outcomes.

Méthode : This was a randomised, controlled, single-centre trial in adult patients receiving CPR including advanced airway management and mechanical ventilation offered by staff of a prehospital physician response unit (PRU). Ventilation was conducted using a turbine-driven ventilator (volume-controlled ventilation, tidal volume 6 ml per kg of ideal body weight, positive end-expiratory pressure (PEEP) 0 mmHg, inspiratory oxygen fraction (FiO₂) 100%), frequency was pre-set at either 10 or 20 breaths per minute according to week of randomisation. If possible, an arterial line was placed and blood gas analysis was performed.

Résultats : The study was terminated early due to slow recruitment. 46 patients (23 per group) were included. Patients in the 20 min^-1 group received higher expiratory minute volumes [8.8 (6.8-9.9) vs. 4.9 (4.2-5.7) litres, p < 0.001] without higher mean airway pressures [11.6 (9.8-13.6) vs. 9.8 (8.5-12.0) mmHg, p = 0.496] or peak airway pressures [42.5 (36.5-45.9) vs. 41.4 (32.2-51.7) mmHg, p = 0.895]. Rates of ROSC [12 of 23 (52%) vs. 11 of 23 (48%), p = 0.768], median pH [6.83 (6.65-7.05) vs. 6.89 (6.80-6.97), p = 0.913], and median pCO2 [78 (51-105) vs. 86 (73-107) mmHg, p > 0.999] did not differ between groups.

Conclusion : 20 instead of 10 mechanical ventilations during CPR increase ventilation volumes per minute, but do not improve CO₂ washout, acidaemia, oxygenation, or rate of ROSC.

Conclusion (proposition de traduction) : 20 cycles respiratoires mécaniques au lieu de 10 pendant la réanimation cardio-pulmonaire augmentent les volumes de ventilation par minute, mais n'améliorent pas l'élimination du CO2, l'acidose, l'oxygénation ou le taux de récupération d'activié cardiaque spontané.

Predictors of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia: a multi-centre observational study.
Price J, Moncur L, Lachowycz K, Major R, Sagi L, McLachlan S, Keeliher C, Steel A, Sherren PB, Barnard EBG. | Scand J Trauma Resusc Emerg Med. 2023 Jun 2;31(1):26
DOI: https://doi.org/10.1186/s13049-023-01091-z  | Télécharger l'article au format  
Keywords: Hypotension; Post-intubation hypotension; Prehospital; Prehospital emergency anaesthesia; Rapid sequence induction.

ORIGINAL RESEARCH

Introduction : Post-intubation hypotension (PIH) after prehospital emergency anaesthesia (PHEA) is prevalent and associated with increased mortality in trauma patients. The objective of this study was to compare the differential determinants of PIH in adult trauma patients undergoing PHEA.

Méthode : This multi-centre retrospective observational study was performed across three Helicopter Emergency Medical Services (HEMS) in the UK. Consecutive sampling of trauma patients who underwent PHEA using a fentanyl, ketamine, rocuronium drug regime were included, 2015-2020. Hypotension was defined as a new systolic blood pressure (SBP) < 90 mmHg within 10 min of induction, or > 10% reduction if SBP was < 90 mmHg before induction. A purposeful selection logistic regression model was used to determine pre-PHEA variables associated with PIH.

Résultats : During the study period 21,848 patients were attended, and 1,583 trauma patients underwent PHEA. The final analysis included 998 patients. 218 (21.8%) patients had one or more episode(s) of hypotension ≤ 10 min of induction. Patients > 55 years old; pre-PHEA tachycardia; multi-system injuries; and intravenous crystalloid administration before arrival of the HEMS team were the variables significantly associated with PIH. Induction drug regimes in which fentanyl was omitted (0:1:1 and 0:0:1 (rocuronium-only)) were the determinants with the largest effect sizes associated with hypotension.

Conclusion : The variables significantly associated with PIH only account for a small proportion of the observed outcome. Clinician gestalt and provider intuition is likely to be the strongest predictor of PIH, suggested by the choice of a reduced dose induction and/or the omission of fentanyl during the anaesthetic for patients perceived to be at highest risk.

Conclusion (proposition de traduction) : Les variables significativement associées à l'hypotension après intubation n'expliquent qu'une petite partie des résultats observés. La pratique clinique et l'intuition du soignant sont susceptibles d'être les meilleurs prédicteurs de l'hypotension après intubation, comme le suggère le choix d'une induction à dose réduite et/ou l'omission du fentanyl pendant l'anesthésie pour les patients perçus comme présentant le risque le plus élevé.

Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study.
Choi H, Kim DW, Jung E, Kye YC, Lee J, Jo S, Kang M, Kim D, Kim B. | Am J Emerg Med. 2023 Jun;68:68-72
DOI: https://doi.org/10.1016/j.ajem.2023.03.020
Keywords: Hematuria; Length of stay; Tranexamic acid.

Original contribution

Introduction : Local applications of tranexamic acid (TXA) have been effective in treating various hemorrhagic conditions. In patients with gross hematuria, the main treatment in the emergency department (ED) is continuous bladder irrigation (CBI). However, CBI has no pharmacological effects except blood clot removal from dilution. The aim of this study was to evaluate the impact of the intravesical TXA injection before CBI.

Méthode : This study was a before-and-after, retrospective, and single-center study. The target population was hematuria patients who received CBI via a 3-way Foley catheter. As the intervention procedure, 1000 mg of TXA was injected through the Foley catheter and after 15 min, the Foley catheter was declamped and CBI started. Since the intervention started in March 2022, the patients from March 2022 to August 2022 were assigned to the after group and the patients from March 2021 to August 2021 were assigned to the before group. The primary outcomes were the length of stay in the ED and duration of Foley catheter placement. The secondary outcomes were the admissions and the revisits for CBI within 48 h after discharge.

Résultats : The numbers of patients in the before group and after group were 73 and 86, respectively. The median length of stay in the ED was shorter in the intervention group than in the group not treated with TXA (274 min vs. 411 mins, P < 0.001). The median duration of Foley catheter placement was also shorter in the intervention group than not treated with TXA (145 min vs. 308 mins, P < 0.001). The revisits after ED discharge were lower in the after group than in the before group (2.3% vs. 12.3%, P = 0.031). There was a trend for lower admissions in the TXA treatment group than before group (29.1% vs. 45.2%, P = 0.052).

Conclusion : After the TXA intervention, reduction in the length of stay in the ED, the duration of Foley catheter placement, and the revisits after ED discharge was observed.

Conclusion (proposition de traduction) : Après le traitement par l'acide tranexamique, on a observé une réduction de la durée du séjour aux urgences, de la durée de pose de la sonde de Foley et des re-consultations après la sortie des urgences.

High or mid-flow oxygen therapy for primary headache disorders: A randomized controlled study..
Kaçer İ, Çağlar A. | Am J Emerg Med. 2023 Jun;68:138-143
DOI: https://doi.org/10.1016/j.ajem.2023.03.037
Keywords: Cluster; Headache; High-flow; Mid-flow; Migraine; Oxygen therapy.

Original contribution

Introduction : Headache is one of the most common causes of emergency department (ED) visits. High-flow oxygen therapy is becoming more attractive as a treatment option because it is safe, effective, and cheap. We aimed to compare the effectiveness of high and medium-flow oxygen therapies with placebo for treating primary headache disorders among middle-aged patients.

Méthode : This prospective, double-blind, placebo-controlled, crossover designed, randomized study was conducted at a regional tertiary hospital's ED. Patients who were treated for primary headache disorder in the ED were evaluated at the time of diagnosis and subsequently included in the study upon their next ED visit. Four different treatment methods were administered; 1) high-flow oxygen (15 L/min oxygen), 2) medium-flow oxygen (8 L/min oxygen), 3) high-flow room air as placebo (15 L/min room air), 4) medium-flow room air as placebo (8 L/min room air). All four treatment methods were administered to all patients included in the study, at four separate ED visits. Patients' data, including demographics, medical history, additional complaints, Visual Analogue Scale (VAS) score, and physical examination findings were recorded by the treating physician.

Résultats : One hundred and four patients with a mean age of 35.14 ± 9.1 years, were included in the study. Patients who received oxygen therapy had a significantly lower VAS score at all control points (15, 30, and 60 min) when compared with placebo (p < 0.001). This difference in scores reached its maximum at 30 min. There was not a significant statistical difference between the high-flow or mid-flow therapies (p > 0.05). It was determined that patients who received placebo therapy were more likely to revisit ED (p < 0.05). There was not a significant statistical difference between the high-flow or mid-flow therapy groups in terms of revisit (p > 0.05) and the 30th-minute analgesia requirement (p > 0.05). Pain duration was significantly less in patients who received oxygen therapy (p < 0.05). Patients who received high-flow oxygen therapy spent less time in the ED (p < 0.001).

Conclusion : Oxygen therapy could be a beneficial treatment option for middle-aged patients with primary headache disorders. Based on the results obtained from high and mid-flow oxygen therapies, it may be more appropriate to begin treatment with mid-flow oxygen.

Conclusion (proposition de traduction) : L'oxygénothérapie pourrait être une option thérapeutique bénéfique pour les patients d'âge moyen souffrant de céphalées primaires. Sur la base des résultats obtenus avec les oxygénothérapies à haut et à moyen débit, il pourrait être plus approprié de commencer le traitement par l'oxygène à moyen débit.

Advanced airway management for pediatric out-of-hospital cardiac arrest: A systematic review and network meta-analysis.
Amagasa S, Utsumi S, Moriwaki T, Yasuda H, Kashiura M, Uematsu S, Kubota M. | Am J Emerg Med. 2023 Jun;68:161-169
DOI: https://doi.org/10.1016/j.ajem.2023.03.049
Keywords: Airway management; Cardiopulmonary resuscitation; Child; Emergency medical services; Heart arrest.

Review

Introduction : Although airway management is important in pediatric resuscitation, the effectiveness of bag-mask ventilation (BMV) and advanced airway management (AAM), such as endotracheal intubation (ETI) and supraglottic airway (SGA) devices, for prehospital resuscitation of pediatric out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to determine the efficacy of AAM during prehospital resuscitation of pediatric OHCA cases.

Méthode : We searched four databases from their inception to November 2022 and included randomized controlled trials and observational studies with appropriate adjustments for confounders that evaluated prehospital AAM for OHCA in children aged <18 years in quantitative synthesis. We compared three interventions (BMV, ETI, and SGA) via network meta-analysis using the GRADE Working Group approach. The outcome measures were survival and favorable neurological outcomes at hospital discharge or 1 month after cardiac arrest.

Résultats : Five studies (including one clinical trial and four cohort studies with rigorous confounding adjustment) involving 4852 patients were analyzed in our quantitative synthesis. Compared with ETI, BMV was associated with survival (relative risk [RR] 0.44 [95% confidence intervals (CI) 0.25-0.77]) (very low certainty). There were no significant association with survival in the other comparisons (SGA vs. BMV: RR 0.62 [95% CI 0.33-1.15] [low certainty], ETI vs. SGA: RR 0.71 [95% CI 0.39-1.32] [very low certainty]). There was no significant association with favorable neurological outcomes in any comparison (ETI vs. BMV: RR 0.33 [95% CI 0.11-1.02]; SGA vs. BMV: RR 0.50 [95% CI 0.14-1.80]; ETI vs. SGA: RR 0.66 [95% CI 0.18-2.46]) (all very low certainty). In the ranking analysis, the hierarches for efficacy for survival and favorable neurological outcome were BMV > SGA > ETI.

Conclusion : Although the available evidence is from observational studies and its certainty is low to very low, prehospital AAM for pediatric OHCA did not improve outcomes.

Conclusion (proposition de traduction) : Bien que les données disponibles proviennent d'études d'observation et que leur degré de certitude soit faible à très faible, la prise en charge préhospitalière des voies aériennes en cas d'arrêt cardiaque extrahospitalier chez l'enfant n'a pas amélioré les résultats.