Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study.
Yamamoto R, Tamura T, Haiden A, Yoshizawa J, Homma K, Kitamura N, Sugiyama K, Tagami T, Yasunaga H, Aso S, Takeda M, Sasaki J; SOS-KANTO 2017 Study Group. | Ann Emerg Med. 2023 Jul;82(1):84-93
DOI: https://doi.org/10.1016/j.annemergmed.2023.02.009 | Télécharger l'article au format
Emergency Medical Services
Introduction : To elucidate the clinical utility of the Clinical Frailty Scale score for predicting poor neurologic functions in patients resuscitated from out-of-hospital cardiac arrest (OHCA).
Méthode : This was a prospective, multicenter, observational study conducted between 2019 and 2021. The study included adults with nontraumatic OHCA admitted to the intensive care unit after return of spontaneous circulation (ROSC). Pre-arrest high Clinical Frailty Scale score was defined as 5 or more. Favorable neurologic outcomes defined as a Cerebral Performance Category score of 2 or less at 30 days after admission were compared between patients with and without high Clinical Frailty Scale scores. Multivariable logistic regression analyses fitted with generalized estimating equations were performed to adjust for patient characteristics, out-of-hospital information, and resuscitation content and account for within-institution clustering.
Résultats : Of 9,909 patients with OHCA during the study period, 1,216 were included, and 317 had a pre-arrest high Clinical Frailty Scale score. Favorable neurologic outcomes were fewer among patients with high Clinical Frailty Scale scores. The high Clinical Frailty Scale score group showed a lower percentage of favorable neurologic outcomes after OHCA than the low Clinical Frailty Scale score group (6.1% vs 24.4%; adjusted odds ratio, 0.45 [95% confidence interval 0.22 to 0.93]). This relationship remained in subgroups with cardiogenic OHCA, with ROSC after hospital arrival, and without a high risk of dying (Clinical Frailty Scale score of 7 or less), whereas the neurologic outcomes were comparable regardless of pre-arrest frailty in those with noncardiogenic OHCA and with ROSC before hospital arrival.
Conclusion : Pre-arrest high Clinical Frailty Scale score was associated with unfavorable neurologic functions among patients resuscitated from OHCA. The Clinical Frailty Scale score would help predict clinical consequences following intensive care after ROSC.
Conclusion (proposition de traduction) : Un score élevé sur l'échelle de fragilité clinique avant l'arrêt cardiaque est associé à des résultats neurologiques défavorables chez les patients réanimés à la suite d'un arrêt cardiaque extrahospitalier. Le score de l'échelle de fragilité clinique aiderait à prédire les conséquences cliniques des soins intensifs après une réanimation.
Managing Peritonsillar Abscess.
Long B, Gottlieb M. | Ann Emerg Med. 2023 Jul;82(1):101-107
Editorial : Peritonsillar abscess is defined as a collection of pus between the palatine tonsil capsule and the pharyngeal muscles. It most often affects the superior pole of the tonsil and, after that, the middle and inferior poles. The condition may be preceded by pharyngitis or tonsillitis, or it may occur without a preceding infection and arise as a result of obstruction of the Weber glands. Peritonsillar abscesses are often polymicrobial, including streptococcal species, staphylococcal species, and respiratory anaerobes (eg, Fusobacterium necrophorum). The annual incidence of peritonsillar abscess approximates 30 per 100,000 persons between the ages of 5 to 49 years; however, the incidence is highest in those ages 15 to 19 years, approaching 167 per 100,000.
Conclusion : If left untreated, patients are at risk of significant morbidity and mortality. Complications of untreated infection include descending mediastinitis, parapharyngeal and retropharyngeal abscess, necrotizing fasciitis, internal jugular vein suppurative thrombophlebitis, and airway obstruction. If a complication does occur, mortality rates can approach 10%. Therefore, early diagnosis and management are critical to improving patient outcomes. This paper does not intend to be a comprehensive review of all aspects pertaining to a peritonsillar abscess but rather seeks to provide the key tenets of management based on the current literature and years of practice.
Conclusion (proposition de traduction) : En l'absence de traitement, les patients risquent une morbidité et une mortalité importantes. Les complications d'une infection non traitée comprennent la médiastinite descendante, l'abcès parapharyngé et rétropharyngé, la fasciite nécrosante, la thrombophlébite suppurée de la veine jugulaire interne et l'obstruction des voies respiratoires. En cas de complication, le taux de mortalité peut avoisiner les 10 %. Par conséquent, un diagnostic et une prise en charge précoces sont essentiels pour améliorer l'état des patients. Ce document n'a pas l'intention d'être une revue complète de tous les aspects relatifs à un abcès péri-amygdalien, mais cherche plutôt à fournir les principes clés de la prise en charge sur la base de la littérature actuelle et d'années de pratique.
Long-term effects of restriction of intravenous fluid in adult ICU patients with septic shock.
Kjær MN, Meyhoff TS, Sivapalan P, Granholm A, Hjortrup PB, Madsen MB, Møller MH, Egerod I, Wetterslev J, Lange T, Cronhjort M, Laake JH, Jakob SM, Nalos M, Ostermann M, Gould D, Cecconi M, Malbrain MLNG, Ahlstedt C, Kiel LB, Bestle MH, Nebrich L, Hildebrandt T, Russell L, Vang M, Rasmussen ML, Sølling C, Brøchner AC, Krag M, Pfortmueller C, Kriz M, Siegemund M, Albano G, Aagaard SR, Bundgaard H, Crone V, Wichmann S, Johnstad B, Martin YK, Seidel P, Mårte. | Intensive Care Med. 2023 Jul;49(7):820-830
DOI: https://doi.org/10.1007/s00134-023-07114-8 | Télécharger l'article au format
Keywords: Cognitive function; Critical illness; Intravenous fluid; Long-term outcomes; Quality of life; Sepsis; Septic shock.
Introduction : To assess long-term outcomes of restrictive versus standard intravenous (IV) fluid therapy in adult intensive care unit (ICU) patients with septic shock included in the European Conservative versus Liberal Approach to Fluid Therapy in Septic Shock in Intensive Care (CLASSIC) trial.
Méthode : We conducted the pre-planned analyses of mortality, health-related quality of life (HRQoL) using EuroQol (EQ)-5D-5L index values and EQ visual analogue scale (VAS), and cognitive function using Mini Montreal Cognitive Assessment (Mini MoCA) test at 1 year. Deceased patients were assigned numerical zero for HRQoL as a state equal to death and zero for cognitive function outcomes as worst possible score, and we used multiple imputation for missing data on HRQoL and cognitive function.
Résultats : Among 1554 randomized patients, we obtained 1-year data on mortality in 97.9% of patients, HRQoL in 91.3%, and cognitive function in 86.3%. One-year mortality was 385/746 (51.3%) in the restrictive-fluid group versus 383/767 (49.9%) in the standard-fluid group, absolute risk difference 1.5%-points [99% confidence interval (CI) - 4.8 to 7.8]. Mean differences were 0.00 (99% CI - 0.06 to 0.05) for EQ-5D-5L index values, - 0.65 for EQ VAS (- 5.40 to 4.08), and - 0.14 for Mini MoCA (- 1.59 to 1.14) for the restrictive-fluid group versus the standard-fluid group. The results for survivors only were similar in both groups.
Conclusion : Among adult ICU patients with septic shock, restrictive versus standard IV fluid therapy resulted in similar survival, HRQoL, and cognitive function at 1 year, but clinically important differences could not be ruled out.
Conclusion (proposition de traduction) : Chez les patients adultes en soins intensifs souffrant d'un choc septique, un remplissage vascualire restrictive par rapport à un remplissage vascualire standard a permis d'obtenir des résultats similaires en termes de survie, de qualité de vie liée à la santé et de capacité cognitive à un an, mais il n'a pas été possible d'exclure des différences importantes sur le plan clinique.
Cushing Syndrome: A Review.
Reincke M, Fleseriu M. | JAMA. 2023 Jul 11;330(2):170-181
Introduction : Cushing syndrome is defined as a prolonged increase in plasma cortisol levels that is not due to a physiological etiology. Although the most frequent cause of Cushing syndrome is exogenous steroid use, the estimated incidence of Cushing syndrome due to endogenous overproduction of cortisol ranges from 2 to 8 per million people annually. Cushing syndrome is associated with hyperglycemia, protein catabolism, immunosuppression, hypertension, weight gain, neurocognitive changes, and mood disorders.
Méthode : Cushing syndrome characteristically presents with skin changes such as facial plethora, easy bruising, and purple striae and with metabolic manifestations such as hyperglycemia, hypertension, and excess fat deposition in the face, back of the neck, and visceral organs. Cushing disease, in which corticotropin excess is produced by a benign pituitary tumor, occurs in approximately 60% to 70% of patients with Cushing syndrome due to endogenous cortisol production. Evaluation of patients with possible Cushing syndrome begins with ruling out exogenous steroid use. Screening for elevated cortisol is performed with a 24-hour urinary free cortisol test or late-night salivary cortisol test or by evaluating whether cortisol is suppressed the morning after an evening dexamethasone dose. Plasma corticotropin levels can help distinguish between adrenal causes of hypercortisolism (suppressed corticotropin) and corticotropin-dependent forms of hypercortisolism (midnormal to elevated corticotropin levels). Pituitary magnetic resonance imaging, bilateral inferior petrosal sinus sampling, and adrenal or whole-body imaging can help identify tumor sources of hypercortisolism. Management of Cushing syndrome begins with surgery to remove the source of excess endogenous cortisol production followed by medication that includes adrenal steroidogenesis inhibitors, pituitary-targeted drugs, or glucocorticoid receptor blockers. For patients not responsive to surgery and medication, radiation therapy and bilateral adrenalectomy may be appropriate.
Conclusion : The incidence of Cushing syndrome due to endogenous overproduction of cortisol is 2 to 8 people per million annually. First-line therapy for Cushing syndrome due to endogenous overproduction of cortisol is surgery to remove the causative tumor. Many patients will require additional treatment with medications, radiation, or bilateral adrenalectomy.
Conclusion (proposition de traduction) : L'incidence du syndrome de Cushing dû à une surproduction endogène de cortisol est de 2 à 8 personnes par million chaque année. Le traitement de première intention du syndrome de Cushing dû à une surproduction endogène de cortisol consiste en une intervention chirurgicale visant à retirer la tumeur responsable. De nombreux patients auront besoin d'un traitement complémentaire par médicaments, radiothérapie ou surrénalectomie bilatérale.
Single Troponin Measurement to Rule Out Myocardial Infarction: JACC Review Topic of the Week.
Jaffe AS, Body R, Mills NL, Aakre KM, Collinson PO, Saenger A, Hammarsten O, Wereski R, Omland T, Sandoval Y, Ordonez-Llanos J, Apple FS; IFCC Committee on Cardiac Bio-Markers. | J Am Coll Cardiol. 2023 Jul 4;82(1):60-69
Keywords: infarction; myocardial infarction; troponin.
Editorial : The term "single-sample rule-out" refers to the ability of very low concentrations of high-sensitivity cardiac troponin (hs-cTn) on presentation to exclude acute myocardial infarction with high clinical sensitivity and negative predictive value. Observational and randomized studies have confirmed this ability. Some guidelines endorse use of a concentration of hs-cTn at the assay's limit of detection, while other studies have validated the use of higher concentrations, allowing this approach to identify a greater proportion of patients at low risk. In most studies, at least 30% of patients can be triaged with this approach. The concentration of hs-cTn varies according to the assay used and sometimes how regulations permit reporting. It is clear that patients need to be at least 2 hours from the onset of symptoms being evaluated. Caution is warranted, particularly with older patients, women, and patients with underlying cardiac comorbidities.
Conclusion : The data presented herein and summarized in the Central Illustration lead to the following recommendations.
First, the evidence-based studies demonstrate that the single-sample rule-out strategy on the basis oflow concentrations of hs-cTn and non ischemic electrocardiographic findings is a safe way to exclude MI. Recent data suggest that perhaps a low HEART (history, electrocardiogram, age, risk factors, and initial troponin) score may help as well.
Second, at present, this strategy should be usedonly in patients presenting > 2 hours after symptom onset. Third, clinical judgment, not hs-cTn concentration alone, must be used to safely implement the single samplerule-out strategy. Particular care in older patients, women, and those with cardiac comorbidities is advised.
Fourth, for each hs-cTn assay and the analytical platform that is used, individualized cutoff concentrations should be derived and validated that optimize the performance of the assay by maintaining an NPV of >99.5%. NPV can be misleading in smaller datasets or when the prevalence of MI islow. Accordingly, all studies should report bothNPV and sensitivity and their respective CIs. When incorporated into a clinical pathway for 30-day risk for MI or death, this will maximize the proportion of patients eligible for early discharge (29%-74%).
Fifth, POC hs-cTn assays must be validated using fresh whole blood for single-sample rule-out strategies for MI. They should meet the same clinical safety and efficacy standards as central laboratory hs-cTnassays. POC testing may solve cTn measurement turnaround time issues when present.
Conclusion (proposition de traduction) : Les données présentées ici et résumées dans l'illustration centrale conduisent aux recommandations suivantes.
Tout d'abord, les études fondées sur des preuves démontrent que la stratégie d'exclusion à partir d'une seule mesure sur la base des concentrations de hs-cTn et des résultats électrocardiographiques non ischémiques est un moyen sûr d'exclure l'infarctus du myocarde. Des données récentes suggèrent qu'un score HEART (antécédents, électrocardiogramme, âge, facteurs de risque et troponine initiale) faible peut également être utile.
Deuxièmement, à l'heure actuelle, cette stratégie ne devrait être utilisée que chez les patients se présentant > 2 heures après l'apparition des symptômes.
Troisièmement, le jugement clinique, et non la concentration de hs-cTn seule, doit être utilisé pour mettre en œuvre en toute sécurité la stratégie d'élimination de l'échantillonneur unique. Il est conseillé d'être particulièrement attentif aux patients âgés, aux femmes et aux patients présentant des comorbidités cardiaques.
Quatrièmement, pour chaque dosage de la hs-cTn et la plateforme analytique utilisée, des concentrations seuils individualisées doivent être établies et validées afin d'optimiser les performances du dosage en maintenant une VPN de > 99,5 %. La VPN peut être trompeuse dans les petits ensembles de données ou lorsque la prévalence de l'infarctus du myocarde est faible. Par conséquent, toutes les études doivent faire état de la VPN et de la sensibilité, ainsi que de leurs IC respectifs. Lorsqu'il est intégré à un cheminement clinique pour le risque d'infarctus ou de décès à 30 jours, ce test maximisera la proportion de patients pouvant bénéficier d'une sortie précoce (29 %-74 %).
Cinquièmement, les prélèvements de hs-cTn au point d'intervention doivent être validés en utilisant du sang total frais pour les stratégies d'exclusion de l'infarctus à partir d'un seul échantillon. Ils doivent répondre aux mêmes normes de sécurité clinique et d'efficacité que les résultats de hs-cTn des laboratoires centraux. Les examens réalisés au point de service peuvent résoudre les problèmes de délai de mesure de la cTn lorsqu'ils existent.
Dispatch of Volunteer Responders to Out-of-Hospital Cardiac Arrests.
Jonsson M, Berglund E, Baldi E, Caputo ML, Auricchio A, Blom MT, Tan HL, Stieglis R, Andelius L, Folke F, Hollenberg J, Svensson L, Ringh M; ESCAPE-NET Investigators. | J Am Coll Cardiol. 2023 Jul 18;82(3):200-210
Keywords: cardiopulmonary resuscitation; out-of-hospital cardiac arrest; volunteer responders.
Introduction : Systems for dispatch of volunteer responders to collect automated external defibrillators and/or to provide cardiopulmonary resuscitation (CPR) in cases of nearby out-of-hospital cardiac arrest (OHCA) are widely implemented.
This study aimed to investigate whether the activation of a volunteer responder system to OHCAs was associated with higher rates of bystander CPR, bystander defibrillation, and 30-day survival vs no system activation.
Méthode : This was a retrospective observational analysis within the ESCAPE-NET (European Sudden Cardiac Arrest network: Towards Prevention, Education, New Effective Treatment) collaborative research network. Included were cases of OHCA between 2015 and 2019 from 5 European sites with volunteer responder systems. At all sites, systems were activated by dispatchers at the emergency medical communication center in response to suspected OHCA. Exposed cases (system activation) were compared with nonexposed cases (no system activation). Risk ratios (RRs) were calculated for the outcomes of bystander CPR, bystander defibrillation, and 30-day survival after inverse probability treatment weighting. Missing data were handled using multiple imputation.
Résultats : In total, 9,553 cases were included. In 4,696 cases, the volunteer responder system was activated, and in 4,857 it was not. The pooled RRs were 1.30 (95% CI: 1.15-1.47) for bystander CPR, 1.89 (95% CI: 1.36-2.63) for bystander defibrillation, and 1.22 (95% CI: 1.07-1.39) for 30-day survival.
Conclusion : Activation of a volunteer response system in cases of OHCA was associated with a higher chance of bystander CPR, bystander defibrillation, and 30-day survival vs no system activation. A randomized controlled trial is necessary to determine fully the causal effect of volunteer responder systems.
Conclusion (proposition de traduction) : L'activation d'un système d'intervention bénévole en cas d'arrêt cardiaque extrahospitalier a été associée à une probabilité plus élevée de RCP et de défibrillation par un témoin et de survie à 30 jours par rapport à l'absence d'activation du système. Un essai contrôlé randomisé est nécessaire pour déterminer pleinement l'effet positif des systèmes d'intervention bénévoles.
Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations.
Forster BL, Thomas F, Arnold SR, Snider MA. | Pediatr Emerg Care. 2023 Jul 1;39(7):524-529
ORIGINAL ARTICLE Early
Introduction : Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission.
Objective: To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions.
Méthode : Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration.
Résultats : A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95).
Conclusion : Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.
Conclusion (proposition de traduction) : L'administration précoce de sulfate de magnésium intraveineux aux patients enfants souffrant d'exacerbations sévères de l'asthme n'entraîne pas une diminution des admissions en unité de soins intensifs pédiatriques.
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. | Resuscitation. 2023 Jul;188:109772
DOI: https://doi.org/10.1016/j.resuscitation.2023.109772 | 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'éduquer 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 davantage la formation des écoliers aux gestes élémentaires de survie.
Electrocardiographic characteristics fail to predict acute coronary occlusions in out-of-hospital cardiac-arrest patients without ST-segment elevation.
Leeper B, Kern KB, Liu S, Sun X. | Resuscitation. 2023 Jul;188:109826
DOI: https://doi.org/10.1016/j.resuscitation.2023.109826 | Télécharger l'article au format
Keywords: Coronary angiography; Post-arrest ECGs; Post-resuscitation care.
Introduction : A minority of out-of-hospital cardiac arrest patients have an acutely occluded coronary artery without manifesting ST-segment elevation on their post-resuscitation ECG. Identifying such patients is an issue to providing timely reperfusion therapy. We aimed to evaluate the usefulness of the initial post-resuscitation electrocardiogram in out-of-hospital-cardiac-arrest patients for selection to perform early coronary angiography.
Méthode : The study population consisted of 74 of the 99 randomized patients from the PEARL clinical trial with both ECG and angiographic data. The purpose of this study was to investigate initial post-resuscitation electrocardiogram findings from out-of-hospital cardiac arrest patients without ST-segment elevation for any association with the presence of acute coronary occlusions. Secondarily, we aimed to observe the distribution of abnormal electrocardiogram findings and survival to hospital discharge of subjects.
Résultats : Initial post-resuscitation electrocardiogram findings, including ST-depression, T-wave inversion, bundle branch block, non-specific changes, were not associated with the presence of an acutely occluded coronary. Normal post-resuscitation electrocardiogram findings were associated with patient survival to hospital discharge but were not associated with the presence or absence of an acute coronary occlusion.
Conclusion : Electrocardiogram findings cannot exclude or identify the presence of an acutely occluded coronary in out-of-hospital-cardiac-arrest patients without ST-segment elevation. An acutely occluded coronary may be present regardless of normal electrocardiogram findings.
Conclusion (proposition de traduction) : Les résultats de l'électrocardiogramme ne permettent pas d'exclure ou d'identifier la présence d'une occlusion coronaire aiguë chez les patients ayant subi un arrêt cardiaque en dehors de l'hôpital et ne présentant pas d'élévation du segment ST. Une occlusion coronaire aiguë peut être présente même si les résultats de l'électrocardiogramme sont normaux.
The association of the post-resuscitation on-scene interval and patient outcomes after out-of-hospital cardiac arrest.
Khan L, Hutton J, Yap J, Dodek P, Scheuermeyer F, Asamoah-Boaheng M, Heidet M, Wall N, Fordyce CB, van Diepen S, Christenson J, Grunau B. | Resuscitation. 2023 Jul;188:109753
DOI: https://doi.org/10.1016/j.resuscitation.2023.109753 | Télécharger l'article au format
Keywords: Emergency medical services; Out-of-hospital cardiac arrest; Post-resuscitation care.
Introduction : After resuscitation from out-of-hospital cardiac arrest (OHCA) by Emergency Medical Services (EMS), the amount of time that should be dedicated to pre-transport stabilization is unclear. We examined whether the time spent on-scene after return of spontaneous circulation (ROSC) was associated with patient outcomes.
Méthode : We examined consecutive adult EMS-treated OHCAs from the British Columbia Cardiac Arrest registry (January 1/2019-June 1/2021) that had on-scene ROSC (sustained to scene departure). The primary outcome was favourable neurological outcome (Cerebral Performance Category ≤ 2) at hospital discharge; secondary outcomes were re-arrest during transport and hospital-discharge survival. Using adjusted logistic regression models, we estimated the association between the post-resuscitation on-scene interval (divided into quartiles) and outcomes.
Résultats : Of 1653 cases, 611 (37%) survived to hospital discharge, and 523 (32%) had favourable neurological outcomes. The median post-resuscitation on-scene interval was 18.8 minutes (IQR:13.0-25.5). Compared to the first post-resuscitation on-scene interval quartile, neither the second (adjusted odds ratio [AOR] 1.19; 95% CI 0.72-1.98), third (AOR 1.10; 95% CI 0.67-1.81), nor fourth (AOR 1.54; 95% CI 0.93-2.56) quartiles were associated with favourable neurological outcomes; however, the fourth quartile was associated with a greater odds of hospital-discharge survival (AOR 1.73; 95% CI 1.05-2.85), and both the third (AOR 0.40; 95% CI 0.22-0.72) and fourth (AOR 0.44;95% CI 0.24-0.81) quartiles were associated with a lower odds of intra-transport re-arrest.
Conclusion : Among resuscitated OHCAs, increased post-resuscitation on-scene time was not associated with improved neurological outcomes, but was associated with improved survival to hospital discharge and decreased intra-transport re-arrest.
Conclusion (proposition de traduction) : Parmi les arrêts cardiaques extrahospitaliers ayant fait l'objet d'une réanimation, l'allongement de l'intervalle post-réanimation sur place n'a pas été associé à une amélioration des résultats neurologiques, mais a été associé à une amélioration de la survie jusqu'à la sortie de l'hôpital et à une diminution du nombre de nouveaux arrêts cardiaque pendant le transport.
Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study.
Branch KRH, Gatewood MO, Kudenchuk PJ, Maynard C, Sayre MR, Carlbom DJ, Edwards RM, Counts CR, Probstfield JL, Brusen R, Johnson N, Gunn ML. | Resuscitation. Resuscitation
DOI: https://doi.org/10.1016/j.resuscitation.2023.109785 | Télécharger l'article au format
Keywords: Abdominopelvic computed tomography; Acute kidney injury; Cardiac computed tomography; Cohort study; Diagnostic testing; Head computed tomography; Out of hospital cardiac arrest; Resuscitation; Standard of care.
Introduction : Our aim was to test whether a head-to-pelvis CT scan improves diagnostic yield and speed to identify causes for out of hospital circulatory arrest (OHCA).
Méthode : CT FIRST was a prospective observational pre-/post-cohort study of patients successfully resuscitated from OHCA. Inclusion criteria included unknown cause for arrest, age >18 years, stability to undergo CT, and no known cardiomyopathy or obstructive coronary artery disease. A head-to-pelvis sudden death CT (SDCT) scan within 6 hours of hospital arrival was added to the standard of care for patients resuscitated from OHCA (post-cohort) and compared to standard of care (SOC) alone (pre-cohort). The primary outcome was SDCT diagnostic yield. Secondary outcomes included time to identifying OHCA cause and time-critical diagnoses, SDCT safety, and survival to hospital discharge.
Résultats : Baseline characteristics between the SDCT (N = 104) and the SOC (N = 143) cohorts were similar. CT scans (either head, chest, and/or abdomen) were ordered in 74 (52%) of SOC patients. Adding SDCT scanning identified 92% of causes for arrest compared to 75% (SOC-cohort; p value < 0.001) and reduced the time to diagnosis by 78% (SDCT 3.1 hours, SOC alone 14.1 hours, p < 0.0001). Identification of critical diagnoses was similar between cohorts, but SDCT reduced delayed (>6 hours) identification of critical diagnoses by 81% (p < 0.001). SDCT safety endpoints were similar including acute kidney injury. Patient survival to discharge was similar between cohorts.
Conclusion : SDCT scanning early after OHCA resuscitation safely improved the efficiency and diagnostic yield for causes of arrest compared to the standard of care alone.
Conclusion (proposition de traduction) : Le body scanner des patients ayant présenté un tableau de mort subite, pratiquée précocement après la réanimation d'un arrêt circulatoire en dehors de l'hôpital, a amélioré en toute sécurité l'efficacité et le rendement diagnostique des causes d'arrêt par rapport au traitement standard seul.
FOCUS may detect wall motion abnormalities in patients with ACS.
Bracey A, Massey L, Pellet AC, Thode HC, Holman TR, Singer AJ, McClure M, Secko MA. | Am J Emerg Med. 2023 Jul;69:17-22
Keywords: Acute coronary syndrome; FOCUS; OMI; POCUS; RWMA.
Introduction : Chest pain is a common presentation to the Emergency Department (ED) with roughly 6 million visits a year. The primary diagnostic modality for the identification of acute coronary syndrome (ACS) is the electrocardiogram (ECG), which is used to screen for electrocardiographic findings representing acute coronary occlusion. It is known that the ischemia generated by an acutely occluded coronary vessel generates a wall motion abnormality which can be visualized by echocardiogram; however, emergency physician-performed focused cardiac ultrasound (FOCUS) currently does not have a formal role in the diagnosis of OMI within the emergency department.
Purpose: We sought to define the characteristics of FOCUS performed by emergency physicians of variable training levels in the identification of RWMA in patients presenting to the emergency department with high suspicion for ACS before undergoing cardiac catheterization or formal echocardiography. We also explored whether RWMA was associated with OMI in these patients.
Méthode : We performed a structured, retrospective review of adult patients presenting to a large, academic, tertiary care center with suspected ACS from July 1st, 2019, and October 24th, 2020. Patients were included if they underwent FOCUS in the ED during the time-period above for suspected ACS looking for RWMA and FOCUS images were stored and reviewable in our middleware software. The primary outcome was the accuracy, sensitivity, and specificity of FOCUS compared to formal echocardiography for the detection of RWMA. Secondary outcomes were sensitivity of FOCUS compared to formal echocardiography for detection of RWMA in patients with and without cardiac catheterization proven OMI and sensitivity and specificity of FOCUS operators based on training.
Résultats : FOCUS for RWMA performed by emergency physicians had a sensitivity of 94% (95% CI, 82-98), specificity 35% (95% CI, 15-61), and overall accuracy of 78% (95% CI, 66-87). Of all subjects, 82% underwent urgent or emergency coronary angiography, of which 71% had OMI at the time of coronary angiography of the procedure. FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. Residents (PGY-1 - PGY-3) (n = 31) were able to detect RWMA with a sensitivity of 86% (95% CI, 64-96), a specificity of 56% (95% CI, 23-85%), and an accuracy of 77 (95% CI, 58-90%). Emergency ultrasound fellows and attendings (n = 34) were able to detect RWMA with a sensitivity of 85% (95% CI, 64-95%), a specificity of 75% (95% CI, 36-96%), and an accuracy of 82% (95% CI, 65-93%).
Conclusion : Our retrospective study concludes FOCUS performed by emergency physicians may be used to detect RWMA in patients with high concern for acute coronary syndrome. This may have its greatest utility in patients presenting without STEMI where the ECG is felt to be equivocal, but the clinician has high concern for OMI, in which the presence of RWMA might result in emergent cath lab activation, though this requires further study. The presence of RWMA in such cases may help to rule in OMI as a cause; however, the absence of RWMA should exclude OMI. Further research is necessary to confirm these findings.
Conclusion (proposition de traduction) : Notre étude rétrospective conclut que l'échocardiographie réalisée par les urgentistes peut être utilisée pour détecter les anomalies régionales des mouvements de la paroi chez les patients présentant un risque élevé de syndrome coronarien aigu. L'utilité de cet examen pourrait être maximale chez les patients présentant un infarctus du myocarde sans sus-décalage du segment ST et dont l'ECG est jugé douteux, mais pour lesquels le clinicien craint fortement un infarctus du myocarde avec occlusion, dans lequel la présence d'anomalies régionales des mouvements de la paroi pourrait entraîner l'activation urgente du laboratoire de cathétérisme, bien que cela nécessite une étude plus approfondie. La présence d'anomalies régionales des mouvements de la paroi dans de tels cas peut aider à conclure à l'infarctus du myocarde par occlusion comme cause ; cependant, l'absence d'anomalies régionales des mouvements de la paroi devrait exclure l'infarctus du myocarde par occlusion. D'autres recherches sont nécessaires pour confirmer ces résultats.
The effect of patient weight on the success of converting sinus rhythm in patients with PSVT treated with standard dose adenosine.
Çorbacioğlu ŞK, Uzunosmanoglu H, Karaarslan FN, Dağar S, Emektar E, Çevik Y. | Am J Emerg Med. 2023 Jul;69:28-33
Keywords: SVT; adenosine; emergency medicine; kilogram; supraventricular tachycardia.
Introduction : The study aimed to investigate whether there is a difference in the amount of adenosine per kilogram (mg/kg) between the patient groups that can and cannot be converted to sinus rhythm (SR) with adenosine therapy in patients with supraventricular tachycardia (SVT).
Méthode : This single-centered, retrospectively designed study was conducted in the ED of a training and research hospital between December 1, 2019 and December 1, 2022 on patients who were admitted to the ED with SVT diagnosis and treated with a 6-12-18 mg adenosine protocol. The main analyses were carried out in three stages. The first analysis was performed considering the first 6 mg dose of adenosine administered. The second analysis was performed by considering the 12 mg adenosine administered as the second dose because it did not respond to the first dose. Finally, the third analysis was performed by considering the 18 mg adenosine administered as the third dose because it did not respond to preciously dosages. The primary outcome variable was determined to be converting SR and created two groups according to this; the success SR group and the failure SR group.
Résultats : During the study period, 73 patients who were admitted to the ED with PSVT diagnosis and treated with intravenous adenosine were included. After the first 6 mg of adenosine treatment was administered to all 73 patients, SR was achieved in only 38% of patients. The mean adenosine dose (mg/kg) was significantly lower in the failure SR group, 0.07373 ± 0.014, compared with 0.08885 ± 0.017 mg/kg in the success SR group (mean difference with 95% CI: -0.01511 [-0.023 to -0.0071]; p < 0.001). In the second and third stage analyses, considering 12 and 18 mg adenosine doses, when the administrations with successful and failed SR were compared, no difference was found in terms of the applied adenosine doses per kilogram.
Conclusion : This study suggest that the success of terminating SVT with the first 6 mg dose of adenosine appears to be dependent on patient weight. In patients given larger doses of adenosine, determinants of PSVT termination success may be factors other than patient weight.
Conclusion (proposition de traduction) : Cette étude suggère que le succès de la fin de la tachycardie supraventriculaire avec la première dose de 6 mg d'adénosine semble dépendre du poids du patient. Chez les patients recevant des doses plus importantes d'adénosine, les facteurs déterminants du succès de l'arrêt de la tachycardie supraventriculaire paroxymale peuvent être des facteurs autres que le poids du patient.
PCO2 on arrival as a predictive biomarker in patients with out-of-hospital cardiac arrest..
Inoue F, Inoue A, Nishimura T, Takahashi R, Nakatani Y, Suga M, Kikuta S, Tada S, Maemura S, Matsuyama S, Ishihara S. | Am J Emerg Med. 2023 Jul;69:92-99
Keywords: Mortality; Neurological outcome; Out-of-hospital cardiac arrest; Partial pressure of carbon dioxide.
Introduction : Treating patients with out-of-hospital cardiac arrest (OHCA) requires early prediction of outcome, ideally on hospital arrival, as it can inform the clinical decisions involved. This study evaluated whether partial pressure of carbon dioxide (PCO2) on arrival is associated with outcome at one month OHCA patients.
Méthode : This was a single-center retrospective study of adult OHCA patients treated between January 2016 and December 2020. Outcomes were defined along the Cerebral Performance Category (CPC) scale. Primary outcome was mortality (CPC 5) at one month. Secondary outcomes were death or unfavorable neurological outcome (CPC 3-5) and unfavorable neurological outcome (CPC 3-4) at one month. Multivariable analysis was adjusted for age, sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, and time from call to emergency medical services to hospital arrival.
Résultats : Out of 977 OHCA patients in the study period, 19 were excluded because they were aged under 18 years, 79 because they underwent extracorporeal cardiopulmonary resuscitation, and 101 due to lack of PCO2 data. This study included 778 patients total; mortality (CPC 5) at one month was observed in 706 (90.7%), death or unfavorable neurological outcome (CPC 3-5) in 743 (95.5%), and unfavorable neurological outcome (CPC 3-4) in 37 (4.8%). In multivariable analysis, high PCO2 levels showed significant association with mortality (CPC 5) at one month (odds ratio [OR] [per 5 mmHg], 1.14; 95% confidence interval [CI], 1.08-1.21), death or unfavorable neurological outcome (CPC 3-5) (OR [per 5 mmHg], 1.29; 95% CI, 1.17-1.42), and unfavorable neurological outcome (CPC 3-4) (OR [per 5 mmHg], 1.21; 95% CI, 1.04-1.41).
Conclusion : High PCO2 on arrival was significantly associated with mortality and unfavorable neurological outcome in OHCA patients.
Conclusion (proposition de traduction) : Une PCO2 élevée à l'arrivée était significativement associée à la mortalité et à une évolution neurologique défavorable chez les patients victimes d'un arrêt cardiaque extrahospitalier.
Crush injury and syndrome: A review for emergency clinicians.
Long B, Liang SY, Gottlieb M. | Am J Emerg Med. 2023 Jul;69:180-187.
Keywords: Acute kidney injury; Crush injury; Crush syndrome; Disaster; Earthquake.
Introduction : Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome.
Méthode : This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians.
Discussion : Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury).
Conclusion : Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.
Conclusion (proposition de traduction) : Des millions de personnes sont touchées chaque année par des catastrophes naturelles ou d'origine humaine. Ces catastrophes peuvent entraîner des pertes humaines massives et des problèmes médicaux graves, notamment des lésions et des syndromes d'écrasement. Les crush syndrome se produisent lors d'un traumatisme physique direct sur le corps humain. Elle peut entraîner une asphyxie, des lésions orthopédiques graves, une hypotension, des lésions organiques, une insuffisance rénale aiguë, une septicémie et un syndrome de détresse respiratoire aiguë. Le crush syndrome est la manifestation systémique d'une lésion musculaire traumatique grave. Les soins sur place nécessitent des personnes formées et se concentrent sur le traitement des blessures potentiellement mortelles, la désincarcération, le triage, le remplissage vasculaire et le transport. Les cliniciens de l'établissement de santé doivent trier les patients de manière appropriée, effectuer les examens primaires et secondaires initiaux et gérer les complications telles que l'insuffisance rénale aiguë, l'infection, les traumatismes thoraciques ou abdominaux graves, les problèmes métaboliques (par exemple, l'hyperkaliémie, l'acidémie) et le syndrome des loges. La connaissance de ces événements et de ces complications peut améliorer les soins prodigués aux patients souffrant de lésions par écrasement et de crush syndrome.
A novel equation successfully calculates tidal volumes for lung protective ventilation.
Self M, Mun C, Goodrich A, Schmidt U. | J Emerg Med. 2023 Jul;65(1):e1-e8
Keywords: ARDS; critical care; lung protective ventilation; mechanical ventilation.
Introduction : Early application of low-tidal-volume ventilation (LTVV) has been associated with improved outcomes in the emergency department (ED) and intensive care unit (ICU), but is not consistently applied. The perceived complexity of calculating an ideal body weight (IBW)-based tidal volume (Vt) may contribute to this disparity. We hypothesized that a simplified equation could successfully predict LTVV. Objective: To create a memorable, single-step, sex-independent equation to estimate LTVV based on height.
Méthode : We conducted a retrospective observational cohort study of patients who received mechanical ventilation (MV) at 2 EDs from January 2016 to June 2019. Data were abstracted by automatic query. Patients < 18 years old, < 60 inches in height, and with implausible or incomplete data were excluded. LTVV was defined as ≤ 8 mL/kg IBW. We created a formula predicting a 6-8-mL/kg IBW Vt. We applied this formula to a population of ICU patients in the same health care system who received MV from January 2017 to December 2019 using the same exclusion criteria. The outcome was whether the equation predicted a 6-8-mL/kg IBW Vt.
Résultats : A total of 982 ED patients were included; 753 (76.7%) had an initial Vt < 8 mL/kg IBW. The equation Vt = 20*(Ht-60) + 300 was derived. A total of 3720 ICU patients were included. The Vt equation successfully predicted a Vt of 6-8 mL/kg IBW in 3720 (100%) of ICU patients.
Conclusion : A novel equation successfully predicted a 6-8-mL/kg IBW Vt in a cohort of patients with height ≥ 60 inches.
Conclusion (proposition de traduction) : Une nouvelle équation a permis de prédire avec succès un Vt de 6-8 ml/kg de poids corporel idéal dans une cohorte de patients ayant une taille ≥ 1,50 mètre.
The association between systolic blood pressure and heart rate in emergency department patients: a multicenter cohort study.
Candel BGJ, Raven W, Nissen SK, Morsink MEB, Gaakeer MI, Brabrand M, van Zwet EW, de Jonge E, de Groot B. | J Emerg Med. 2023 Jul;65(1):7-16
Keywords: critical care; emergency medical services; geriatric emergency medicine; hypotension; shock.
Introduction : Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. Objective: To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years).
Méthode : A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]).
Résultats : A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection.
Conclusion : No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.
Conclusion (proposition de traduction) : Aucune association entre la pression artérielle systolique et la fréquence cardiaque n'a été observée chez les patients des urgences, quelle que soit leur catégorie d'âge, ni chez les patients hospitalisés pour une infection présumée, même pendant et après le traitement aux urgences. Les médecins urgentistes peuvent être induits en erreur par les concepts traditionnels concernant les troubles de la fréquence cardiaque, car la tachycardie peut être absente en cas d'hypotension.
Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial.
Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CC; OPAL Investigators Coordinators. | Lancet. 2023 Jul 22;402(10398):304-312
Introduction : Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain.
Méthode : OPAL was a triple-blinded, placebo-controlled randomised trial that recruited adults (aged ≥18 years) presenting to one of 157 primary care or emergency department sites in Sydney, NSW, Australia, with 12 weeks or less of low back or neck pain (or both) of at least moderate pain severity. Participants were randomly assigned (1:1) using statistician-generated randomly permuted blocks to guideline-recommended care plus an opioid (oxycodone-naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks. The primary outcome was pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale), analysed in all eligible participants who provided at least one post-randomisation pain score, by use of a repeated measures linear mixed model. Safety was analysed in all randomly assigned eligible participants.
Résultats : Between Feb 29, 2016, and March 10, 2022, 347 participants were recruited (174 to the opioid group and 173 to the placebo group). 170 (49%) of 346 participants were female and 176 (51%) were male. 33 (19%) of 174 participants in the opioid group and 25 (15%) of 172 in the placebo group had discontinued from the trial by week 6, due to loss to follow-up and participant withdrawals. 151 participants in the opioid group and 159 in the placebo group were included in the primary analysis. Mean pain score at 6 weeks was 2·78 (SE 0·20) in the opioid group versus 2·25 (0·19) in the placebo group (adjusted mean difference 0·53, 95% CI -0·00 to 1·07, p=0·051). 61 (35%) of 174 participants in the opioid group reported at least one adverse event versus 51 (30%) of 172 in the placebo group (p=0·30), but more people in the opioid group reported opioid-related adverse events (eg, 13 [7·5%] of 174 participants in the opioid group reported constipation vs six [3·5%] of 173 in the placebo group).
Conclusion : Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions.
Conclusion (proposition de traduction) : Les opioïdes ne devraient pas être recommandés en cas de lombalgie ou de cervicalgie aiguë non spécifique, étant donné que nous n'avons pas trouvé de différence significative dans l'intensité de la douleur par rapport au placebo. Cette constatation appelle à un changement dans l'utilisation fréquente des opioïdes pour ces affections.