End-tidal carbon dioxide measured at emergency department triage outperforms standard triage vital signs in predicting in-hospital mortality and intensive care unit admission.
Ladde JG, Miller S, Chin K, Feffer C, Gulenay G, Kepple K, Hunter C, Thundiyil JG, Papa L. | Acad Emerg Med. 2023 Aug;30(8):832-841
DOI: https://doi.org/10.1111/acem.14703
Keywords: emergency; end-tidal carbon dioxide (ETCO2); intensive care unit (ICU); metabolic acidosis; mortality; triage.

ORIGINAL ARTICLE

Introduction : This study assessed the ability of end-tidal carbon dioxide (ETCO2 ) in predicting in-hospital mortality and intensive care unit (ICU) admission compared to standard vital signs at ED triage as well as comparing to measures of metabolic acidosis.

Méthode : This prospective study enrolled adult patients presenting to the ED of a tertiary care Level I trauma center over 30 months. Patients had standard vital signs measured along with exhaled ETCO₂ at triage. Outcome measures included in-hospital mortality; ICU admission; and correlations with lactate, sodium bicarbonate (HCO₃), and anion gap.

Résultats : There were 1136 patients enrolled and 1 091 patients with outcome data available. There were 26 (2.4 %) patients who did not survive to hospital discharge. Mean ETCO₂ levels were 34 (33-34) in survivors and 22 (18-26) nonsurvivors (p < 0.001). The area under the curve (AUC) for predicting in-hospital mortality for ETCO₂ was 0.82 (0.72-0.91). In comparison the AUC for temperature was 0.55 (0.42-0.68), respiratory rate (RR) 0.59 (0.46-0.73), systolic blood pressure (SBP) 0.77 (0.67-0.86), diastolic blood pressure (DBP) 0.70 (0.59-0.81), heart rate (HR) 0.76 (0.66-0.85), and oxygen saturation (SpO₂) 0.53 (0.40-0.67). There were 64 (6 %) patients admitted to the ICU, and the ETCO₂ AUC for predicting ICU admission was 0.75 (0.67-0.80). In comparison the AUC for temperature was 0.51, RR 0.56, SBP 0.64, DBP 0.63, HR 0.66, and SpO₂ 0.53. Correlations between expired ETCO₂ and serum lactate, anion gap, and HCO3 were rho = -0.25 (p < 0.001), rho = -0.20 (p < 0.001), and rho = 0.330 (p < 0.001), respectively.

Conclusion : ETCO₂ was a better predictor of in-hospital mortality and ICU admission than the standard vital signs at ED triage. ETCO₂ correlated significantly with measures of metabolic acidosis.

Conclusion (proposition de traduction) : L'ETCO2 est un meilleur indicateur de la mortalité à l'hôpital et de l'admission en unité de soins intensifs que les signes vitaux standard lors du triage aux urgences. L'ETCO2 est en corrélation significative avec les mesures de l'acidose métabolique.

Aggressive intravenous fluid resuscitation for acute pancreatitis.
Long B, Gottlieb M. | Acad Emerg Med. 2023 Aug;30(8):880-881
DOI: https://doi.org/10.1111/acem.14741
Keywords: fluids; gastroenterology; hydration; pancreatitis; resuscitation

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Acute pancreatitis (AP) has an incidence of 34 cases per 100,000 person-years and mortality of 1.6 deaths per 100,000 person-years. International guidelines recommend early fluid resuscitation with isotonic crystalloids to treat hypovolemia and prevent organ hypoperfusion. Several meta-analyses, however, have demonstrated inconsistent findings with aggressive intravenous (IV) fluid therapy in AP. Moreover, the recent WATERFALL trial reported a threefold increased risk of fluid overload in those who received aggressive IV fluid hydration. Therefore, it is important to assess the evidence for aggressive IV fluid resuscitation in patients with AP.

Conclusion : Aggressive IV hydration was associated with increased risk of mor- tality compared to nonaggressive fluid hydration when data for pa- tients with severe and nonsevere AP were pooled together (nine RCTs, risk ratio [RR] 2.4, 95% confidence interval [CI] 1.4– 4.2, absolute risk difference [ARD] 4.7%, number needed to harm [NNH] 21). Aggressive fluid hydration was associated with increased risk of mortality in those with severe AP (two RCTs, pooled RR 2.5, 95% CI 1.4– 4.4, ARD 19.5%, NNH 5) but not in patients with nonsevere AP (three RCTs). Regarding secondary outcomes, the authors found increased risk of fluid- related complications (five RCTs, pooled RR 2.5, 95% CI 1.7– 3.8, ARD 12.5%, NNH 7) when patients with severe and nonsevere AP were pooled.

Conclusion (proposition de traduction) : L'hydratation IV agressive a été associée à un risque accru de mortalité par rapport à l'hydratation liquide non agressive lorsque les données concernant les patients atteints de pancréatite aiguë sévère et non sévère ont été regroupées (neuf essais contrôlés randomisés, rapport de risque [RR] 2,4, intervalle de confiance à 95 % [IC] 1,4- 4,2, différence de risque absolu [ARD] 4,7 %, nombre nécessaire pour nuire 21). Le remplissage vasculaire agressif a été associée à un risque accru de mortalité chez les patients atteints de pancréatite aiguë sévère (deux essais contrôlés randomisés, RR groupé 2,5, IC à 95 % 1,4- 4,4, ARD 19,5 %, nombre nécessaire pour nuire 5), mais pas chez les patients présentant une pancréatite aiguë non sévère (trois essais contrôlés randomisés). En ce qui concerne les résultats secondaires, les auteurs ont constaté un risque accru de complications liées aux fluides (cinq essais contrôlés randomisés, RR groupé 2,5, IC à 95 % 1,7- 3,8, ARD 12,5 %, nombre nécessaire pour nuire 7) lorsque les patients atteints de pancréatite aiguë sévère et non sévère ont été regroupés.

Effect of Carbon Monoxide Poisoning on Epilepsy Development: A Nationwide Population-Based Cohort Study.
Meng YH, Hsieh MS, Chi YC, How CK, Chen PC, Chang CM. | Ann Emerg Med. 2023 Aug;82(2):145-151
DOI: https://doi.org/10.1016/j.annemergmed.2022.11.021  | Télécharger l'article au format  
Keywords: Aucun

Toxicology

Introduction : Carbon monoxide (CO) poisoning causes central nervous system toxicity resulting in delayed neurologic sequelae. This study aims to evaluate the risk of epilepsy in patients with a history of CO intoxication.

Méthode : We conducted a retrospective population-based cohort study using the Taiwan National Health Insurance Research Database and enrolled patients with and without CO poisoning matched for age, sex, and index year in a 1:5 ratio, between 2000 and 2010. Multivariable survival models were used to assess the risk of epilepsy. The primary outcome was newly developed epilepsy after the index date. All patients were followed until a new diagnosis of epilepsy, death, or December 31, 2013. Stratification analyses by age and sex were also conducted.

Résultats : This study included 8,264 patients with CO poisoning and 41,320 without. Patients with a history of CO poisoning were strongly associated with subsequent epilepsy (adjusted hazard ratio [HR] 8.40; 95% confidence interval [CI], 6.48 to 10.88). In the age-stratified analysis, intoxicated patients aged 20 to 39 years had the highest HR (adjusted HR 11.06; 95% CI, 7.17 to 17.08). In the sex-stratified analysis, adjusted HRs for male and female patients were 8.00 (95% CI, 5.86 to 10.92) and 9.53 (95% CI, 5.95 to 15.26), respectively.

Conclusion : Patients with CO poisoning were associated with an increased risk of developing epilepsy compared with those without CO poisoning. This association was more prominent in the young population.

Conclusion (proposition de traduction) : Les patients ayant été intoxiqués au CO présentaient un risque accru de développer une épilepsie par rapport à ceux qui n'avaient pas été intoxiqués au CO. Cette association était plus marquée chez les jeunes.

Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction.
Koechlin L, Strebel I, Zimmermann T, Nestelberger T, Walter J, Lopez-Ayala P, Boeddinghaus J, Shrestha S, Arslani K, Stefanelli S, Reuthebuch B, Wussler D, Ratmann PD, Christ M, Badertscher P, Wildi K, Giménez MR, Gualandro DM, Miró Ò, Fuenzalida C, Martin-Sanchez FJ, Kawecki D, Bürgler F, Keller DI, Abächerli R, Reuthebuch O, Eckstein FS, Twerenbold R, Reichlin T, Mueller C; APACE investigators. | Ann Emerg Med. 2023 Aug;82(2):194-202
DOI: https://doi.org/10.1016/j.annemergmed.2022.12.003  | Télécharger l'article au format  
Keywords: Les ondes T suraiguës, définies comme une augmentation de l'amplitude des ondes T dépassant le 95e percentile, n'ont pas fourni d'informations utiles pour le diagnostic de l'infarctus du myocarde dans cet échantillon.

Cardiology

Introduction : The diagnostic performance of T-wave amplitudes for the detection of myocardial infarction is largely unknown. We aimed to address this knowledge gap.

Méthode : T-wave amplitudes were automatically measured in 12-lead ECGs of patients presenting with acute chest discomfort to the emergency department within a prospective diagnostic multicenter study. The final diagnosis was centrally adjudicated by 2 independent cardiologists. Patients with left ventricular hypertrophy, complete left bundle branch block, or paced ventricular depolarization were excluded. The performance for lead-specific 95th-percentile thresholds were reported as likelihood ratios (lr), specificity, and sensitivity.

Résultats : Myocardial infarction was the final diagnosis in 445 (18%) of 2457 patients. In most leads, T-wave amplitudes tended to be greater in patients without myocardial infarction than those with myocardial infarction, and T-wave amplitude exceeding the 95th percentile had positive and negative lr close to 1 or with confidence intervals (CIs) crossing 1. The exceptions were leads III, aVR, and V1, which had positive lrs of 3.8 (95% CI, 2.7 to 5.3), 4.3 (95% CI, 3.1 to 6.0) and 2.0 (95% CI, 1.4 to 2.9), respectively. These leads normally have inverted T waves, so T-wave amplitude exceeding the 95th percentile reflects upright rather than increased-amplitude hyperacute T waves.

Conclusion (proposition de traduction) : Hyperacute T waves, when defined as increased T-wave amplitude exceeding the 95th percentile, did not provide useful information in diagnosing myocardial infarction in this sample.

Family-Witnessed Cardiopulmonary Resuscitation During Emergency Department Cardiac Arrest Care: A Resident Perspective.
Toy J. | Ann Emerg Med. 2023 Aug;82(2):207-215
DOI: https://doi.org/10.1016/j.annemergmed.2023.01.027
Keywords: Aucun

Cardiology

Editorial : For centuries, an individual’s birth and death most often occurred within their home while surrounded by family. However, with advancements in modern medicine and industrialization, these 2 natural occurrences have been sequestered behind hospital walls. Until the 1960s, fathers were routinely excluded from the delivery room during childbirth. An obstetric physician was quoted as: “.he [father] would faint and fall on the floor and the nurse would have to take care of him... Your infection rate would go up, and your malpractice rate would go up.” Over the past 50 years, a shift toward patient- and family-centric obstetrical care has resulted in the partner’s presence at the bedside being commonplace during delivery.

Conclusion : Currently, there is minimal research in the ED setting to inform the practice of family-witnessed CPR in adult nontraumatic cardiac arrest care. Nonetheless, research from the out-of-hospital setting shows an association between offering family-witnessed CPR and a reduction in PTSD-related symptoms among family members and no demonstrated harmful effects. Additionally, survey studies from various settings report that patients, families, and nurses generally support family-witnessed CPR. Many major professional organizations also collectively support this practice. In taking these findings and recommendations into consideration, I believe it would be prudent patient- and family-centric practice for emergency physicians and residents to consider routinely offering family-witnessed CPR during adult nontraumatic cardiac arrest care. Future ED-based research is needed to inform the development of a widespread family-witnessed CPR policy.

Conclusion (proposition de traduction) : À l'heure actuelle, peu de recherches ont été menées dans le contexte des urgences pour éclairer la pratique de la réanimation cardio-pulmonaire en présence d'un témoin dans le cadre de la prise en charge d'un arrêt cardiaque non traumatique chez l'adulte. Néanmoins, les recherches menées en milieu extrahospitalier montrent qu'il existe un lien entre la pratique de la RCP par la famille et la réduction des symptômes liés au stress post-traumatique chez les membres de la famille, sans qu'aucun effet néfaste n'ait été démontré. En outre, des enquêtes menées dans différents contextes indiquent que les patients, les familles et les infirmières sont généralement favorables à la RCP pratiquée par les familles. De nombreuses organisations professionnelles majeures soutiennent également collectivement cette pratique. Compte tenu de ces résultats et de ces recommandations, je pense qu'il serait prudent que les médecins urgentistes et les internes, centrés sur le patient et la famille, envisagent de proposer systématiquement la RCP avec témoin familial lors de la prise en charge d'un arrêt cardiaque non traumatique chez l'adulte. De futures recherches sur les urgences sont nécessaires pour éclairer l'élaboration d'une politique généralisée en matière de RCP avec témoin familial.

Epinephrine in Out-of-Hospital Cardiac Arrest: A Network Meta-analysis and Subgroup Analyses of Shockable and Nonshockable Rhythms.
Fernando SM, Mathew R, Sadeghirad B, Rochwerg B, Hibbert B, Munshi L, Fan E, Brodie D, Di Santo P, Tran A, McLeod SL, Vaillancourt C, Cheskes S, Ferguson ND, Scales DC, Lin S, Sandroni C, Soar J, Dorian P, Perkins GD, Nolan JP. | Chest. 2023 Aug;164(2):381-393
DOI: https://doi.org/10.1016/j.chest.2023.01.033  | Télécharger l'article au format  
Keywords: critical care medicine; emergency medicine; epinephrine; out-of-hospital cardiac arrest; return of spontaneous circulation.

Original Research

Introduction : Epinephrine is the most commonly used drug in out-of-hospital cardiac arrest (OHCA) resuscitation, but evidence supporting its efficacy is mixed.
Research question: What are the comparative efficacy and safety of standard dose epinephrine, high-dose epinephrine, epinephrine plus vasopressin, and placebo or no treatment in improving outcomes after OHCA?

Méthode : In this systematic review and network meta-analysis of randomized controlled trials, we searched six databases from inception through June 2022 for randomized controlled trials evaluating epinephrine use during OHCA resuscitation. We performed frequentist random-effects network meta-analysis and present ORs and 95% CIs. We used the the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the certainty of evidence. Outcomes included return of spontaneous circulation (ROSC), survival to hospital admission, survival to discharge, and survival with good functional outcome.

Résultats : We included 18 trials (21,594 patients). Compared with placebo or no treatment, high-dose epinephrine (OR, 4.27; 95% CI, 3.68-4.97), standard-dose epinephrine (OR, 3.69; 95% CI, 3.32-4.10), and epinephrine plus vasopressin (OR, 3.54; 95% CI, 2.94-4.26) all increased ROSC. High-dose epinephrine (OR, 3.53; 95% CI, 2.97-4.20), standard-dose epinephrine (OR, 3.00; 95% CI, 2.66-3.38), and epinephrine plus vasopressin (OR, 2.79; 95% CI, 2.27-3.44) all increased survival to hospital admission as compared with placebo or no treatment. However, none of these agents may increase survival to discharge or survival with good functional outcome as compared with placebo or no treatment. Compared with placebo or no treatment, standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm (OR, 2.10; 95% CI, 1.21-3.63), but not in those with shockable rhythm (OR, 0.85; 95% CI, 0.39-1.85).

Conclusion : Use of standard-dose epinephrine, high-dose epinephrine, and epinephrine plus vasopressin increases ROSC and survival to hospital admission, but may not improve survival to discharge or functional outcome. Standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm, but not those with shockable rhythm.

Conclusion (proposition de traduction) : L'utilisation de l'adrénaline à dose normale, à dose élevée et associée à la vasopressine augmente la survie jusqu'à l'admission à l'hôpital, mais n'améliore pas pour autant la survie jusqu'à la sortie de l'hôpital ou les résultats fonctionnels. L'adrénaline à dose normale améliore la survie jusqu'à la sortie de l'hôpital chez les patients dont le rythme n'est pas choquable, mais pas chez ceux dont le rythme est choquable.

Recommendations for endotracheal tube insertion depths in children.
Ebenebe CU, Schriever K, Apostolidou S, Wolf M, Herrmann J, Singer D, Deindl P. | Emerg Med J. 2023 Aug;40(8):583-587
DOI: https://doi.org/10.1136/emermed-2022-212494  | Télécharger l'article au format  
Keywords: Rapid Sequence Induction and Intubation; airway; clinical; critical care; pediatric emergency medicine.

Original research

Introduction : Endotracheal tube (ETT) malposition is frequent in paediatric intubation. The current recommendations for ETT insertion depths are based on formulae that hold various limitations. This study aimed to develop age-based, weight-based and height-based curve charts and tables for ETT insertion depth recommendations in children.

Méthode : In this retrospective single-centre study, we determined the individual optimal ETT insertion depths in paediatric patients by evaluating postintubation radiographic images. Age-based, weight-based and height-based ETT insertion depth recommendations were developed using regression analysis. We compared the insertion depths predicted by the models with previously published formulae.

Résultats : Intubations of 167 children (0-17.9 years) were analysed. Best-fit curves generated with logistic regression analysis revealed R² values between 0.784 and 0.880. The insertion depths predicted by the models corresponded well with published age-based and height-based formulae. However, they demonstrated the unsuitability of weight-related linear formulae to predict ETT depth in children.

Conclusion : The recommendations developed in this study facilitate a fast and accurate determination of recommended ETT insertion depths in children. Our recommendations provide greater accuracy than previously published formulae and demonstrate that weight-related linear formulae are unsuitable for predicting ETT depth in children.

Conclusion (proposition de traduction) : Les recommandations formulées dans cette étude permettent une détermination rapide et précise des profondeurs d'insertion recommandées pour les tubes endotrachéaux chez les enfants. Nos recommandations sont plus précises que les formules précédemment publiées et démontrent que les formules linéaires liées au poids ne conviennent pas pour prédire la profondeur du tube endotrachéal chez les enfants.

A pictorial review of imaging findings associated with upper cervical trauma.
Ismail R, Manganaro M, Schartz D, Worley L, Kessler A. | Emerg Radiol. 2023 Aug;30(4):485-497
DOI: https://doi.org/10.1007/s10140-023-02141-w
Keywords: Key imaging features; Radiographic clues; Upper cervical trauma.

REVIEW ARTICLE

Editorial : The diagnosis of cervical spine injury in the emergency department remains a critical skill of emergency room physicians as well as radiologists. Such diagnoses are often associated with high morbidity and mortality unless readily identified and treated appropriately. Both computed tomography (CT) and magnetic resonance imaging (MRI) often are crucial in the workup of spinal injury and play a key role in arriving at a diagnosis. Unfortunately, missed cervical spine injuries are not necessarily uncommon and often precede detrimental neurologic sequalae. With the increase in whole-body imaging ordered from the emergency department, it is critical for radiologists to be acutely aware of key imaging features associated with upper cervical trauma, possible mimics, and radiographic clues suggesting potential high-risk patient populations. This pictorial review will cover key imaging features from several different imaging modalities associated with upper cervical spine trauma, explore patient epidemiology, mechanism, and presentation, as well as identify confounding radiographic signs to aid in confident and accurate diagnoses.

Conclusion : Evaluation of the upper cervical spine remains a critical aspect of the emergency room physician. With the increase in “pan-scan” protocols in the emergency department and unreliable stream of clinical information, it is critical for radiologists to be acutely aware of key imaging features of upper cervical trauma, possible mimics, and radiographic clues suggesting high-risk patient populations.

Conclusion (proposition de traduction) : L'évaluation de la colonne cervicale supérieure reste un aspect critique pour le médecin urgentiste. Avec l'augmentation des protocoles "pan-scan" dans les services d'urgence et le manque de fiabilité du traitement des informations cliniques, il est essentiel que les radiologues soient parfaitement conscients des principales caractéristiques d'imagerie des traumatismes du rachis cervical supérieur, des similitudes possibles et des indices radiographiques suggérant des populations de patients à haut risque.

Accuracy of pulse CO-oximetry to evaluate blood carboxyhemoglobin level: a systematic review and meta-analysis of diagnostic test accuracy studies.
Papin M, Latour C, Leclère B, Javaudin F. | Eur J Emerg Med. 2023 Aug 1;30(4):233-243
DOI: https://doi.org/10.1097/mej.0000000000001043  | Télécharger l'article au format  
Keywords: carbon monoxide poisoning, carboxyhemoglobin, carbon monoxide saturation, CO oximeters, pulse oximetry

Review

Introduction : Carbon monoxide (CO) poisoning is one of the most common causes of poisoning death and its diagnosis requires an elevated carboxyhemoglobin (COHb) level. Noninvasive CO saturation by pulse oximetry (SpCO) has been available since 2005 and has the advantage of being portable and easy to use, but its accuracy in determining blood COHb level is controversial.

Méthode : To evaluate the accuracy of SpCO (index test) to estimate COHb (reference test). Systematic review and meta-analysis of diagnostic test accuracy (DTA) studies. Four electronic databases were searched (Medline, Embase, Cochrane Central Register of Controlled Trials, and OpenGrey) on 2 August 2022. All studies of all designs published since the 2000s evaluating the accuracy and reliability of SpCO measurement compared to blood COHb levels in human volunteers or ill patients, including children, were included. The primary outcome was to assess the diagnostic accuracy of SpCO for estimating COHb by blood sampling by modeling receiver operating characteristic (ROC) curves and calculating sensitivity and specificity (primary measures). The secondary measures were to calculate the limits of agreement (LOA) and the mean bias. This systematic review was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis-DTA 2018 guidelines and has been registered on International Prospective Register of Systematic Reviews (PROSPERO, CRD42020177940). The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

Résultats : Twenty-one studies were eligible for the systematic review; 11 could be included for the quantitative analysis of the primary measures and 18 for the secondary measures. No publication bias was found. The area under the summary ROC curve was equal to 86%. The mean sensitivity and specificity were 0.77, 95% confidence interval (CI, 0.66-0.85) and 0.83, 95% CI (0.74-0.89), respectively (2089 subjects and 3381 observations). The mean bias was 0.75% and the LOA was -7.08% to 8.57%, 95% CI (-8.89 to 10.38) (2794 subjects and 4646 observations).

Conclusion : Noninvasive measurement of COHb (SpCO) using current pulse CO oximeters do not seem to be highly accurate to estimate blood COHb (moderate sensitivity and specificity, large LOA). They should probably not be used to confirm (rule-in) or exclude (rule-out) CO poisoning with certainty.

Conclusion (proposition de traduction) : La mesure non invasive de la carboxyhémoglobine (SpCO) à l'aide des oxymètres de CO pulsés actuels ne semble pas très précise pour estimer la carboxyhémoglobine sanguine (sensibilité et spécificité modérées, larges limites de concordance). Elles ne devraient probablement pas être utilisées pour confirmer (rule-in) ou exclure (rule-out) avec certitude une intoxication au CO.

The potential of point-of-care diagnostics to optimise prehospital trauma triage: a systematic review of literature.
Stojek L, Bieler D, Neubert A, Ahnert T, Imach S. | Eur J Trauma Emerg Surg. 2023 Aug;49(4):1727-1739
DOI: https://doi.org/10.1007/s00068-023-02226-8  | Télécharger l'article au format  
Keywords: Advanced trauma life support care; Emergency medical service; Focused assessment with sonography for trauma; Point-of-care testing; Triage.

ORIGINAL ARTICLE

Introduction : In the prehospital care of potentially seriously injured patients resource allocation adapted to injury severity (triage) is a challenging. Insufficiently specified triage algorithms lead to the unnecessary activation of a trauma team (over-triage), resulting in ineffective consumption of economic and human resources. A prehospital trauma triage algorithm must reliably identify a patient bleeding or suffering from significant brain injuries. By supplementing the prehospital triage algorithm with in-hospital established point-of-care (POC) tools the sensitivity of the prehospital triage is potentially increased. Possible POC tools are lactate measurement and sonography of the thorax, the abdomen and the vena cava, the sonographic intracranial pressure measurement and the capnometry in the spontaneously breathing patient. The aim of this review was to assess the potential and to determine diagnostic cut-off values of selected instrument-based POC tools and the integration of these findings into a modified ABCDE based triage algorithm.

Méthode : A systemic search on MEDLINE via PubMed, LIVIVO and Embase was performed for patients in an acute setting on the topic of preclinical use of the selected POC tools to identify critical cranial and peripheral bleeding and the recognition of cerebral trauma sequelae. For the determination of the final cut-off values the selected papers were assessed with the Newcastle-Ottawa scale for determining the risk of bias and according to various quality criteria to subsequently be classified as suitable or unsuitable.

Résultats : 267 papers were identified as potentially relevant and processed in full text form. 61 papers were selected for the final evaluation, of which 13 papers were decisive for determining the cut-off values. Findings illustrate that a preclinical use of point-of-care diagnostic is possible. These adjuncts can provide additional information about the expected long-term clinical course of patients. Clinical outcomes like mortality, need of emergency surgery, intensive care unit stay etc. were taken into account and a hypothetic cut-off value for trauma team activation could be determined for each adjunct. The cut-off values are as follows: end-expiratory CO2: < 30 mm/hg; sonography thorax + abdomen: abnormality detected; lactate measurement: > 2 mmol/L; optic nerve diameter in sonography: > 4.7 mm.

Conclusion : A preliminary version of a modified triage algorithm with hypothetic cut-off values for a trauma team activation was created. However, further studies should be conducted to optimize the final cut-off values in the future. Furthermore, studies need to evaluate the practical application of the modified algorithm in terms of feasibility (e.g. duration of application, technique, etc.) and the effects of the new algorithm on over-triage. Limiting factors are the restriction with the search and the heterogeneity between the studies (e.g. varying measurement devices, techniques etc.).

Conclusion (proposition de traduction) : La version préliminaire d'un algorithme de tri modifié avec des valeurs seuils théoriques pour l'activation d'une équipe trauma (grave) a été créée. Cependant, d'autres études devraient être menées à l'avenir pour optimiser les valeurs limites retenues. En outre, des études doivent évaluer la mise en pratique de l'algorithme modifié en termes de faisabilité (par exemple, durée d'application, technique, etc.) et les effets du nouvel algorithme sur le surtriage. Les facteurs limitants sont la restriction de la recherche et l'hétérogénéité entre les études (par exemple, différents dispositifs de mesure, techniques, etc.)

Commentaire : 

Coronavirus disease 2019.
Arabi YM, Diaz J, Lamontagne F.. | Intensive Care Med. 2023 Sep;49(9):1103-1106
DOI: https://doi.org/10.1007/s00134-023-07168-8  | Télécharger l'article au format  
Keywords: Aucun

Recent Advances in ICU

Editorial : In less than 4 years, coronavirus disease 2019 (COVID- 19) has been diagnosed in 768 million people worldwide, leading to close to 7 million deaths (https:// covid 19. who. int). In response to this global pandemic, accelerated efforts have been made to evaluate the management of critically ill patients with COVID-19, leading to major advances in the field. We focus this article on patient- level advances during the pandemic, recognizing that the wide introduction of vaccines and improvements in healthcare system response over the course of the pan- demic have greatly reduced the severity of the infection and the likelihood of its progression to critical illness [1]. We also address areas with little advances that represent lessons and opportunities for improvement.

Conclusion : With the increasing use of novel adaptive platform trials, there are ongoing learning opportunities regarding their strengths and limitations. Much more is to be learned about the heterogeneity of treatment effect and the presence of subgroup effects, for example, of anticoagulation, so a more individualized patient evidence- based approach according can be applied. Most clinical trials evaluated treatment effectiveness based on short-term mortality but long-term outcomes remained largely unknown. Only a few clinical trials collected and disseminated long-term data; reassuringly, the results were consistent with short-term outcomes.
There is so much to learn from the unparalleled advances made during the COVID-19 pandemic, but there are also so many lessons from the limitations, opening exciting opportunities for improvement.

Conclusion (proposition de traduction) : Avec l'utilisation croissante de nouvelles plateformes d'essais adaptatives, il existe des opportunités d'apprentissage continu concernant leurs forces et leurs limites. Il reste encore beaucoup à apprendre sur l'hétérogénéité de l'effet du traitement et la présence d'effets de sous-groupe, par exemple, de l'anticoagulation, de sorte qu'une approche plus individualisée, basée sur les preuves, puisse être appliquée. La plupart des essais cliniques ont évalué l'efficacité du traitement sur la base de la mortalité à court terme, mais les résultats à long terme sont restés largement inconnus. Seuls quelques essais cliniques ont recueilli et diffusé des données à long terme ; ce qui est rassurant, c'est que les résultats étaient cohérents avec les résultats à court terme.
Il y a tant à apprendre des progrès sans précédent réalisés au cours de la pandémie de COVID-19, mais il y a aussi tant de leçons à tirer des limites, ce qui ouvre des perspectives d'amélioration passionnantes.

Prehospital stratification and prioritisation of non-ST-segment elevation acute coronary syndrome patients (NSTEACS): the MARIACHI scale.
Solà-Muñoz S, Jorge M, Jiménez-Fàbrega X, Jiménez-Delgado S, Azeli Y, Marsal JR, Jordán S, Mauri J, Jacob J. | Intern Emerg Med. 2023 Aug;18(5):1317-1327
DOI: https://doi.org/10.1007/s11739-023-03274-z
Keywords: Non-ST-elevation myocardial infarction; Prehospital; Score; Unstable angina.

IM - ORIGINAL

Introduction : The objective of this study was to develop and validate a risk scale (MARIACHI) for patients classified as non-ST-segment elevation acute coronary syndrome (NSTEACS) in a prehospital setting with the ability to identify patients at an increased risk of mortality at an early stage.

Méthode : A retrospective observational study conducted in Catalonia over two periods: 2015-2017 (development and internal validation cohort) and Aug 2018-Jan 2019 (external validation cohort). We included patients classified as prehospital NSTEACS, assisted by an advanced life support unit and requiring hospital admission. The primary outcome was in-hospital mortality. Cohorts were compared using logistic regression and a predictive model was created using bootstrapping techniques.

Résultats : The development and internal validation cohort included 519 patients. The model is composed of five variables associated with hospital mortality: age, systolic blood pressure, heart rate > 95 bpm, Killip-Kimball III-IV and ST depression ≥ 0.5 mm. The model showed good overall performance (Brier = 0.043) and consistency in discrimination (AUC 0.88, 95% CI 0.83-0.92) and calibration (slope = 0.91; 95% CI 0.89-0.93). We included 1316 patients for the external validation sample. There was no difference in discrimination (AUC 0.83, 95% CI 0.78-0.87; DeLong Test p = 0.071), but there was in calibration (p < 0.001), so it was recalibrated. The finally model obtained was stratified and scored into three groups according to the predicted risk of patient in-hospital mortality: low risk: < 1% (-8 to 0 points), moderate risk: 1-5% (+ 1 to + 5 points) and high risk: > 5% (6-12 points).

Conclusion : The MARIACHI scale showed correct discrimination and calibration to predict high-risk NSTEACS. Identification of high-risk patients may help with treatment and low referral decisions at the prehospital level.

Conclusion (proposition de traduction) : L'échelle MARIACHI a montré une discrimination et une calibration correctes pour prédire le syndrome coronarien aigu sans sus-décalage du segment ST à haut risque. L'identification des patients à haut risque peut aider à prendre des décisions en matière de traitement et d'orientation au niveau préhospitalier.

Acute dyspnea in the emergency department: a clinical review.
Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. | Intern Emerg Med. 2023 Aug;18(5):1491-1507
DOI: https://doi.org/10.1007/s11739-023-03322-8  | Télécharger l'article au format  
Keywords: Cardiogenic edema; Dyspnea; High flow oxygen; Non-invasive ventilation; Respiratory failure; Respiratory support.

EM - REVIEW

Editorial : Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.

Conclusion : Dyspnea is a symptom, generated by complex interactions between various physiological, psychological, pathological, and environmental factors, frequently leading patients to the ED. Its non-specificity makes the rapid and accurate identi- fication of the underlying causes a clinical challenge. Nev- ertheless, dyspnea requires prompt diagnostic evaluation, as some diseases causing dyspnea can be life-threatening, and delaying diagnosis can increase morbidity, time to discharge and treatment costs. Once history and examination gener- ate clinical suspicion for various diagnoses, they should be confirmed or disproved by the use of biomarkers and imag- ing techniques. Among them, lung ultrasound is gathering interest and popularity among ED physicians, and it is likely that in the future its use will become widespread, as long as more clinical studies will support its utility in the ED setting. Even before reaching a correct diagnosis of the cause of dyspnea, ED physicians by inspection and physical examination should promptly identify patients with severe respiratory distress, that may require non-invasive ventila- tory support or immediate endotracheal intubation.

Conclusion (proposition de traduction) : La dyspnée est un symptôme qui résulte d'interactions complexes entre divers facteurs physiologiques, psychologiques, pathologiques et environnementaux, et qui conduit fréquemment les patients aux urgences. Sa non-spécificité fait de l'identification rapide et précise des causes sous-jacentes un défi clinique. Néanmoins, la dyspnée nécessite une évaluation diagnostique rapide, car certaines maladies causant une dyspnée peuvent mettre en jeu le pronostic vital, et retarder le diagnostic, peut augmenter la morbidité, le délai de sortie et les coûts de traitement. Une fois que l'anamnèse et l'examen ont permis de suspecter divers diagnostics, ceux-ci doivent être confirmés ou infirmés par l'utilisation de biomarqueurs et de techniques d'imagerie. Parmi celles-ci, l'échographie pulmonaire suscite de plus en plus d'intérêt et de popularité parmi les médecins urgentistes, et il est probable que son utilisation se généralisera à l'avenir, à condition que davantage d'études cliniques soutiennent son utilité dans le contexte des urgences. Avant même de parvenir à un diagnostic correct de la cause de la dyspnée, les médecins urgentistes doivent, par l'inspection et l'examen physique, identifier rapidement les patients présentant une détresse respiratoire grave, qui peut nécessiter une assistance respiratoire non invasive ou une intubation endotrachéale immédiate.

Commentaire : 

Point of Care Ultrasonographic Life Support in Emergency (PULSE)—a quasi-experimental study.
Ali N, Chhotani AA, Iqbal SP, Soomar SM, Raheem A, Waheed S. | Int J Emerg Med. 2023 Aug 9;16(1):49
DOI: https://doi.org/10.1186/s12245-023-00525-w  | Télécharger l'article au format  
Keywords: Emergency; Life support; Point of care; Ultrasound.

RESEARCH

Editorial : Point of Care Ultrasonographic Life Support in Emergency (PULSE) - une étude quasi-expérimentale

Introduction : Many physicians use point-of-care ultrasound (PoCUS) in their clinical practice to improve their diagnostic capabilities, accuracy, and timeliness. Over the last two decades, the use of PoCUS in the emergency room has dramatically increased. This study aimed to determine emergency physicians' retention of knowledge and skills after a brief training workshop on a focused ultrasound-guided approach to a patient presenting with undifferentiated shock, shortness of breath, and cardiac arrest in the emergency department of a tertiary care hospital. The secondary aim was to deliver the PoCUS-guided algorithmic approach to manage a patient presenting with undifferentiated shock, respiratory distress, and cardiac arrest in the emergency department.

Méthode : A quasi-experimental study was conducted with a single-day Point of Care Ultrasonographic Life Support in Emergency (PULSE) training workshop in October 2021 at the Aga Khan University Hospital, Karachi, Pakistan. A total of 32 participants attended the course, including twenty-one junior residents (PGY 1 and 2) and medical officers with experience of fewer than two years working in different emergency departments of urban tertiary care hospitals across Karachi, Pakistan. Pre- and post-assessment tools comprised a written examination, evaluating participants' knowledge and skills in ultrasound image acquisition and interpretation. Cronbach's alpha was used to calculate the validity of the tool. Results obtained before and after the training session were compared by the McNemar's test. A p value of ≤ 0.05 was considered significant.

Résultats : There was a significant improvement in response to each question pre to post-test after completion of the course (Table 1). The significant change can be seen in questions 7, 8, 13, and 15, with a percentage change of 33.3, 80.9, 42.9, and 47.7. There was a significant improvement in the understanding and knowledge of participants after the training. The scores in the post-test were high compared to the pre-test in each category, i.e., respiratory distress (p < 0.017), cardiac arrest (p < 0.041), basic ultrasound knowledge (p < 0.001), and undifferentiated shock (p < 0.001).

Conclusion : All participants showed improvement in their knowledge and confidence regarding using PoCUS in life-threatening conditions. Through this study, we have also developed an algorithmic approach to managing undifferentiated shock, respiratory failure, and cardiac arrest. Future studies must assess the effectiveness and feasibility of incorporating these algorithms into clinical practice.

Conclusion (proposition de traduction) : Tous les participants ont amélioré leurs connaissances et leur confiance dans l'utilisation du PoCUS dans les situations de détresse vitale. Grâce à cette étude, nous avons également développé une approche algorithmique de la gestion du choc indifférencié, de l'insuffisance respiratoire et de l'arrêt cardiaque. Les études futures devront évaluer l'efficacité et la faisabilité de l'incorporation de ces algorithmes dans la pratique clinique.

Low-Dose Colchicine for Secondary Prevention of Coronary Artery Disease.
Nelson K, Fuster V, Ridker PM. | J Am Coll Cardiol. 2023 Aug 15;82(7):648-660
DOI: https://doi.org/10.1016/j.jacc.2023.05.055
Keywords: atherosclerosis; colchicine; inflammation; residual inflammatory risk.

JACC Review Topic of the Week

Editorial : Among statin-treated patients, inflammation assessed by means of high-sensitivity C-reactive protein (hsCRP) is a more powerful determinant of cardiovascular death and all-cause mortality than low-density-lipoprotein cholesterol (LDL-C). Several therapies that target residual inflammatory risk significantly reduce vascular event rates. For coronary artery disease patients already taking guideline-directed medical care, including statins, low-dose colchicine (0.5 mg/d orally) has been shown to safely lower major adverse cardiovascular events by 31% among those with stable atherosclerosis and by 23% after recent myocardial infarction. These magnitudes of benefit are larger than those seen in contemporary secondary prevention trials of adjunctive lipid-lowering agents. Low-dose colchicine is contraindicated in patients with significant renal or liver dysfunction and should be temporarily discontinued when taking concomitant agents such as clarithromycin, ketoconazole, and cyclosporine that share metabolism pathways. Lipid lowering and inflammation inhibition are not in conflict but are synergistic. In the future, combined use of aggressive LDL-C-lowering and inflammation-inhibiting therapies may become standard of care for most atherosclerosis patients. In June 2023, the U.S. Food and Drug Administration approved the use of low-dose colchicine to reduce the risk of myocardial infarction, stroke, coronary revascularization, and cardiovascular death in adult patients with established atherosclerotic disease or with multiple risk factors for cardiovascular disease.

Conclusion : Pharmacologic lowering of LDL-C is an exceptionally effective method to lower cardiovascular risk, and trials of statin therapy compared to placebo demonstrate a consistent linear reduction in risk for proportionate reductions in blood cholesterol (Figure 5, orange diamonds). Targeted anti-inflammatory therapy with canakinumab (as shown in CANTOS) or with oral low dose colchicine 0.5 mg (as shown in LoDoCo2 and COLCOT) also substantially reduces cardiovascular risk yet does so in the absence of any change in LDL-C or apolipoprotein B cholesterol (Figure 5, red diamonds). For reasons of convenience, safety, and cost-effectiveness, lowdose colchicine (0.5 mg/d) is currently the most widely available agent with proven anti-inflammatory cardiovascular benefits, and its use should be given serious consideration for high-risk patients with atherosclerotic disease and preserved renal and hepatic function. Patients with ischemic heart disease are heterogeneous, so patient subgroups may not benefit equally from low-dose colchicine, an effect also true for lipid lowering. As with lipid lowering, joint decision making for colchicine should be done on an individualized basis balancing risks and benefits.
Lipid lowering and inflammation inhibition are not in conflict but are fully synergistic interventions. Our current biological understanding of atherosclerosis suggests that targeting LDL-C alone is unlikely to eliminate atherosclerotic risk and that attention to inflammatory pathways and residual inflammatory risk offers a second adjunctive method to reduce fatal and nonfatal vascular events. Over time, we anticipate that combination therapies that incorporate aggressive lipid lowering and aggressive inflammation inhibition will become standard care for atherosclerosis patients.

Conclusion (proposition de traduction) : La réduction pharmacologique du LDL-C est une méthode exceptionnellement efficace pour réduire le risque cardiovasculaire, et les essais de traitement par statines comparés au placebo démontrent une réduction linéaire constante du risque pour des réductions proportionnelles du cholestérol sanguin (figure 5, losanges orange). Le traitement anti-inflammatoire ciblé par le canakinumab (comme le montre l'étude CANTOS) ou par une faible dose de colchicine 0,5 mg par voie orale (comme le montrent les études LoDoCo2 et COLCOT) réduit également de manière substantielle le risque cardiovasculaire, mais en l'absence de toute modification du LDL-C ou du cholestérol de l'apolipoprotéine B (figure 5, losanges rouges). Pour des raisons de commodité, de sécurité et de rentabilité, la colchicine à faible dose (0,5 mg/j) est actuellement l'agent le plus largement disponible avec des bénéfices cardiovasculaires anti-inflammatoires prouvés, et son utilisation devrait être sérieusement envisagée pour les patients à haut risque présentant une maladie athérosclérotique et des fonctions rénales et hépatiques préservées. Les patients atteints de cardiopathie ischémique sont hétérogènes, de sorte que les sous-groupes de patients peuvent ne pas bénéficier de la même manière d'une faible dose de colchicine, ce qui est également vrai pour l'abaissement des lipides. Comme pour l'abaissement des taux de lipides, la prise de décision conjointe concernant la colchicine doit se faire sur une base individuelle en équilibrant les risques et les avantages.
L'abaissement des lipides et l'inhibition de l'inflammation ne sont pas en conflit, mais constituent des interventions totalement synergiques. Notre compréhension biologique actuelle de l'athérosclérose suggère qu'il est peu probable que le ciblage du LDL-C seul élimine le risque d'athérosclérose et que l'attention portée aux voies inflammatoires et au risque inflammatoire résiduel offre une deuxième méthode complémentaire pour réduire les événements vasculaires mortels et non mortels. Avec le temps, nous prévoyons que les traitements combinées qui intègrent une réduction agressive des lipides et une inhibition agressive de l'inflammation deviendront des soins standard pour les patients atteints d'athérosclérose.

Point-of-Care Ultrasound for the Diagnosis of Pediatric Testicular Torsion: A Retrospective Case Series Analysis.
Koppel JH, Patt YS, Berant R. | Pediatr Emerg Care. 2023 Aug 1;39(8):623-628
DOI: https://doi.org/10.1097/pec.0000000000002863
Keywords: Aucun

ORIGINAL ARTICLE Point-of-Care

Introduction : Acute testicular torsion is a surgical emergency that warrants prompt treatment. The diagnosis is typically confirmed by ultrasonography interpreted by a radiologist (RADUS); however, in this study, we describe the clinical course of 23 patients for whom point-of-care ultrasound (POCUS) was performed by pediatric emergency medicine physicians during the initial assessment for testicular torsion in the pediatric emergency department (PED).

Méthode : A retrospective case series analysis of patients aged 0 to 18 years who were diagnosed with acute testicular torsion after undergoing scrotal POCUS through our PED.

Résultats : Between June 2015 and December 2020, 155 boys received an International Classification of Diseases-9 code of Torsion of Testis after presenting to our PED. Seventy-three patients were imaged preoperatively, of which 50 (68.5%) were diagnosed via RADUS alone. Twenty-three patients (31.5%) underwent POCUS (median age 14.1 years [interquartile range {IQR}: 11.4-15.9 years]), of which 14 (60.9%) were imaged by POCUS alone, whereas the remaining 9 patients (39.1%) underwent POCUS before RADUS. Thirteen of the 23 patients (56.5%) who underwent POCUS had intraoperative findings consistent with acute testicular torsion, whereas another 3 patients (13.0%) required manual detorsion in the PED before orchiopexy. Six patients required orchiectomy. All patients for which POCUS findings were suggestive of acute testicular torsion were correctly classified.The median length of stay from time to admission to orchiopexy for those who received RADUS only versus POCUS only was 184 minutes (IQR: 136-255), and 121 minutes (IQR: 80-202), respectively ( P = 0.036). Among the patients who experienced POCUS, the median length of stay for those who underwent RADUS in addition to POCUS compared with those who underwent POCUS alone was 202 minutes (IQR: 136-338.4) ( P = 0.031).

Conclusion : Point-of-care ultrasound performed by pediatric emergency medicine physicians can be used to expedite surgical management and streamline the management of pediatric patients suspected of acute testicular torsion.

Conclusion (proposition de traduction) : L'échographie au point de service réalisée par les médecins des urgences pédiatriques peut être utilisée pour accélérer la prise en charge chirurgicale et rationaliser la prise en charge des patients pédiatriques suspectés de torsion testiculaire aiguë.

Weight Estimation for Drug Dose Calculations in the Prehospital Setting - A Systematic Review.
Wells M, Henry B, Goldstein L. | Prehosp Disaster Med. 2023 Aug;38(4):471-484
DOI: https://doi.org/10.1017/s1049023x23006027  | Télécharger l'article au format  
Keywords: Broselow tape; PAWPER XL tape; drug dosing; weight estimation.

SYSTEMATIC REVIEW

Introduction : Weight estimation is required to enable dose calculations for weight-based drugs administered during emergency care. The accuracy of the estimation will determine the accuracy of the administered dose. This is an important matter of patient safety. The objective of this systematic review was to collect, review, evaluate, and create a synthesis of the current literature focusing on the accuracy of weight estimation in the prehospital environment.

Méthode : This systematic review followed the PRISMA guidelines. Studies were identified and included if they were peer reviewed, full length, published in English, and contained original data. Studies utilizing any form of weight estimation methodology in the prehospital setting (in children or adults) were included. Data on the quality of the studies and accuracy of the weight estimation systems were extracted. Common themes were also identified.

Résultats : Twenty-five studies met the inclusion criteria, with only nine studies (36.0%) containing useful weight estimation accuracy data. The overall quality of the studies was poor. The Broselow tape and paramedic estimates were the most studied methods of weight estimation, but there was insufficient evidence to support conclusions about accuracy. The major themes identified included the importance of accurate weight estimation and drug dosing as critical matters of patient safety, and the need for training to ensure these processes are performed accurately.

Conclusion : There were limited robust data identified on the accuracy of different weight estimation methods used in the prehospital setting. Future high-quality clinical research in this area is of critical importance to ensure patient safety in the prehospital environment.

Conclusion (proposition de traduction) : Peu de données fiables ont été trouvées sur la précision des différentes méthodes d'estimation du poids utilisées dans le cadre préhospitalier. Une future recherche clinique de haute qualité dans ce domaine est d'une importance cruciale pour assurer la sécurité des patients dans l'environnement préhospitalier.

Factors Associated with Symptom-to-Door Delay in Patients with ST-Segment Myocardial Infarction: A Systematic Review.
Lu X, Xia W, Wang X, Xie F, Sun X. | Prehosp Disaster Med. 2023 Aug;38(4):485-494
DOI: https://doi.org/10.1017/s1049023x23006039
Keywords: Emergency Medical Services; ST-segment myocardial infarction; prehospital delay; symptom-to-door delay; systematic review.

SYSTEMATIC REVIEW

Introduction : Decreasing symptom-to-door (S2D) delay is of vital importance for reducing morbidity and mortality in patients with ST-segment elevation myocardial infarction (STEMI). The factors associated with S2D delay in STEMI patients have not been well-characterized.
objectives: The aim of this study was to identify factors associated with S2D delay in patients with STEMI.

Méthode : The PubMed, CINAHL, and Embase databases were searched for data. References from the selected articles and relevant background papers were also manually searched to identify additional eligible studies. The included articles were reviewed and assessed for risk of bias. The level of evidence for each identified factor was evaluated using a semiquantitative synthesis.

Résultats : Twelve (12) papers were included in the review. Factors associated with S2D delay were complex and could be divided into sociodemographic, clinical history, and onset characteristics. The level of evidence regarding female sex and diabetes was strong, and the evidence was moderate regarding older age, smoking, history of hypertension, self-transport, or referral.

Conclusion : Female sex, older age, previous diabetes, previous hypertension, smoking, and self-transport are all strong or moderate risk factors for S2D time delay in patients with ST-segment myocardial infarction. More efforts should be made to educate at-risk populations concerning symptoms of STEMI and the importance of seeking early medical assistance.

Conclusion (proposition de traduction) : Le sexe féminin, l'âge élevé, les antécédents de diabète et d'hypertension, le tabagisme et le transport par ses propres moyens sont tous des facteurs de risque forts ou modérés pour le délai entre les symptômes et la prise en charge chez les patients souffrant d'un infarctus du myocarde du segment ST. Des efforts supplémentaires devraient être faits pour éduquer les populations à risque sur les symptômes de l'infarctus du myocarde avec sus-décalage du segment ST et sur l'importance d'une assistance médicale précoce.

Oxygen targets after cardiac arrest: A narrative review.
Bray J, Skrifvars MB, Bernard S. | Resuscitation. 2023 Aug;189:109899
DOI: https://doi.org/10.1016/j.resuscitation.2023.109899  | Télécharger l'article au format  
Keywords: Heart arrest; Oxygen; Post-resuscitation care; Resuscitation.

Review

Editorial : A significant focus of post-resuscitation research over the last decade has included optimising oxygenation. This has primarily occurred due to an improved understanding of the possible harmful biological effects of high oxygenation, particularly the neurotoxicity of oxygen free radicals. Animal studies and some observational research in humans suggest harm with the occurrence of severe hyperoxaemia (PaO2 > 300 mmHg) in the post-resuscitation phase. This early data informed in a change in treatment recommendations, with the International Liaison Committee on Resuscitation (ILCOR) recommending the avoidance of hyperoxaemia. However, the optimal oxygenation level for maximal survival has not yet been determined. Recent Phase 3 randomised control trials (RCTs) provide further insight into when oxygen titration should occur. The EXACT RCT suggested that decreasing oxygen fraction post-resuscitation in the prehospital setting, with limited ability to titrate and measure oxygenation, is too soon. The BOX RCT, suggests delaying titration to a normal level in intensive care may be too late. While further RCTs are currently underway in ICU cohorts, titration of oxygen early after arrival at hospital should be considered.

Conclusion : There is limited robust data to inform the clinician regarding oxygen management in-hospital. Targeting strict normoxia in the ICU has not been shown to improve outcomes based on current evidence. Several observational studies have observed an inverted U-shaped relationship between PaO2 mortality, suggesting that higher or lower extremes should be avoided and that the PaO2 range associated with increased mortality may be >180 mmHg, which is lower than the usual definition of severe hyperoxaemia.

Conclusion (proposition de traduction) : Il existe peu de données solides pour informer le clinicien sur la gestion de l'oxygène à l'hôpital. Il n'a pas été démontré que le fait de viser une normoxie stricte dans l'unité de soins intensifs améliorait les résultats sur la base des données actuelles. Plusieurs études d'observation ont observé une relation en forme de U inversé entre la PaO2 et la mortalité, suggérant que les extrêmes supérieurs ou inférieurs devraient être évités et que la plage de PaO2 associée à une mortalité accrue pourrait être >180 mmHg, ce qui est inférieur à la définition habituelle de l'hyperoxémie sévère.

Commentaire : 

Video triage in calls concerning children with fever at an out-of-hours medical helpline: a prospective quality improvement study.
Gren C, Hasselager AB, Linderoth G, Frederiksen MS, Folke F, Ersbøll AK, Gamst-Jensen H, Cortes D. | Scand J Trauma Resusc Emerg Med. 2023 Aug 29;31(1):41
DOI: https://doi.org/10.1186/s13049-023-01106-9  | Télécharger l'article au format  
Keywords: Fever; Parents; Patient participation; Pediatrics; Primary health care; Telemedicine; Telenursing; Triage.

ORIGINAL RESEARCH

Introduction : Parents often contact out-of-hours services due to worry concerning febrile children, despite the children rarely being severely ill. As telephone triage of children is challenging, many children are referred to hospital assessment. This study investigated if video triage resulted in more children staying at home. Secondary aims included safety, acceptability and feasibility of this new triage tool.

Méthode :  In this prospective quality improvement study, nurse call-handlers enrolled febrile children aged 3 months-5 years to video or telephone triage (1:1), with follow-up within 48 h after call. The setting was an out-of-hours call-center for non-urgent illness in Copenhagen, Denmark, receiving over 1 million calls annually and predominately staffed by registered nurses. Main outcome measure was difference in number of children assessed at hospital within 8 h after call between video-and telephone triage group. Rates of feasibility, acceptability and safety (death, lasting means, transfer to intensive care unit) were compared between the triage groups.

Résultats : There was no difference in triage outcome (home care vs. hospital referral) or number of patients assessed at hospital between triage groups. However, more video triaged patients received in-hospital treatment, testing and hospitalization.

Conclusion : Video triage was feasible to conduct, acceptable to parents and as safe as telephone triage. The study did not show that more children stayed at home after video triage, possibly because the allocation strategy was not upheld, as video triage sometimes was chosen in cases of complex and severe symptoms, and this likely has changed study outcome.

Conclusion (proposition de traduction) : Le triage vidéo était réalisable, acceptable pour les parents et aussi sûr que le triage téléphonique. L'étude n'a pas montré que plus d'enfants restaient à la maison après le triage vidéo, peut-être parce que la stratégie d'attribution n'a pas été respectée, car le triage vidéo a parfois été choisi dans les cas de symptômes complexes et graves, ce qui a probablement modifié les résultats de l'étude.

The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study.
Jakob DA, Müller M, Jud S, Albrecht R, Hautz W, Pietsch U. | Scand J Trauma Resusc Emerg Med. 2023 Aug 7;31(1):37
DOI: https://doi.org/10.1186/s13049-023-01107-8  | Télécharger l'article au format  
Keywords: Chest decompression; Helicopter emergency medical services; Hemorrhage control; Prehospital management; Traumatic cardiac arrest.

ORIGINAL RESEARCH

Introduction : Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies.

Méthode : This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI).

Résultats : Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group.

Conclusion : Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.

Conclusion (proposition de traduction) : Les taux de décompression thoracique et les mesures de contrôle précoce des hémorragies sont des domaines susceptibles d'être améliorés dans les soins préhospitaliers.

Effects of morphine and P2Y inhibitor amongst patients with acute coronary syndrome: A meta-analysis of comparative studies.
Lee SW, Kuo N, Hou SK, Kang YN. | Am J Emerg Med. 2023 Aug;70:119-126
DOI: https://doi.org/10.1016/j.ajem.2023.05.010
Keywords: Aucun

Original contribution

Introduction : P2Y inhibitor and morphine are widely used in caring for patients with the acute coronary syndrome (ACS), but there are some concerns about the combination use due to interaction in metabolism. Therefore, this study aimed to examine whether using morphine with antiplatelets in patients with ACS affects the clinical outcomes based on currently available evidence.

Méthode : Three databases were searched for comparative studies on this topic by using relevant keywords of ACS and morphine. Two authors independently extracted study information, mortality, major adverse cardiac event (MACE), major bleeding, and length of hospital stay. Then, they evaluated the quality of evidence independently. Meta-analysis was planned to be conducted in random-effects model. Risk ratio (RR) was used for most outcomes except hospital stay, and Peto odds ratio (POR) was used if there were any zero cells. Pooled estimate was presented with 95% confidence interval (CI).

Résultats : Fourteen studies (n = 73,033) met eligibility criteria, and there was non-significant difference in mortality between antiplatelet with and without morphine (RR = 1.13, 95%CI: 0.78 to 1.64). Antiplatelet therapy without morphine significantly reduced the risk of MACE (RR = 0.78, 95%CI: 0.67 to 0.89; I-square = 0%), but increased the odds of major bleeding (POR = 1.87, 95%CI: 1.04 to 3.35; I-square = 0%) as compared with the combined use of antiplatelet therapy and morphine.

Conclusion : In conclusion, there is no statistically significant difference in mortality in patients with ACS using morphine or not, but clinicians ought to make a trade-off between a lower risk of MACE and a higher risk of major bleeding before adding morphine to antiplatelet therapy.

Conclusion (proposition de traduction) : En conclusion, il n'y a pas de différence statistiquement significative en termes de mortalité chez les patients souffrant d'un syndrome coronarien aigu et utilisant ou non de la morphine, mais les médecins devraient faire un compromis entre un risque plus faible d'événement cardiaque majeur et un risque plus élevé d'hémorragie majeure avant d'ajouter la morphine au traitement antiplaquettaire.

Efficacy of analgesic and sub-dissociative dose ketamine for acute pain in the emergency department.
Beaudrie-Nunn AN, Wieruszewski ED, Woods EJ, Bellolio F, Mara KC, Canterbury EA. | Am J Emerg Med. 2023 Aug;70:133-139
DOI: https://doi.org/10.1016/j.ajem.2023.05.026
Keywords: Acute pain; Analgesics; Emergency department; Ketamine; Pain management.

Original contribution

Introduction : Acute pain accounts for over 70% of Emergency Department (ED) visits. Sub-dissociative dose ketamine (0.1-0.6 mg/kg) is safe and effective for the management of acute pain in the ED. However, the optimal dose of intravenous ketamine that provides effective analgesia and minimizes the risk of adverse effects has yet to be identified. The objective of this study was to describe an effective analgesia dose range of IV ketamine for acute pain in the ED.

Méthode : This multi-center, retrospective cohort study evaluated adult patients who received analgesic and sub-dissociative dose ketamine for the management of acute pain between May 5, 2018, and August 30, 2021, in 21 emergency departments at academic, community, and critical access hospitals across four states. Patients were excluded if they received ketamine for an indication other than pain, such as procedural sedation or intubation, or for whom there was incomplete documentation for the primary outcome. Patients who received a ketamine dose <0.3 mg/kg were stratified into the low-dose group, and those who received a dose of 0.3 mg/kg or higher to the high-dose group. The primary outcome was change in pain scores within 60 min using a standard 11-point numeric rating scale (NRS). Secondary outcomes included incidence of adverse effects and use of rescue analgesics. Continuous variables were compared between dose groups using student t-test or Wilcoxon Rank-Sum test. Linear regression was used to assess the association between the change in NRS pain scores within 60 min and dose after adjusting for baseline pain, requiring an additional dose of ketamine, and receiving an opioid.

Résultats : From 3796 patient encounters screened for receipt of ketamine, 384 patients met inclusion criteria including 258 in the low-dose group, and 126 in the high-dose group. The primary reason for exclusion was incomplete documentation of pain scores, or ketamine used for sedation. Median baseline pain scores were 8.2 in the low-dose group and 7.8 in the high-dose group (difference 0.5; 95% CI 0 to 1, p = 0.04). Both groups demonstrated significant reductions in their mean NRS pain scores within 60 min following the first administration of IV ketamine. There were no differences in the change in pain scores between both groups (-2.2 vs -2.6, mean difference 0.4, 95% CI -0.4 to 1.1, p = 0.34). Use of rescue analgesics (40.7% vs 36.5%, p = 0.43) and adverse effects were similar between groups, including early discontinuation of the ketamine infusion (37.2% vs. 37.3%, p = 0.99). Overall, the most common adverse effects were agitation (7.3%) and nausea (7.0%).

Conclusion : The analgesic efficacy and safety of high-dose sub-dissociative ketamine (≥0.3 mg/kg) was not superior to low-dose (< 0.3 mg/kg) for the management of acute pain in the ED. Low-dose ketamine <0.3 mg/kg is an effective and safe pain management strategy in this population.

Conclusion (proposition de traduction) : L'efficacité analgésique et la sécurité de la kétamine à forte dose subdissociative (≥ 0,3 mg/kg) n'étaient pas supérieures à celles de la kétamine à faible dose (< 0,3 mg/kg) pour la prise en charge de la douleur aiguë aux urgences. La kétamine à faible dose < 0,3 mg/kg est une stratégie efficace et sûre de prise en charge de la douleur dans cette population.

Comparison of carotid artery ultrasound and manual method for pulse check in cardiopulmonary resuscitation.
Özlü S, Bilgin S, Yamanoglu A, Kayalı A, Efgan MG, Çınaroğlu OS, Tekyol D. | Am J Emerg Med. 2023 Aug;70:157-162
DOI: https://doi.org/10.1016/j.ajem.2023.05.045
Keywords: Bedside ultrasound; CPA; CPR; Cardiopulmonary arrest; ROSC; Return of spontaneous circulation.

Original contribution

Introduction : The success of the manual pulse check method frequently employed during cardiopulmonary resuscitation (CPR) is controversial due to its subjective, patient- and operator-dependent, and time-consuming nature. Carotid ultrasound (c-USG) has recently emerged as an alternative, although there are still insufficient studies on the subject. The purpose of the present study was to compare the success of the manual and c-USG pulse check methods during CPR.

Méthode : This prospective observational study was conducted in the critical care area of a university hospital emergency medicine clinic. Pulse checks in patients with non-traumatic cardiopulmonary arrest (CPA) undergoing CPR were performed using the c-USG method from one carotid artery and the manual method from the other. The gold standard in the decision regarding return of spontaneous circulation (ROSC) was the clinical judgment made using the rhythm on the monitor, manual femoral pulse check, end tidal carbon dioxide (ETCO₂), and cardiac USG instruments. The success in predicting ROSC and measurement times of the manual and c-USG methods were compared. The success of both methods was calculated as sensitivity and specificity, and the clinical significance of the difference between the methods' sensitivity and specificity was evaluated Newcombe's method.

Résultats : A total of 568 pulse measurements were performed on 49 CPA cases using both c-USG and the manual method. The manual method exhibited 80% sensitivity and 91% specificity in predicting ROSC (+PV: 35%, -PV: 64%), while c-USG exhibited 100% sensitivity and 98% specificity (+PV: 84%, -PV: 100%). The difference in sensitivities between the c-USG and manual methods was -0.0704 (95% CI: -0.0965; -0.0466), and the difference between their specificities was 0.0106 (95% CI: 0.0006; 0.0222). The difference between the specificities and sensitivities was statistically significant at analysis performed adopting the clinical judgment of the team leader using multiple instruments as the gold standard. The manual method yielded an ROSC decision in 3 ± 0.17 s and c-USG in 2.8 ± 0.15 s, the difference being statistically significant.

Conclusion : According to the results of this study, the pulse check method with c-USG may be superior to the manual method in terms of fast and accurate decision making in CPR.

Conclusion (proposition de traduction) : Selon les résultats de cette étude, la méthode de vérification du pouls par échographie carotidienne peut être supérieure à la méthode manuelle en termes de rapidité et de précision de la prise de décision en réanimation cardio-pulmonaire.

Pharmacotherapy optimization for rapid sequence intubation in the emergency department.
Engstrom K, Brown CS, Mattson AE, Lyons N, Rech MA. | Am J Emerg Med. 2023 Aug;70:19-29
DOI: https://doi.org/10.1016/j.ajem.2023.05.004
Keywords: Induction; Neuromuscular blocking agent; Pharmacotherapy; Rapid sequence intubation.

Review

Introduction : Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods.

Méthode : There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use.

Conclusion : The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Conclusion (proposition de traduction) : La sélection, le dosage et l'administration optimaux des médicaments pour l'intubation en séquence rapide sont compliqués et des recherches supplémentaires sont nécessaires dans plusieurs domaines. Des études prospectives supplémentaires sont nécessaires pour déterminer le choix et le dosage optimaux de l'agent d'induction chez les patients en état de choc ou en état septique. Il existe une controverse sur l'ordre optimal d'administration des médicaments (curare d'abord ou induction d'abord) et sur le dosage des médicaments chez les patients obèses, mais il n'y a pas suffisamment de preuves pour modifier de manière significative les pratiques actuelles en matière de dosage et d'administration des médicaments. Il est nécessaire de poursuivre les recherches sur la sensibilisation à la curarisation pendant l'intubation en séquence rapide avant de pouvoir apporter des modifications définitives et généralisées à la pratique de l'utilisation des médicaments pendant l'intubation en séquence rapide.

High risk and low prevalence diseases: Blast injuries.
Bukowski J, Nowadly CD, Schauer SG, Koyfman A, Long B. | Am J Emerg Med. 2023 Aug;70:46-56
DOI: https://doi.org/10.1016/j.ajem.2023.05.003
Keywords: Blast injury; Combat; Explosion; IED; Improvised explosive device; Military; Wound.

Review

Introduction : Blast injury is a unique condition that carries a high rate of morbidity and mortality, often with mixed penetrating and blunt injuries.

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

Discussion : Explosions may impact multiple organ systems through several mechanisms. Patients with suspected blast injury and multisystem trauma require a systematic evaluation and resuscitation, as well as investigation for injuries specific to blast injuries. Blast injuries most commonly affect air-filled organs but can also result in severe cardiac and brain injury. Understanding blast injury patterns and presentations is essential to avoid misdiagnosis and balance treatment of competing interests of patients with polytrauma. Management of blast victims can also be further complicated by burns, crush injury, resource limitation, and wound infection. Given the significant morbidity and mortality associated with blast injury, identification of various injury patterns and appropriate management are essential.

Conclusion : Blast injury is associated with significant morbidity and mortality. The blast mechanism can lead to damage across multiple organ systems. The primary blast wave causes unique effects, with blast injuries affect- ing the pulmonary, neurologic, auditory, cardiac, ocular, musculoskele- tal, and GI systems. Identification of these effects is important for emergency clinicians managing the care of these potentially complex patients. An understanding of the mechanism of blast injury and the corresponding common injuries can assist emergency clinicians in diag- nosing and managing this potentially deadly spectrum of injuries.

Conclusion (proposition de traduction) : Les lésions dues aux explosions sont associées à une morbidité et une mortalité importantes. Le mécanisme de l'explosion peut entraîner des dommages sur plusieurs systèmes organiques. L'onde de souffle primaire provoque des effets uniques, avec des lésions de souffle affectant les systèmes pulmonaire, neurologique, auditif, cardiaque, oculaire, musculo-squelettique et gastro-intestinal. L'identification de ces effets est importante pour les cliniciens d'urgence qui gèrent les soins de ces patients potentiellement complexes. La compréhension du mécanisme des lésions dues à l'explosion et des lésions courantes correspondantes peut aider les cliniciens d'urgence à diagnostiquer et à prendre en charge ce spectre de lésions potentiellement mortelles.

A Review of Bicarbonate Use in Common Clinical Scenarios.
Wardi G, Holgren S, Gupta A, Sobel J, Birch A, Pearce A, Malhotra A, Tainter C. | J Emerg Med. 2023 Aug;65(2):e71-e80
DOI: https://doi.org/10.1016/j.jemermed.2023.04.012  | Télécharger l'article au format  
Keywords: cardiac arrest; diabetic ketoacidosis; lactic acidosis; metabolic acidosis; rhabdomyolysis; sodium bicarbonate.

Clinical Review

Introduction : The use of sodium bicarbonate to treat metabolic acidosis is intuitive, yet data suggest that not all patients benefit from this therapy.

Méthode : In this narrative review, we describe the physiology behind commonly encountered nontoxicologic causes of metabolic acidosis, highlight potential harm from the indiscriminate administration of sodium bicarbonate in certain scenarios, and provide evidence-based recommendations to assist emergency physicians in the rational use of sodium bicarbonate.

Discussion : Sodium bicarbonate can be administered as a hypertonic push, as a resuscitation fluid, or as an infusion. Lactic acidosis and cardiac arrest are two common scenarios where there is limited benefit to routine use of sodium bicarbonate, although certain circumstances, such as patients with concomitant acute kidney injury and lactic acidosis may benefit from sodium bicarbonate. Patients with cardiac arrest secondary to sodium channel blockade or hyperkalemia also benefit from sodium bicarbonate therapy. Recent data suggest that the use of sodium bicarbonate in diabetic ketoacidosis does not confer improved patient outcomes and may cause harm in pediatric patients. Available evidence suggests that alkalinization of urine in rhabdomyolysis does not improve patient-centered outcomes. Finally, patients with a nongap acidosis benefit from sodium bicarbonate supplementation.

Conclusion : Empiric use of sodium bicarbonate in patients with nontoxicologic causes of metabolic acidosis is not warranted and likely does not improve patient-centered outcomes, except in select scenarios. Emergency physicians should reserve use of this medication to conditions with clear benefit to patients.

Conclusion (proposition de traduction) : L'utilisation empirique de bicarbonate de sodium chez les patients présentant des causes d'acidose métabolique non toxicologiques n'est pas justifiée et n'améliore probablement pas le devenir pour le patient, sauf dans certains cas. Les urgentistes doivent réserver l'utilisation de ce médicament à des situations présentant un bénéfice évident pour les patients.

Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults.
Prekker ME, Driver BE, Trent SA, Resnick-Ault D, Seitz KP, Russell DW, Gaillard JP, Latimer AJ, Ghamande SA, Gibbs KW, Vonderhaar DJ, Whitson MR, Barnes CR, Walco JP, Douglas IS, Krishnamoorthy V, Dagan A, Bastman JJ, Lloyd BD, Gandotra S, Goranson JK, Mitchell SH, White HD, Palakshappa JA, Espinera A, Page DB, Joffe A, Hansen SJ, Hughes CG, George T, Herbert JT, Shapiro NI, Schauer SG, Long BJ, Imhoff B, Wang L, Rhoads JP, Womack KN, Janz DR, Self WH, Rice. | N Engl J Med. 2023 Aug 3;389(5):418-429
DOI: https://doi.org/10.1056/nejmoa2301601
Keywords: Aucun

Original Article

Introduction : Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.

Méthode : In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

Résultats : The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.

Conclusion : Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope.

Conclusion (proposition de traduction) : Parmi les adultes gravement malades bénéficiant d'une intubation trachéale dans un service d'urgence ou une unité de soins intensifs, l'utilisation d'un vidéo-laryngoscope a permis d'obtenir une incidence plus élevée d'intubation réussie lors de la première tentative que l'utilisation d'un laryngoscope direct.

Commentaire : Cet essai a été arrêté précocement au bout de 1 420 inclusions en raison d’un avantage certain de la vidéolaryngoscopie avec une réussite au premier passage qui présentait une différence absolue de 14,3 %. C’est-à-dire qu’on passait de 85 à 71 % grâce à ce premier passage, avec un p évidemment significatif. Il n’y avait pas plus de complications graves ou de patients qui ont désaturé à moins de 80 % de saturation dans les deux groupes – c’était exactement les mêmes chiffres.
La réussite au premier passage est au bénéfice de la vidéolaryngoscopie.

ATTENTION, selon l'article de Aziz MF, Berkow L. Pro-Con Debate: Videolaryngoscopy Should Be Standard of Care for Tracheal Intubation. Anesth Analg. 2023 Apr 1;136(4):683-688  , la vidéolaryngoscopie n'est pas exempte de complications et ne présente pas un taux de réussite de 100 %. En cas d'échec, il est important d'avoir des plans de secours pour la gestion des voies aériennes. Il est recommandé que les professionnels de la gestion des voies aériennes supérieures disposent toujours de deux méthodes pour oxygéner, de deux méthodes pour intuber et de deux méthodes pour ventiler en cas d'échec de l'intubation.
Si le passage de la laryngoscopie directe à la vidéolaryngoscopie peut améliorer les résultats de la gestion des voies aériennes, la dépendance à l'égard de la vidéolaryngoscopie peut dégrader d'autres compétences cliniques importantes au moment où elles sont le plus nécessaires.
Si la vidéolaryngoscopie est adoptée comme norme de soins, les professionnels des voies aériennes risquent de ne plus pratiquer et de ne plus conserver les compétences dans d'autres techniques de gestion des voies aériennes qui pourraient être nécessaires en cas d'échec de la vidéolaryngoscopie.