Survival by time-to-administration of amiodarone, lidocaine, or placebo in shock-refractory out-of-hospital cardiac arrest.
Lupton JR, Neth MR, Sahni R, Jui J, Wittwer L, Newgard CD, Daya MR. | Acad Emerg Med. 2023 Sep;30(9):906-917
DOI: https://doi.org/10.1111/acem.14716
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Amiodarone and lidocaine have not been shown to have a clear survival benefit compared to placebo for out-of-hospital cardiac arrest (OHCA). However, randomized trials may have been impacted by delayed administration of the study drugs. We sought to evaluate how timing from emergency medical services (EMS) arrival on scene to drug administration affects the efficacy of amiodarone and lidocaine compared to placebo.

Méthode : This is a secondary analysis of the 10-site, 55-EMS-agency double-blind randomized controlled amiodarone, lidocaine, or placebo in OHCA study. We included patients with initial shockable rhythms who received the study drugs of amiodarone, lidocaine, or placebo before achieving return of spontaneous circulation. We performed logistic regression analyses evaluating survival to hospital discharge and secondary outcomes of survival to admission and functional survival (modified Rankin scale score ≤ 3). We evaluated the samples stratified by early (<8 min) and late administration groups (≥8 min). We compared outcomes for amiodarone and lidocaine compared to placebo and adjust for potential confounders.

Résultats : There were 2802 patients meeting inclusion criteria, with 879 (31.4%) in the early (<8 min) and 1923 (68.6%) in the late (≥8 min) groups. In the early group, patients receiving amiodarone, compared to placebo, had significantly higher survival to admission (62.0% vs. 48.5%, p = 0.001; adjusted OR [95% CI] 1.76 [1.24-2.50]), survival to discharge (37.1% vs. 28.0%, p = 0.021; 1.56 [1.07-2.29]), and functional survival (31.6% vs. 23.3%, p = 0.029; 1.55 [1.04-2.32]). There were no significant differences with early lidocaine compared to early placebo (p > 0.05). Patients in the late group who received amiodarone or lidocaine had no significant differences in outcomes at discharge compared to placebo (p > 0.05).

Conclusion : The early administration of amiodarone, particularly within 8 min, is associated with greater survival to admission, survival to discharge, and functional survival compared to placebo in patients with an initial shockable rhythm.

Conclusion (proposition de traduction) : L'administration précoce d'amiodarone, en particulier dans les 8 premières minutes, est associée à une plus grande survie à l'admission, à la sortie et à la survie fonctionnelle par rapport au placebo chez les patients ayant un rythme initial choquable.

Safety of the pulmonary embolism rule-out criteria rule: Findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry.
Truong P, Mazzolai L, Font C, Ciammaichella M, González-Martínez J, Tufano A, Gavín-Sebastián O, Le Mao R, Monreal M, Hugli O; RIETE Investigators. | Acad Emerg Med. 2023 Sep;30(9):935-945
DOI: https://doi.org/10.1111/acem.14744rrrrrrrrrrrrr  | Télécharger l'article au format  
Keywords: PERC; RIETE; diagnostic algorithm; pretest probability; pulmonary embolism; pulmonary embolism rule-out criteria rule.

ORIGINAL ARTICLE

Introduction : The diagnostic strategy for pulmonary embolism (PE) includes a D-dimer test when PE probability is low or intermediate, but false-positive D-dimer results are frequent and can result in an unnecessary computed tomography pulmonary angiogram. The PE rule-out criteria (PERC) rule excludes PE without D-dimer testing when pretest probability is <15%. The aim of this study was to assess the safety of the PERC rule strategy in patients included in the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry.

Méthode : This retrospective cohort study used data from the RIETE registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the failure rate of the PERC strategy, represented by the proportion of PERC-negative (PERC-N) patients with a PE included in the registry. Secondary outcomes were a comparison of the clinical characteristics, treatment strategy, and outcome of PERC-N versus PERC-positive (PERC-P) patients at 3 months.

Résultats : From 2001 to 2021, a total of 49,793 patients with acute PE were enrolled in the RIETE registry. We included 48,903 in the final analysis after exclusion of 890 patients with an undetermined PERC status. Only 346 patients were PERC-N with a failure rate of 0.7% (95% confidence interval 0.6%-0.8%). PERC-N patients presented more frequently with chest pain but less often with dyspnea, syncope, or hypotension. They also had subsegmental or segmental PE more frequently, were more often treated with direct oral anticoagulants, and received mechanical or pharmacological thrombolysis less often. In addition, PERC-N patients had a lower incidence of recurrent deep vein thrombosis, major bleeding, and death attributed to PE during the 3-month follow-up.

Conclusion : A low failure rate of the PERC rule was observed in the RIETE registry, thus supporting its use to safely identify patients with an unlikely probability of PE.

Conclusion (proposition de traduction) : Un petit nombre d'échecs de la règle PERC a été observé dans le registre RIETE, ce qui justifie son utilisation pour identifier en toute sécurité les patients dont la probabilité d'une EP est peu probable.

Managing Pulmonary Embolism.
Westafer LM, Long B, Gottlieb M. | Ann Emerg Med. 2023 Sep;82(3):394-402
DOI: https://doi.org/10.1016/j.annemergmed.2023.01.019  | Télécharger l'article au format  
Keywords: Aucun

PULMONARY/EXPERT CLINICAL MANAGEMENT

Editorial : L'embolie pulmonaire (EP) est fréquemment rencontrée dans les services d'urgence, avec une incidence annuelle estimée entre 39 et 115 pour 100 000 personnes. Les facteurs de risque classiques sont les suivants : traumatisme majeur, chirurgie des membres inférieurs, antécédents de thromboembolie veineuse, hospitalisation récente, contraception orale, période post-partum, tumeur maligne et thrombophilie. Cependant, il existe de nombreux autres facteurs de risque.

Conclusion : Historically, patients with PE have been admitted to the hospital. However, 2 clinical trials and several observational studies have found outpatient management of select patients with acute PE to be safe and effective. The introduction of direct oral anticoagulants has increased the ease of outpatient treatment. As a result, professional society guidelines recommend that patients with low-risk acute PE be managed as outpatients. Several risk stratification tools are available to identify patients who can be safely managed as outpatients, including the Pulmonary Embolism Severity Index (PESI), Simplified PESI (sPESI), and Hestia criteria. The PESI and sPESI were developed to predict 30-day mortality using comorbidities and features of clinical presentation. Patients with a PESI of I or II or a sPESI of 0 are considered low-risk, with a 90-day mortality of 0.8% (95% CI 0.4% to 1.8%).
Both PESI and sPESI identify patients with low risk of mortality but do not encompass all patients who may need hospitalization. Unlike PESI and sPESI, the Hestia criteria were specifically created to identify patients who can be safely treated as outpatients and includes comorbidities and psychosocial factors. As a result, we recommend using the Hestia criteria to identify patients eligible for outpatient management (Table 4).76 Figure 4 demonstrates one possible treatment pathway recommended by a consensus group on criteria for outpatient treatment with international treatment guidelines.

Conclusion (proposition de traduction) : Historiquement, les patients atteints d'EP sont admis à l'hôpital. Cependant, deux essais cliniques et plusieurs études d'observation ont montré que la prise en charge ambulatoire de certains patients souffrant d'une EP aiguë était sûre et efficace. L'introduction des anticoagulants oraux directs a facilité le traitement ambulatoire. Par conséquent, les recommandations des sociétés professionnelles préconisent que les patients présentant une EP aiguë à faible risque soient pris en charge en ambulatoire. Plusieurs outils de stratification du risque sont disponibles pour identifier les patients qui peuvent être pris en charge en toute sécurité en ambulatoire, notamment l'indice de gravité de l'embolie pulmonaire (PESI), le PESI simplifié (sPESI) et les critères Hestia. Le PESI et le sPESI ont été développés pour prédire la mortalité à 30 jours en utilisant les comorbidités et les caractéristiques de la consultation médicale. Les patients ayant un PESI de I ou II ou un sPESI de 0 sont considérés comme étant à faible risque, avec un taux de mortalité à 90 jours de 0,8 % (IC 95 % : 0,4 % à 1,8 %).
Le PESI et le sPESI détectent tous deux les patients présentant un faible risque de mortalité, mais n'englobent pas tous les patients susceptibles d'avoir besoin d'une hospitalisation. Contrairement au PESI et au sPESI, les critères Hestia ont été spécifiquement créés pour identifier les patients qui peuvent être traités en toute sécurité en ambulatoire et incluent les comorbidités et les facteurs psychosociaux. Par conséquent, nous recommandons d'utiliser les critères Hestia pour identifier les patients éligibles à une prise en charge ambulatoire (tableau 4). La figure 4 illustre une voie de traitement possible recommandée par un groupe de consensus sur les critères de traitement ambulatoire avec des directives de traitement internationales.

Commentaire : 



En cas de score Hestia = 0, une prise en charge ambulatoire peut être proposée en toute sécurité (aucun décès sur 275 patients pris en charge à la maison ; VPN de 100 %)

Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine.
No authors listed | Ann Emerg Med. 2023 Sep;82(3):e115-e155
DOI: https://doi.org/10.1016/j.annemergmed.2023.06.005
Keywords: Aucun

POLICY STATEMENT

Editorial : L'échographie clinique (CUS) fait désormais partie intégrante des soins d'urgence aux États-Unis depuis plus de 20 ans.
Depuis la dernière mise à jour de ces lignes directrices en 2016, le rôle de l'échographie s'est étendu à l'ensemble de la médecine clinique. Le large éventail d'applications reconnues pour l'échographie offre des avantages diagnostiques et thérapeutiques aux patients du monde entier. Les avantages de l'échographique au point d'intervention sont notamment son coût relativement faible, l'absence de rayonnement ionisant, sa portabilité et sa facilité d'utilisation. Des données ont démontré que l'ECU peut améliorer la précision du diagnostic dans de nombreuses présentations cliniques courantes, notamment la dyspnée, les douleurs abdominales et les luxations d'articulations. Le guidage par ultrasons a également été incorporé dans les procédures au chevet du patient, ce qui a permis d'améliorer la réussite et de réduire les complications involontaires.

Conclusion : Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine
1. Introduction
2. Scope of Practice
3. Training and Proficiency
4. Hospital Credentialing and Privileging
5. Specialty Certification
6. Quality and Ultrasound Management
7. Value and Reimbursement
8. Clinical Ultrasound Leadership in Health Care Systems
9. Future Issues
10. Conclusion

Conclusion (proposition de traduction) : Lignes directrices sur l'échographie d'urgence, l'échographie au point de service et l'échographie clinique en médecine abordent les points suivants :
1. Introduction
2. Champ d'application
3. Formation et compétence
4. Accréditation et privilèges des hôpitaux
5. Certification des spécialités
6. Qualité et gestion des ultrasons
7. Valeur et remboursement
8. Leadership en matière d'échographie clinique dans les en santé
9. Questions d'avenir
10. Conclusion

Commentaire : 

Multidisciplinary expert panel report on fluid stewardship: perspectives and practice.
Malbrain MLNG, Caironi P, Hahn RG, Llau JV, McDougall M, Patrão L, Ridley E, Timmins A. | Ann Intensive Care. 2023 Sep 25;13(1):89
DOI: https://doi.org/10.1186/s13613-023-01177-y  | Télécharger l'article au format  
Keywords: Buffered solutions; Critical care; Crystalloids; Fluid stewardship; Fluid therapy; Perioperative care.

REVIEW

Editorial : Although effective and appropriate fluid management is a critical aspect of quality care during hospitalization, the widespread adoption of consistent policies that ensure adequate fluid stewardship has been slow and heterogenous. Despite evidence-based guidelines on fluid management being available, clinical opinions continue to diverge on important aspects of care in this setting, and the consistency of guideline implementation is far from ideal. A multidisciplinary panel of leading practitioners and experts convened to discuss best practices for ongoing staff education, intravenous fluid therapy, new training technologies, and strategies to track the success of institutional fluid stewardship efforts. Fluid leads should be identified in every hospital to ensure consistency in fluid administration and monitoring. In this article, strategies to communicate the importance of effective fluid stewardship for the purposes of education, training, institutional support, and improvement of patient outcomes are reviewed and recommendations are summarized.

Conclusion : Recent surveys and evidence of practice gaps sug- gest additional education is needed on the appropri- ate administration, timing, dosage, duration, rate, de-escalation, and monitoring of fluids in all hospital settings and wards. Therefore, effective fluid stewards should be identified in every hospital to ensure consist- ency in fluid administration and monitoring. We describe best practices for fluid stewardship and review strategies to communicate the importance of effective fluid stew- ardship programs for the purposes of education, train- ing, institutional support, and improvement of patient outcomes.

Conclusion (proposition de traduction) : Des enquêtes récentes et des preuves de carences dans la pratique suggèrent qu'une formation supplémentaire est nécessaire sur l'administration, le moment, le dosage, la durée, la vitesse, la désescalade et la surveillance appropriés des solutés dans tous les environnements hospitaliers et les services. Par conséquent, des référents solutés compétents devraient être identifiés dans chaque hôpital afin de garantir la cohérence de l'administration et de la surveillance des solutés. Nous décrivons les meilleures pratiques en matière de gestion des solutés et passons en revue les stratégies visant à communiquer l'importance de programmes efficaces de gestion des solutés à des fins d'éducation, de formation, de soutien institutionnel et d'amélioration des résultats pour les patients.

Development and Validation of the DOAC Score: A Novel Bleeding Risk Prediction Tool for Patients With Atrial Fibrillation on Direct-Acting Oral Anticoagulants.
Aggarwal R, Ruff CT, Virdone S, Perreault S, Kakkar AK, Palazzolo MG, Dorais M, Kayani G, Singer DE, Secemsky E, Piccini J, Tahir UA, Shen C, Yeh RW. | Circulation. 2023 Sep 19;148(12):936-946
DOI: https://doi.org/10.1161/circulationaha.123.064556  | Télécharger l'article au format  
Keywords: DOAC Score; apixaban; atrial fibrillation; dabigatran; edoxaban; hemorrhage; risk; rivaroxaban.

ORIGINAL RESEARCH ARTICLE

Introduction : Current clinical decision tools for assessing bleeding risk in individuals with atrial fibrillation (AF) have limited performance and were developed for individuals treated with warfarin. This study develops and validates a clinical risk score to personalize estimates of bleeding risk for individuals with atrial fibrillation taking direct-acting oral anticoagulants (DOACs).

Méthode : Among individuals taking dabigatran 150 mg twice per day from 44 countries and 951 centers in this secondary analysis of the RE-LY trial (Randomized Evaluation of Long-Term Anticoagulation Therapy), a risk score was developed to determine the comparative risk for bleeding on the basis of covariates derived in a Cox proportional hazards model. The risk prediction model was internally validated with bootstrapping. The model was then further developed in the GARFIELD-AF registry (Global Anticoagulant Registry in the Field-Atrial Fibrillation), with individuals taking dabigatran, edoxaban, rivaroxaban, and apixaban. To determine generalizability in external cohorts and among individuals on different DOACs, the risk prediction model was validated in the COMBINE-AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) pooled clinical trial cohort and the Quebec Régie de l'Assurance Maladie du Québec and Med-Echo Administrative Databases (RAMQ) administrative database. The primary outcome was major bleeding. The risk score, termed the DOAC Score, was compared with the HAS-BLED score.

Résultats : Of the 5684 patients in RE-LY, 386 (6.8%) experienced a major bleeding event, within a median follow-up of 1.74 years. The prediction model had an optimism-corrected C statistic of 0.73 after internal validation with bootstrapping and was well-calibrated based on visual inspection of calibration plots (goodness-of-fit P=0.57). The DOAC Score assigned points for age, creatinine clearance/glomerular filtration rate, underweight status, stroke/transient ischemic attack/embolism history, diabetes, hypertension, antiplatelet use, nonsteroidal anti-inflammatory use, liver disease, and bleeding history, with each additional point scored associated with a 48.7% (95% CI, 38.9%-59.3%; P<0.001) increase in major bleeding in RE-LY. The score had superior performance to the HAS-BLED score in RE-LY (C statistic, 0.73 versus 0.60; P for difference <0.001) and among 12 296 individuals in GARFIELD-AF (C statistic, 0.71 versus 0.66; P for difference = 0.025). The DOAC Score had stronger predictive performance than the HAS-BLED score in both validation cohorts, including 25 586 individuals in COMBINE-AF (C statistic, 0.67 versus 0.63; P for difference <0.001) and 11 945 individuals in RAMQ (C statistic, 0.65 versus 0.58; P for difference <0.001).

Conclusion : In individuals with atrial fibrillation potentially eligible for DOAC therapy, the DOAC Score can help stratify patients on the basis of expected bleeding risk.

Conclusion (proposition de traduction) : Chez les personnes atteintes de fibrillation auriculaire potentiellement éligibles à un traitement par AOD, le score AOD peut aider à stratifier les patients sur la base du risque hémorragique attendu.

Updates in heart failure.
Rees OL, Wheen P, Anderson LJ. | Clin Med (Lond). 2023 Sep;23(5):432-436
DOI: https://doi.org/10.7861/clinmed.2023-2023-23.5.cardio1  | Télécharger l'article au format  
Keywords: device therapy; guidelines; heart failure; pharmacotherapy; revascularisation.

CME CARDIOLOGY

Editorial : This review provides a contemporary overview of HF management and highlights the key studies which have informed recent European HF guidelines.

Conclusion : Where there is a clinical suspicion of heart failure (HF), utilise NT-proBNP measurement followed by echocardiography to triage, diagnose, classify, and appropriately refer.
HF is classified by left ventricular ejection fraction (LVEF), which in turn guides management: HF with reduced EF (HFrEF, ≤40%), HF with mildly reduced EF (HFmrEF, 41–49%) and HF with preserved EF (HFpEF, ≥50%).
Beta blockers, ACE-inhibitors (ACE-I)/angiotensin II receptor blockers (ARB)/angiotensin II receptor-neprilysin inhibitors (ARNI), mineralocorticoid receptor antagonists (MRA), and sodium glucose co-transporter-2 (SGLT-2) inhibitors are the ‘four pillars’ of HF pharmacotherapy for reduced ejection fraction.
SGLT-2 inhibitors are the first drug class to demonstrate effectiveness in terms of reduced HF hospitalisation rates across the EF spectrum.
All patients admitted with acute HF should be reviewed by specialist HF services within 24 hrs to investigate aetiology, guide offloading strategies, and initiate prognostic HF therapy.

Conclusion (proposition de traduction) : En cas de suspicion clinique d'insuffisance cardiaque (IC), la mesure du NT-proBNP suivie d'une échocardiographie permet de trier, de diagnostiquer, de classer et d'orienter les patients de manière appropriée.
L'insuffisance cardiaque est classée en fonction de la fraction d'éjection du ventricule gauche (FEVG), qui oriente à son tour la prise en charge : insuffisance cardiaque avec fraction d'éjection réduite (ICRF, ≤40%), insuffisance cardiaque avec fraction d'éjection légèrement réduite (ICRFm, 41-49%) et insuffisance cardiaque avec fraction d'éjection préservée (ICPF, ≥50%).
Les bêtabloquants, les inhibiteurs de l'enzyme de conversion de l'angiotensine (IEC), les inhibiteurs des récepteurs de l'angiotensine II (ARA), les inhibiteurs des récepteurs de l'angiotensine II et de la néprilysine (IRA), les antagonistes des récepteurs minéralocorticoïdes (ARM) et les inhibiteurs du sodium-glucose-transporteur-2 (SGLT-2) sont les "quatre piliers" de la pharmacothérapie de l'insuffisance cardiaque en cas de fraction d'éjection réduite.
Les inhibiteurs du SGLT-2 sont la première classe de médicaments à avoir démontré leur efficacité en termes de réduction des taux d'hospitalisation pour insuffisance cardiaque sur l'ensemble du spectre de la fraction d'éjection.
Tous les patients admis pour insuffisance cardiaque aiguë doivent être examinés par des services spécialisés dans l'insuffisance cardiaque dans les 24 heures afin de rechercher l'étiologie, de guider les stratégies de délestage et d'initier un traitement pronostique de l'insuffisance cardiaque.

Commentaire :  Lignes directrices du NICE   résumant l'investigation d'une suspicion d'insuffisance cardiaque chronique.
Il s'agit d'un résumé des recommandations du NICE sur les tests à proposer pour diagnostiquer l'insuffisance cardiaque chronique dans sa ligne directrice sur l'insuffisance cardiaque chronique. La ligne directrice couvre également la prise en charge. Résumé de la prise en charge de l'HFrEF dans les lignes directrices 2021 de l'ESC    sur l'HF.
La couleur sarcelle foncée indique la classe de recommandation I ("indiqué ou recommandé") et la couleur sarcelle claire indique la classe de recommandation IIa ("devrait être envisagé").
ACE-I = angiotensinconverting enzyme inhibitor; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor-neprilysin inhibitor; BB = beta-blocker; b.p.m. = beats per minute; BTC = bridge to candidacy; BTT = bridge to transplantation; CABG = coronary artery bypass graft; CRT-D = cardiac resynchronization therapy with defibrillator; CRT-P = cardiac resynchronization therapy pacemaker; DT = destination therapy; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; ICD = implantable cardioverter-defibrillator; ISDN = isosorbide dinitrate; LBBB = left bundle branch block; MCS = mechanical circulatory support; MRA = mineralocorticoid receptor antagonist; MV = mitral valve; PVI = pulmonary vein isolation; QOL = quality of life; SAVR = surgical aortic valve replacement; SGLT2i = sodium-glucose co-transporter 2 inhibitor; SR = sinus rhythm; TAVI = transcatheter aortic valve replacement; TEE = transcatheter edge to edge.

Diagnosis and management of ventricular tachycardia.
Whitaker J, Wright MJ, Tedrow U. | Clin Med (Lond). 2023 Sep;23(5):442-448
DOI: https://doi.org/10.7861/clinmed.2023-23.5.cardio3  | Télécharger l'article au format  
Keywords: Ventricular tachycardia; wide-complex tachycardia; arrhythmia; ablation; ECG

CME CARDIOLOGY

Editorial : Ventricular tachycardia (VT) describes rapid heart rhythms originating from the ventricles. Accurate diagnosis of VT is important to allow prompt referral to specialist services for ongoing management. The diagnosis of VT is usually made based on electrocardiographic data, most commonly 12-lead echocardiography (ECG), as well as supportive cardiac telemetric monitoring. Distinguishing between VT and supraventricular arrhythmias on ECG can be difficult. However, the VT diagnosis frequently needs to be made rapidly in the acute setting. In this review, we discuss the definition of VT, review features of wide-complex tachycardia (WCT) on ECG that might be helpful in diagnosing VT, discuss the different substrates in which VT can occur and offer brief comments on management considerations for patients found to have VT.

Conclusion : VT is an arrhythmia with a rate >100 beats per minute arising from the ventricular myocardium or specialised conduction tissue below the penetrating atrioventricular bundle.
VT can present as an irregular broad complex tachycardia and, therefore, an irregular rhythm does not exclude it as a diagnosis.
Where there is any uncertainty, particularly in emergent situations, a wide-complex tachycardia should be treated as VT until proven otherwise and, ∼80% of the time, the diagnosis will prove to be VT, especially in patients aged >35 years.
Most VT occurs in patients with underlying heart disease but ∼10% occurs in those with structurally normal hearts, often arising from the outflow tracts.
Management of patients with VT can involve risk stratification for sudden cardiac death; the use of implantable cardioverter- defibrillators; suppression of VT through the treatment of any underlying myocardial disease; the use of anti-arrhythmic drugs; catheter ablation; and, in refractory cases, emerging approaches, such as cardiac stereotactic body radiation therapy.

Conclusion (proposition de traduction) : La tachycardie ventriculaire est une arythmie dont le rythme est supérieur à 100 battements par minute et qui trouve son origine au niveau du myocarde ventriculaire ou d'un tissu de conduction spécialisé situé sous le faisceau atrio-ventriculaire entrant.
La tachycardie ventriculaire peut se présenter comme une tachycardie irrégulière à complexe large et, par conséquent, un rythme irrégulier n'exclut pas le diagnostic.
En cas d'incertitude, en particulier dans les situations d'urgence, une tachycardie à complexe large doit être traitée comme une tachycardie ventriculaire jusqu'à preuve du contraire et, dans ∼80% des cas, le diagnostic s'avérera être une tachycardie ventriculaire, en particulier chez les patients âgés de plus de 35 ans.
La plupart des tachycardies ventriculaires surviennent chez des patients souffrant d'une cardiopathie sous-jacente, mais ∼10% surviennent chez des patients dont le cœur est structurellement normal, souvent à partir de voies d'accessoire.
La prise en charge des patients présentant une tachycardie ventriculaire peut impliquer la stratification du risque de mort cardiaque subite, l'utilisation de défibrillateurs cardioverteurs implantables, la suppression de la tachycardie ventriculaire par le traitement de toute maladie myocardique sous-jacente, l'utilisation de médicaments antiarythmiques, l'ablation par cathéter et, dans les cas réfractaires, des approches récentes, telles que la radiothérapie stéréotaxique cardiaque.

Commentaire :  Caractéristiques de l'ECG qui aident à diagnostiquer une tachycardie ventriculaire.
La dissociation auriculo-ventriculaire (AV) permet de diagnostiquer une tachycardie ventriculaire. Des critères morphologiques peuvent être appliqués en fonction de la similarité globale du complexe QRS dans la dérivation V1 avec une morphologie typique de "bloc de branche gauche" ou de "bloc de branche droit". Après avoir fait la distinction entre ces deux types de morphologie, d'autres critères peuvent être appliqués. Sur l'image, la durée du QRS, la concordance des dérivations précordiales et l'axe du QRS suggèrent une TV. Reproduit via une licence Creative Commons Attribution-NonCommercial License de Kashou et al  .

Pulmonary hypertension - the latest updates for physicians.
Virsinskaite R, Karia N, Kotecha T, Schreiber BE, Coghlan JG, Knight DS. | Clin Med (Lond). 2023 Sep;23(5):449-454
DOI: https://doi.org/10.7861/clinmed.2023-23.5.cardio4  | Télécharger l'article au format  
Keywords: Pulmonary hypertension; chronic thromboembolic pulmonary hypertension; pulmonary arterial hypertension; screening; systemic sclerosis.

CME CARDIOLOGY

Editorial : Pulmonary hypertension (PH) is common, with an estimated prevalence of approximately 1% that increases with age. Prompt and accurate diagnosis is key to institute timely and appropriate therapy to improve symptoms and prognosis. The international guidelines for the diagnosis and management of PH have recently been updated, with a lowering of the haemodynamic threshold for diagnosis to a mean pulmonary artery pressure >20 mmHg. New diagnostic algorithms and revised indications for screening in at-risk groups have been developed to facilitate early referral to specialist PH centres. This includes fast-track referral pathways for patients who are either clinically high-risk or are at-risk for pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH). This review summarises key changes in the PH guidelines for general physicians who are, most often, the first healthcare professionals to encounter these patients and consequently have a key role as referrers into specialist PH services.

Conclusion : Pulmonary hypertension is common, with multiple subtypes and aetiologies that have individualised management recommendations.
The haemodynamic definition of PH by right heart catheterisation (RHC) has changed to a lower mean pulmonary arterial pressure (mPAP) at rest of >20 mmHg based upon the upper normal limit in healthy individuals along with supportive prognostic data. However, there is currently no evidence for the efficacy of targeted PH medications in patients with mPAP <25 mmHg and pulmonary vascular resistance (PVR) <3 WU, which remains an evidence gap.
Early detection and referral to a specialist PH centre is crucial to institute targeted management that can improve symptoms and optimise prognosis. Physicians should be familiar with the streamlined pathway for suspicion, detection and confirmation of PH, the latter step being performed at PH centres. Fast-track referral pathways should be taken for clinically high-risk patients and for patient cohorts ‘at-risk’ of developing pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH).
Annual systematic screening using the DETECT algorithm is a class 1 recommendation in asymptomatic adults with systemic sclerosis of more than 3 years’ duration, forced vital capacity (FVC) ≥40%, and a transfer factor (DLCO) <60%.
Patients with ongoing dyspnoea after 3 months of anticoagulation in the setting of a history of previous thromboembolic disease require further evaluation for chronic thromboembolic pulmonary disease (CTEPD) or CTEPH.

Conclusion (proposition de traduction) : L'hypertension pulmonaire est fréquente, avec de multiples sous-types et étiologies qui font l'objet de recommandations de prise en charge individualisées.
La définition hémodynamique de l'hypertension pulmonaire par cathétérisme cardiaque droit (CCD) a changé pour une pression artérielle pulmonaire moyenne inférieure (PAPm) au repos de > 20 mmHg, sur la base de la limite normale supérieure chez les individus en bonne santé et de données pronostiques favorables. Cependant, il n'existe actuellement aucune preuve de l'efficacité des médicaments ciblés contre l'hypertension pulmonaire chez les patients ayant une PAPm < 25 mmHg et des résistances vasculaires pulmonaires (RVP) < 3 WU, ce qui reste une lacune dans les données probantes.
La détection précoce et l'orientation vers un centre spécialisé dans l'hypertension pulmonaire sont essentielles pour mettre en place une prise en charge ciblée susceptible d'améliorer la qualité de vie des patients est cruciale pour mettre en place une prise en charge ciblée susceptible d'améliorer les symptômes et d'optimiser le pronostic. Les médecins doivent connaître la procédure simplifiée de suspicion, de détection et de confirmation de l'hypertension pulmonaire, cette dernière étape étant réalisée dans les centres spécialisés dans l'hypertension pulmonaire. Les patients à haut risque clinique et les cohortes de patients « à risque » de développer une hypertension artérielle pulmonaire (HTAP) ou une hypertension pulmonaire thromboembolique chronique (HTPC) doivent bénéficier d'une procédure d'orientation accélérée.
Le dépistage systématique annuel à l'aide de l'algorithme DETECT est une recommandation de classe 1 chez les adultes asymptomatiques atteints de sclérose systémique depuis plus de 3 ans, présentant une capacité vitale forcée (CVF) ≥ 40 % et un facteur de transfert (DLCO) < 60 %.
Les patients présentant une dyspnée continue après 3 mois d'anticoagulation dans le cadre d'un antécédent de maladie thromboembolique nécessitent une évaluation plus approfondie de la maladie pulmonaire thromboembolique chronique (CTEPD) ou de la CTEPH.

Atrial fibrillation: a contemporary update.
Saleh K, Haldar S. | Clin Med (Lond). 2023 Sep;23(5):437-441
DOI: https://doi.org/10.7861/clinmed.2023-23.5.cardio2  | Télécharger l'article au format  
Keywords: atrial fibrillation; AF; ablation; arrhythmia; ECG; devices

CME CARDIOLOGY

Editorial : Atrial fibrillation (AF) is the most common cardiac arrhythmia and imposes a significant healthcare burden. The landscape of AF has changed considerably over the past few years, with the advent of novel diagnostic approaches, advances in therapies and changing recommendations on best practice from the latest major trials. In this article, we review our evolving understanding of the natural history of AF and explore the contemporary landscape of its diagnosis and management.

Conclusion : AF is the most common cardiac arrhythmia, particularly among the ageing population, and is a major risk factor for thromboembolic stroke, heart failure and mortality.
AF primarily begins as a paroxysmal condition, driven by focal triggers, but progresses over time to a persistent phenotype through electrical and structural atrial remodelling.
A 12-lead ECG or >30-second rhythm strip is diagnostic for AF according to the latest European Society of Cardiology guidelines. Subclinical device-detected AF does not carry the same prognostic risk and must be interpreted in the context of AF burden and stroke risk.
Holistic care with lifestyle and cardiovascular risk factor modification is a key treatment priority to prevent AF recurrence and improve the efficacy of AF rhythm management.
Maintenance of sinus rhythm should be prioritised in early disease states to prevent AF disease progression and to improve long-term clinical outcomes.

Conclusion (proposition de traduction) : La fibrillation auriculaire est l'arythmie cardiaque la plus fréquente, en particulier dans la population vieillissante, et constitue un facteur de risque majeur d'accident vasculaire cérébral thromboembolique, d'insuffisance cardiaque et de mortalité.
La fibrillation auriculaire est d'abord un trouble paroxystique, provoqué par des déclencheurs focaux, mais elle évolue avec le temps vers un stade persistant en raison d'un remodelage électrique et structurel de l'oreillette.
Un ECG à 12 dérivations ou une analyse du rythme de >30 secondes permet de diagnostiquer la fibrillation auriculaire selon les dernières directives de la Société européenne de cardiologie. La fibrillation auriculaire infraclinique détectée par un appareil ne comporte pas le même risque pronostique et doit être interprétée dans le contexte du poids de la fibrillation auriculaire et du risque d'accident vasculaire cérébral.
Une prise en charge holistique avec modification du mode de vie et des facteurs de risque cardiovasculaire est une priorité essentielle du traitement pour prévenir la récidive de la fibrillation auriculaire et améliorer l'efficacité de la gestion du rythme de la fibrillation auriculaire.
Le maintien du rythme sinusal doit être une priorité dans les stades précoces de la maladie afin de prévenir la progression de la fibrillation auriculaire et d'améliorer les résultats cliniques à long terme.

Commentaire :  Algorithme de diagnostic pour les patients présentant une dyspnée inexpliquée et/ou suspectés d'hypertension pulmonaire. Adapté des lignes directrices ESC/ERS de 2022   pour le diagnostic et le traitement de l'hypertension pulmonaire.
ABG = arterial blood gas; BNP = brain natriuretic peptide; CPET = cardiopulmonary exercise testing; CT = computed tomography; CTEPH = chronic thromboembolic pulmonary hypertension; ECG = electrocardiogram; HIV = human immunodeficiency virus; N = no; NT-proBNP = N-terminal pro-brain natriuretic peptide; PAH = pulmonary arterial hypertension; PE = pulmonary embolism; PFT = pulmonary function tests; PH = pulmonary hypertension; Y = yes.

Treatment of hypercalcaemia of malignancy in adults.
Mc Donald D, Drake MT, Crowley RK. | Clin Med (Lond). 2023 Sep;23(5):503-507
DOI: https://doi.org/10.7861/clinmed.2023-0227  | Télécharger l'article au format  
Keywords: antiresorptive; bisphosphonate; calcimimetic; calcitonin; cancer; denosumab; glucocorticoids; hypercalcaemia; malignancy; parathyroid cancer.

CONCISE GUIDANCE

Editorial : Hypercalcaemia of malignancy (HCM) is a common metabolic complication of advanced malignancies with a prevalence varying from 2–30%, depending on cancer type and disease stage. HCM is associated with impaired quality of life, increased risk of hospitalisation and limited survival. Evidence-based guidelines for management of HCM have been lacking to date, despite its prevalence and detrimental impact. This concise guidance highlights key recommendations from the recent Endocrine Society Clinical Practice Guidelines on Treatment of Hypercalcaemia of Malignancy in Adults, published in December 2022. A systematic review and meta-analysis was commissioned to support the guideline development process. Key suggestions include the use of denosumab in preference to intravenous bisphosphonates as first-line treatment for HCM and the use of denosumab in cases of recurrent or refractory HCM in patients previously treated with intravenous bisphosphonates. The guideline also identifies priority areas for future research.

Commentaire :  Proposition de schéma pour la prise en charge de l'hypercalcémie d'origine maligne.
L'approche thérapeutique dépend à la fois de la physiopathologie et de la gravité de l'hypercalcémie. Reproduit avec l'autorisation d'Oxford University Press  . BP = bisphosphonate; Dmab = denosumab; HCM = hypercalcaemia of malignancy.

Complications of Body Piercings: A Systematic Review.
Conte S, Kamali K, Muncey-Buckley M, Abbas K, Sabljic T, Mukovozov IM. | Cutis. 2023 September;112(3):139-145
DOI: https://doi.org/10.12788/cutis.0847  | Télécharger l'article au format  
Keywords: Aucun

CLINICAL REVIEW

Editorial : The practice of body piercing has been present in many cultures worldwide for centuries, whether for religious or spiritual reasons or as a form of self-expression. In recent years, body piercings have become increasingly popular in all genders, with the most common sites being the ears, mouth, nose, eyebrows, nipples, navel, and genitals. However, despite the widespread utilization of piercings, a comprehensive literature review of associated complications is lacking. This scoping review aims to summarize the literature regarding complications associated with cutaneous and mucosal piercings. Given that body piercing has become more prevalent in recent years and that studies have noted an increase in a variety of piercing-induced complications, it is of utmost importance that piercing salons have proper hygiene practices in place and that patients are aware of the multitude of potential complications that can arise.

Conclusion : Given that cutaneous and mucosal piercing has become more prevalent in recent years, along with an increase in the variety of piercing-induced complications, it is of utmost importance that piercing salons have proper hygiene practices in place and that patients are aware of the multitude of potential complications that can arise—whether common and benign or rare but life-threatening.

Conclusion (proposition de traduction) : Le piercing cutané et muqueux étant de plus en plus répandu ces dernières années et les complications induites par le piercing étant de plus en plus nombreuses, il est de la plus haute importance que les salons de piercing mettent en place des pratiques d'hygiène adéquates et que les patients soient conscients de la multitude de complications potentielles qui peuvent survenir, qu'elles soient courantes et bénignes ou rares, mais potentiellement mortelles.

Isopropyl alcohol inhalation for the treatment of nausea in adult emergency department patients: a systematic review and meta-analysis.
Lee SY, Tamale JR. | Emerg Med J. 2023 Sep;40(9):660-665
DOI: https://doi.org/10.1136/emermed-2022-212871
Keywords: Systematic Review; emergency department; theraputics.

Original research

Introduction : Nausea and vomiting is a common ED chief complaint. However, randomised trials comparing antiemetic agents to placebo have not demonstrated superiority. This systematic review investigates the efficacy of inhaled isopropyl alcohol (IPA) compared with usual care or placebo in adults presenting to the ED with nausea and vomiting.

Méthode : We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, other relevant trial registries, journals, and conference proceedings up to September 2022. Randomised controlled trials using IPA to treat adult ED patients with nausea and vomiting were included. The primary outcome was change in severity of nausea, measured by a validated scale. A secondary outcome was vomiting during the ED stay. We used a random-effects model for the meta-analysis, and assessed certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation system.

Résultats : Two trials comparing inhaled IPA to saline placebo and including a total of 195 patients were pooled for meta-analysis of the primary outcome. A third study comparing a group receiving inhaled IPA and oral ondansetron to another group receiving inhaled saline placebo and oral ondansetron did not qualify for the original registered protocol, but was included in a secondary analysis. All studies were judged to be at low or unclear risk of bias. The pooled mean difference for the primary analysis was a reduction in reported nausea of 2.18 on a 0-10 scale (95% confidence interval (CI) 1.60 to 2.76), favouring IPA over placebo, where the minimum clinically significant difference was defined as 1.5. The evidence level was graded as moderate, due to imprecision from low patient numbers. Only the study included in the secondary analysis assessed the secondary outcome of vomiting, and did not find a difference between intervention and control.

Conclusion : This review suggests that IPA likely has a modest effect in reducing nausea in adult ED patients, compared with placebo. Larger multicentre trials are needed, as the evidence is limited by few trials and patients.

Conclusion (proposition de traduction) : Cette revue suggère que l'alcool isopropylique a probablement un effet modeste sur la réduction des nausées chez les patients adultes des services d'urgence, par rapport au placebo. Des essais multicentriques de plus grande envergure sont nécessaires, car les données probantes sont limitées par le nombre restreint d'essais et de patients.

Ten tips to manage severe acute pancreatitis in an intensive care unit.
Finkenstedt A, Jaber S, Joannidis M. | Intensive Care Med. 2023 Sep;49(9):1127-1130
DOI: https://doi.org/10.1007/s00134-023-07121-9  | Télécharger l'article au format  
Keywords: Aucun

Understanding the disease

Editorial : The prevalence of acute pancreatitis has continuously increased over the past decades. Although the majority of patients with acute pancreatitis presents with mild, interstitial oedematous pancreatitis and fully recovers with supportive treatment within a few days, more than 10% develop a more severe course requiring hospitalisation in an intensive care unit (ICU).

Conclusion : This article gives a quick guidance on how to approach these patients.

Conclusion (proposition de traduction) : Cet article donne des conseils rapides sur la manière d'aborder ces patients.

Commentaire :  Bilan diagnostique, évaluation et traitement d'un patient souffrant de pancréatite aiguë.

Assessment of E/A ratio helps emergency clinicians in the management of patients with acute dyspnea.
Arnone MI, Sforza A, Carlino MV, Guarino M, Candido R, Bertolone D, Fucile I, De Luca N, Mancusi C. | Intern Emerg Med. 2023 Sep;18(6):1823-1830
DOI: https://doi.org/10.1007/s11739-023-03279-8  | Télécharger l'article au format  
Keywords: Diastolic function; Emergency department; Focused cardiac ultrasonography; Lung ultrasound; Multi-organ ultrasound.

EM - ORIGINAL

Editorial : Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Department (ED). In the last years integrated ultrasound examination (IUE) of lung, heart and inferior vena cava (IVC) has become an extension of clinical examination for a fast differential diagnosis. The aim of present study is to assess the feasibility and diagnostic accuracy of E/A ratio for diagnosing acute heart failure (aHF) in patients with acute dyspnea. We included 92 patients presenting to the ED of CTO Hospital in Naples (Italy) for AD. All patients underwent IUE of lung-heart-IVC with a portable ultrasound device. Left ventricle diastolic function was assessed using pulse wave doppler at the tips of the mitral valve and E wave velocity and E/A ratio were recorded. The FINAL diagnosis was determined by two expert reviewers: acute HF or non-acute HF (non-aHF). We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive and negative predictive value of ultrasound parameters for the diagnosis of AD, comparing with the FINAL diagnosis. Lung ultrasound (LUS) showed high sensitivity, good specificity and accuracy in identification of patients with aHF. However, the highest accuracy was obtained by diastolic function parameters. The E/A ratio showed the highest diagnostic performance with an AUC for aHF of 0.93. In patients presenting with AD, E/A ratio is easy to obtain in a fast ultrasound protocol and showed an excellent accuracy for diagnosis of aHF.

Conclusion : Integrated ultrasound examination is a useful tool for differential diagnosis in patients admitted to the ED with acute dyspnea. In all types of heart failures regardless of ejection fraction, the left ventricle diastolic dysfunction plays an important role in congestion or pulmonary edema and consequent respiratory symptoms. E/A ratio showed an excellent diagnostic accuracy in diagnosing acute HF when assessed in ultrafast ultrasound protocol.

Conclusion (proposition de traduction) : L'examen échographique intégré est un outil utile pour le diagnostic différentiel chez les patients admis aux urgences pour une dyspnée aiguë. Dans tous les types d'insuffisance cardiaque, quelle que soit la fraction d'éjection, le dysfonctionnement diastolique du ventricule gauche joue un rôle important dans la congestion ou l'œdème pulmonaire et les symptômes respiratoires qui en découlent. Le rapport E/A a montré une excellente précision dans le diagnostic de l'insuffisance cardiaque aiguë lorsqu'il a été évalué dans le cadre d'un protocole d'échographie ultrarapide.

Commentaire : 

Voir l'article :
Vignon P. Évaluation des pressions de remplissage ventriculaire gauche par échocardiographie-doppler. Réanimation. 2007;16(2):139-148  .

Out-of-Hospital Pediatric Video Laryngoscopy With an Adult Device: A Case Series Presented With a Contemporary Group Intubated With Direct Laryngoscopy.
Miller M, Storey H, Andrew J, Christian E, Hayes-Bradley C. | Pediatr Emerg Care. 2023 Sep 1;39(9):666-671
DOI: https://doi.org/10.1097/pec.0000000000002909
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : After introducing an adult video laryngoscope (VL) in our physician-paramedic prehospital and retrieval medical service, our quality assurance process identified this blade being used during pediatric intubations. We present a case series of pediatric intubations using this oversized adult VL alongside a contemporaneous group of direct laryngoscopy (DL) intubations.

Méthode : We performed a retrospective review of intubated patients 15 years or younger in our electronic quality assurance registry from January 1, 2017, to December 31, 2020. Data collected were demographic details, intubation equipment, drug doses, the number of intubation attempts, and complications. Results are presented according to those intubated with C-MAC4 VL (Karl Storz) alongside age-appropriate DL sizes.

Résultats : Ninety-nine pediatric patients were intubated, 67 (67%) by CMAC4 and 32 (33%) by DL. Video laryngoscopy had a first-attempt success rate of 96% and DL 91%. A Cormach and Lehane view 1 or 2 was found in 66 VL (99%) and 29 DL patients (91%). Desaturation was reported in two VL and 1 DL patient.

Conclusion : Adult VL became the most common method of intubation in patients older than 1 year during the study period. An adult C-MAC4 VL could be considered for clinicians who prefer VL when a pediatric VL is unavailable or as a second-line device if a pediatric VL is not present when intubating children older than 1 year.

Conclusion (proposition de traduction) : Le vidéolaryngoscope pour adultes est devenu la méthode d'intubation la plus courante chez les patients âgés de plus d'un an au cours de la période d'étude. Un vidéo-laryngoscope C-MAC4 pour adultes pourrait être envisagé pour les cliniciens qui préfèrent le vidéo-laryngoscope lorsqu'un vidéo-laryngoscope pédiatrique n'est pas disponible ou comme dispositif de seconde ligne si un vidéo-laryngoscope pédiatrique n'est pas présent lors de l'intubation d'enfants âgés de plus d'un an.

Commentaire : 

Impact of time-to-compression on out-of-hospital cardiac arrest survival outcomes: A national registry study.
Goh JL, Pek PP, Fook-Chong SMC, Ho AFW, Siddiqui FJ, Leong BS, Mao DRH, Ng W, Tiah L, Chia MY, Tham LP, Shahidah N, Arulanandam S, Ong MEH; PAROS Clinical Research Network. | Resuscitation. 2023 Sep;190:109917
DOI: https://doi.org/10.1016/j.resuscitation.2023.109917  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Neurological outcomes; Out-of-hospital cardiac arrest; Survival outcomes; Time-to-compression.

Clinical paper

Introduction : We aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30th day. Our secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation.

Méthode : All OHCAs from 2012 to 2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30th day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval.

Résultats : 12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function- aOR 0.98 (95%CI: 0.97-0.98); survival to discharge- aOR 0.98 (95%CI: 0.98-0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests.

Conclusion : We demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (>7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional 'down-times', which could aid clinical decisions in TOR or OHCA management.

Conclusion (proposition de traduction) : Nous avons démontré qu'un intervalle sans circulation cardiaque (no-flow) prolongé avait un effet significatif sur la diminution des chances de résultats neurologiques favorables, la futilité médicale survenant lorsque cet intervalle sans circulation cardiaque était > 12 minutes (>7,5 minutes pour les arrêts devant témoin). Notre étude vient s'ajouter à la littérature sur l'importance d'une RCP et d'une intervention précoces des services médicaux d'urgence et a fourni un seuil au-delà des "temps d'arrêt cardiaque" traditionnels, qui pourrait aider les décisions cliniques dans la prise de décision de la fin de la réanimation ou des arrêts cardiaques extra-hospitaliers.

Pre-hospital endotracheal intubation Open Access in severe traumatic brain injury: ventilation targets and mortality—a retrospective analysis of 308 patients.
Knapp J, Doppmann P, Huber M, Meuli L, Albrecht R, Sollid S, Pietsch U. | Scand J Trauma Resusc Emerg Med. 2023 Sep 12;31(1):46
DOI: https://doi.org/10.1186/s13049-023-01115-8  | Télécharger l'article au format  
Keywords: HEMS; Prehospital emergency medicine; Tracheal intubation; Traumatic brain injury; Ventilation.

ORIGINAL RESEARCH

Introduction : Traumatic brain injury (TBI) remains one of the main causes of mortality and long-term disability worldwide. Maintaining physiology of brain tissue to the greatest extent possible through optimal management of blood pressure, airway, ventilation, and oxygenation, improves patient outcome. We studied the quality of prehospital care in severe TBI patients by analyzing adherence to recommended target ranges for ventilation and blood pressure, prehospital time expenditure, and their effect on mortality, as well as quality of prehospital ventilation assessed by arterial partial pressure of CO₂ (PaCO₂) at hospital admission.

Méthode : This is a retrospective cohort study of all TBI patients requiring tracheal intubation on scene who were transported to one of two major level 1 trauma centers in Switzerland between January 2014 and December 2019 by Swiss Air Rescue (Rega). We assessed systolic blood pressure (SBP), end-tidal partial pressure of CO₂ (PetCO₂), and PaCO₂ at hospital admission as well as prehospital and on-scene time. Quality markers of prehospital care (PetCO₂, SBP, prehospital times) and prehospital ventilation (PaCO₂) are presented as descriptive analysis. Effect on mortality was calculated by multivariable regression analysis and a logistic general additive model.

Résultats : Of 557 patients after exclusions, 308 were analyzed. Adherence to blood pressure recommendations was 89%. According to PetCO₂, 45% were normoventilated, and 29% had a SBP ≥ 90 mm Hg and were normoventilated. Due to the poor correlation between PaCO₂ and PetCO₂, only 33% were normocapnic at hospital admission. Normocapnia at hospital admission was strongly associated with reduced probability of mortality. Prehospital and on-scene times had no impact on mortality.

Conclusion : PaCO₂ at hospital admission is strongly associated with mortality risk, but normocapnia is achieved only in a minority of patients. Therefore, the time required for placement of an arterial cannula and prehospital blood gas analysis may be warranted in severe TBI patients requiring on-scene tracheal intubation.

Conclusion (proposition de traduction) : La PaCO₂ à l'admission à l'hôpital est fortement associée au risque de mortalité, mais la normocapnie n'est atteinte que chez une minorité de patients. Par conséquent, le temps nécessaire à la mise en place d'un cathéter artériel et à l'analyse préhospitalière des gaz du sang peut être justifié chez les patients victimes d'un traumatisme crânien grave nécessitant une intubation trachéale sur place.

Can Asking Emergency Physicians Whether or Not They Would Have Done Something Differently (WYHDSD) be a Useful Screening Tool to Identify Emergency Department Error?.
Arastehmanesh D, Mangino A, Eshraghi N, Wolfe RE, Grossman SA. | J Emerg Med. 2023 Sep;65(3):e250-e255
DOI: https://doi.org/10.1016/j.jemermed.2023.05.005
Keywords: adverse events; marker; medical error; near miss; patient care; reviewers.

Administration of Emergency Medicine

Introduction : Error in emergency medicine remains common and difficult to identify.
Objective: To evaluate if questioning emergency physician reviewers as to whether or not they would have done something differently (Would you have done something differently? [WYHDSD]) can be a useful marker to identify error.

Méthode : Prospective data were collected on all patients presenting to an academic emergency department (ED) between 2017 and 2021. All cases who met the following criteria were identified: 1) returned to ED within 72 h and admitted; 2) transferred to intensive care unit from floor within 24 h of admission; 3) expired within 24 h of arrival; or 4) patient or provider complaint. Cases were randomly assigned to emergency physicians and reviewed using an electronic tool to assess for error and adverse events. Reviewers were then mandated to answer WYHDSD in the management of the case.

Résultats : During the study period, 6672 cases were reviewed. Of the 5857 cases where reviewers would not have done something differently, 5847 cases were found to have no error. The question WYHDSD had a sensitivity of 97.4% in predicting error and a negative predictive value of 99.8%.

Conclusion : There was a significantly higher rate of near misses, adverse events, and errors attributable to an adverse event in cases where the reviewer would have done something differently (WHDSD) compared with cases where they would not. Therefore, asking reviewers if they WHDSD could potentially be used as a marker to identify error and improve patient care in the ED.

Conclusion (proposition de traduction) : Le taux d'accidents évités de justesse, d'événements indésirables et d'erreurs attribuables à un événement indésirable était significativement plus élevé dans les cas où l'examinateur aurait agi différemment (WHDSD) que dans les cas où il n'aurait pas agi différemment. Par conséquent, le fait de demander aux évaluateurs s'ils auraient fait quelque chose différemment pourrait potentiellement servir de marqueur pour identifier les erreurs et améliorer les soins aux patients dans le service des urgences.