Bibliographie de Médecine d'Urgence

Mois d'octobre 2023

American Journal of Respiratory and Critical Care Medicine

Conservative versus Liberal Oxygenation Targets in Intensive Care Unit Patients (ICONIC): A Randomized Clinical Trial.
van der Wal LI, Grim CCA, Del Prado MR, van Westerloo DJ, Boerma EC, Rijnhart-de Jong HG, Reidinga AC, Loef BG, van der Heiden PLJ, Sigtermans MJ, Paulus F, Cornet AD, Loconte M, Schoonderbeek FJ, de Keizer NF, Bakhshi-Raiez F, Le Cessie S, Serpa Neto A, Pelosi P, Schultz MJ, Helmerhorst HJF, de Jonge E; ICONIC investigators. | Am J Respir Crit Care Med. 2023 Oct 1;208(7):770-779
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Keywords: hyperoxia; hypoxia; intensive care medicine; mechanical ventilation; oxygen.

Original article

Introduction : Supplemental oxygen is widely administered to ICU patients, but appropriate oxygenation targets remain unclear. Objectives: This study aimed to determine whether a low-oxygenation strategy would lower 28-day mortality compared with a high-oxygenation strategy.

Méthode : This randomized multicenter trial included mechanically ventilated ICU patients with an expected ventilation duration of at least 24 hours. Patients were randomized 1:1 to a low-oxygenation (PaO2, 55-80 mm Hg; or oxygen saturation as measured by pulse oximetry, 91-94%) or high-oxygenation (PaO2, 110-150 mm Hg; or oxygen saturation as measured by pulse oximetry, 96-100%) target until ICU discharge or 28 days after randomization, whichever came first. The primary outcome was 28-day mortality. The study was stopped prematurely because of the COVID-19 pandemic when 664 of the planned 1,512 patients were included.

Résultats : Between November 2018 and November 2021, a total of 664 patients were included in the trial: 335 in the low-oxygenation group and 329 in the high-oxygenation group. The median achieved PaO2 was 75 mm Hg (interquartile range, 70-84) and 115 mm Hg (interquartile range, 100-129) in the low- and high-oxygenation groups, respectively. At Day 28, 129 (38.5%) and 114 (34.7%) patients had died in the low- and high-oxygenation groups, respectively (risk ratio, 1.11; 95% confidence interval, 0.9-1.4; P = 0.30). At least one serious adverse event was reported in 12 (3.6%) and 17 (5.2%) patients in the low- and high-oxygenation groups, respectively.

Conclusion : Among mechanically ventilated ICU patients with an expected mechanical ventilation duration of at least 24 hours, using a low-oxygenation strategy did not result in a reduction of 28-day mortality compared with a high-oxygenation strategy.

Conclusion (proposition de traduction) : Chez les patients sous ventilation mécanique en unité de soins intensifs dont la durée prévue de la ventilation mécanique était d'au moins 24 heures, l'utilisation d'une stratégie de faible oxygénation n'a pas entraîné de réduction de la mortalité à 28 jours par rapport à une stratégie de forte oxygénation.

Anesthesia & Analgesia

The Timing of Initiating Hydrocortisone and Long-term Mortality in Septic Shock.
Zhang L, Gu WJ, Huang T, Lyu J, Yin H. | Anesth Analg. 2023 Oct 1;137(4):850-858
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Keywords: Aucun

Original Clinical research report

Introduction : Previous studies on the association between the timing of corticosteroid administration and mortality in septic shock focused only on short-term mortality and produced conflicting results. We performed a retrospective review of a large administrative database of intensive care unit (ICU) patients to evaluate the association between the timing of hydrocortisone initiation and short- and long-term mortality in septic shock. We hypothesized that a longer duration between the first vasopressor use for sepsis and steroid initiation was associated with increased mortality.

Méthode : Data were extracted from the Medical Information Mart in the Intensive Care-IV database. We included adults who met Sepsis-3 definition for septic shock and received hydrocortisone. The exposure of interest was the time in hours from vasopressor use to hydrocortisone initiation (>12 as late and ≤12 as early). The primary outcome was 1-year mortality. Secondary outcomes included 28-day mortality, 90-day mortality, in-hospital mortality, and length of hospital stay. Cox proportional hazard models were used to estimate the association between exposure and mortality. Competing risk regression models were used to evaluate the association between exposure and length of hospital stay.

Résultats : A total of 844 patients were included in this cohort: 553 in the early group and 291 in the late group. The median time to hydrocortisone initiation was 7 hours (interquartile range, 2.0-19.0 hours). After multivariable Cox proportional hazard analysis, we found that hydrocortisone initiation >12 hours after vasopressor use was associated with increased 1-year mortality when compared with initiation <12 hours (adjusted hazard ratio, 1.39; 95% confidence interval, 1.13-1.71; P = .002, E-value = 2.13). Hydrocortisone initiation >12 hours was also associated with increased 28-day, 90-day, and in-hospital mortality and prolonged length of hospital stay.

Conclusion : In patients with septic shock, initiating hydrocortisone >12 hours after vasopressor use was associated with an increased risk of both short-term and long-term mortality, and a prolonged length of hospital stay.

Conclusion (proposition de traduction) : Chez les patients en état de choc septique, l'administration d'hydrocortisone plus de 12 heures après l'utilisation d'un vasopresseur a été associée à un risque accru de mortalité à court et à long terme, ainsi qu'à une durée d'hospitalisation plus longue.


Lower vs Higher Fluid Volumes in Adult Patients With Sepsis: An Updated Systematic Review With Meta-Analysis and Trial Sequential Analysis.
Sivapalan P, Ellekjaer KL, Jessen MK, Meyhoff TS, Cronhjort M, Hjortrup PB, Wetterslev J, Granholm A, Møller MH, Perner A. | Chest. 2023 Oct;164(4):892-912
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Keywords: fluid therapy; intensive care; sepsis; septic shock.

Original Research

Introduction : IV fluids are recommended for adults with sepsis. However, the optimal strategy for IV fluid management in sepsis is unknown, and clinical equipoise exists.
Research question: Do lower vs higher fluid volumes improve patient-important outcomes in adult patients with sepsis?

Méthode : We updated a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing lower vs higher IV fluid volumes in adult patients with sepsis. The coprimary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. We followed the recommendations from the Cochrane Handbook and used the Grading of Recommendations Assessment, Development and Evaluation approach. Primary conclusions were based on trials with low risk of bias if available.

Résultats : We included 13 trials (N = 4,006) with four trials (n = 3,385) added to this update. The meta-analysis of all-cause mortality in eight trials with low risk of bias showed a relative risk of 0.99 (97% CI, 0.89-1.10; moderate certainty evidence). Six trials with predefined definitions of serious adverse events showed a relative risk of 0.95 (97% CI, 0.83-1.07; low certainty evidence). Health-related quality of life was not reported.

Conclusion : Among adult patients with sepsis, lower IV fluid volumes probably result in little to no difference in all-cause mortality compared with higher IV fluid volumes, but the interpretation is limited by imprecision in the estimate, which does not exclude potential benefit or harm. Similarly, the evidence suggests lower IV fluid volumes result in little to no difference in serious adverse events. No trials reported on health-related quality of life.

Conclusion (proposition de traduction) : Chez les patients adultes présentant un sepsis, des volumes de remplissage vasculaitre plus faibles entraînent probablement peu ou pas de différence en termes de mortalité toutes causes confondues par rapport à des volumes plus élevés, mais l'interprétation est limitée par l'imprécision de l'estimation, ce qui n'exclut pas un bénéfice ou un dommage potentiel. De même, les données suggèrent que des volumes de remplissage plus faibles n'entraînent que peu ou pas de différence en termes d'événements indésirables graves. Aucun essai n'a fait état de la qualité de vie liée à la santé.

Noninvasive Oxygenation Strategies in Adult Patients With Acute Hypoxemic Respiratory Failure: A Systematic Review and Network Meta-Analysis.
Pitre T, Zeraatkar D, Kachkovski GV, Leung G, Shligold E, Dowhanik S, Angriman F, Ferreyro BL, Scales DC, Rochwerg B. | Chest. 2023 Oct;164(4):913-928
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Keywords: COVID-19; acute hypoxemic respiratory failure; high-flow nasal cannula; network meta-analysis; noninvasive ventilation.

Original Research

Introduction : Several recently published randomized controlled trials have evaluated various noninvasive oxygenation strategies for the treatment of acute hypoxemic respiratory failure.
Research question: Which available noninvasive oxygen strategies are effective for acute hypoxic respiratory failure?

Méthode : A systematic review of Medline, Embase, Cochrane CENTRAL, CINAHL, Web of Science, MedRxiv, and Research Square was conducted from inception to October 1, 2022. A random effects frequentist network meta-analysis was performed, and the results are presented using absolute risk difference per 1,000 patients. The Grading of Recommendations, Assessment, Development and Evaluation framework was used to rate the certainty of the evidence. Mortality, invasive mechanical ventilation, duration of hospitalization and ICU stay, ventilator-free days, and level of comfort are reported.

Résultats : Thirty-six trials (7,046 patients) were included. It was found that helmet CPAP probably reduces mortality compared with standard oxygen therapy (SOT) (231 fewer deaths per 1,000; 95% CI, 126-273 fewer) (moderate certainty). A high-flow nasal cannula (HFNC) probably reduces the need for invasive mechanical ventilation (103.5 fewer events per 1,000; 95% CI, 40.5-157.5 fewer) (moderate certainty). All noninvasive oxygenation strategies may reduce the duration of hospitalization as compared with SOT (low certainty). Helmet bilevel ventilation (4.84 days fewer; 95% CI, 2.33-7.36 days fewer) and helmet CPAP (1.74 days fewer; 95% CI, 4.49 fewer-1.01 more) may reduce the duration of ICU stay as compared with SOT (both low certainty). SOT may be more comfortable than face mask noninvasive ventilation and no different in comfort compared with an HFNC (both low certainty).

Conclusion : A helmet interface for noninvasive ventilation probably reduces mortality and the risk of mechanical ventilation, as well as the duration of hospital and ICU stay. An HFNC probably reduces the risk of invasive mechanical ventilation and may be as comfortable as SOT. Further research is necessary to understand the role of these interfaces in acute hypoxemic respiratory failure.

Conclusion (proposition de traduction) : Une interface avec casque (helmet) pour la ventilation non invasive réduit probablement la mortalité et le risque de ventilation mécanique, ainsi que la durée de l'hospitalisation et du séjour en soins intensifs. L'oxygénothérapie nasale à haut débit réduit probablement le risque de ventilation mécanique invasive et peut être aussi confortables que l'oxygénothérapie standard. Des recherches supplémentaires sont nécessaires pour comprendre le rôle de ces interfaces dans l'insuffisance respiratoire hypoxémique aiguë.

Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis.
Eamer G, Povolo CA, Petropoulos JA, Ohinmaa A, Vanhouwelingen L. | Chest. 2023 Oct;164(4):1007-1018
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Keywords: cost; cost-utility analysis; economic analysis; spontaneous pneumothorax; systematic review.

Original Research

Introduction : Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed.
Research question: Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility?

Méthode : A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed.

Résultats : Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I2 = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I2 = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I2 = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I2 = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations.

Conclusion : Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.

Conclusion (proposition de traduction) : L'observation est le choix dominant par rapport à l'aspiration et à la mise en place d'un drain thoracique dans le cas d'un pneumothorax spontané primaire. Elle doit être considérée comme le traitement de première intention chez les patients sélectionnés de manière appropriée.


2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; American Heart Association. | Circulation. 2023 Oct 17;148(16):e149-e184
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Keywords: AHA Scientific Statements; American Heart Association; advanced cardiac life support; antidotes; drug overdose; heart arrest; poisoning; resuscitation.

AHA Focused Updates

Editorial : In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

Conclusion : 1. Treatment of cardiac arrest and life-threatening toxicity due to poisoning often requires specialized treatments that most clinicians do not use frequently such as antidotes and venoarterial extracorporeal membrane oxygenation, in addition to effective basic and advanced life support. Timely consultation with a medical toxicologist, clinical toxicologist, or regional poison center facilitates rapid and effective therapy.
2. Opioid overdose remains the leading cause of cardiac arrest due to poisoning in North America. Naloxone administration may reverse respiratory arrest, preventing progression to cardiac arrest.
3. High-dose insulin therapy is recommended early in the treatment of patients with life- threatening β-blocker and calcium channel blocker poisoning.
4. Standard advanced life support with the addition of administration of sodium bicarbonate is appropriate for the treatment of life-threatening dysrhythmias caused by cocaine or other sodium channel blockers.
5. If cyanide poisoning is suspected, do not wait for confirmatory testing. Treat immediately with hydroxocobalamin (preferred) or sodium nitrite plus sodium thiosulfate.
6. Administration of digoxin-specific immune antibody fragments can reverse life-threatening dysrhythmias from digoxin poisoning.
7. Use of 20% intravenous lipid emulsion can be efficacious in the resuscitation of life-threatening local anesthetic toxicity, especially from bupivacaine.
8. Patients with severe agitation from sympathomimetic poisoning require sedation to manage hyperthermia and acidosis, to prevent rhabdomyolysis and injury, and to allow evaluation for other life-threatening conditions.
9. Flumazenil reverses central nervous system and respiratory depression from benzodiazepine poisoning, but important risks and contraindications limit its use.
10. Venoarterial extracorporeal membrane oxygen- ation can be lifesaving for patients with cardiogenic shock or dysrhythmias that are refractory to other treatment measures. Because venoarterial extracorporeal membrane oxygenation implementation takes time, the process should be started early in patients who are not responding well to other therapies.

Conclusion (proposition de traduction) : 1. Le traitement de l'arrêt cardiaque et de la toxicité grave due à une intoxication nécessite souvent des traitements spécialisés que la plupart des cliniciens n'utilisent pas fréquemment, tels que les antidotes et l'oxygénation par membrane extracorporelle veino-artérielle, en plus d'une réanimation de base et d'une réanimation avancée efficaces. La consultation rapide d'un toxicologue médical, d'un toxicologue clinicien ou d'un centre antipoison régional facilite une thérapeutique rapide et efficace.
2. L'overdose d'opioïdes reste la principale cause d'arrêt cardiaque par empoisonnement en Amérique du Nord. L'administration de naloxone peut inverser l'arrêt respiratoire et éviter la dégradation en arrêt cardiaque.
3. L'insulinothérapie à forte dose est recommandée dès le début du traitement des patients présentant un empoisonnement par β-bloquant et inhibiteur calcique mettant en jeu le pronostic vital.
4. Les soins avancés de réanimation standard avec l'ajout de l'administration de bicarbonate de sodium sont appropriés pour le traitement des troubles du rythme cardiaque potentiellement mortels causés par la cocaïne ou d'autres inhibiteurs des canaux sodiques.
5. Si l'on soupçonne un empoisonnement au cyanure, ne pas attendre les tests de confirmation. Traiter immédiatement avec de l'hydroxocobalamine (de préférence) ou du nitrite de sodium plus du thiosulfate de sodium.
6. L'administration de fragments d'anticorps immunitaires spécifiques de la digoxine peut inverser les dysrythmies potentiellement mortelles résultant d'un intoxication à la digoxine.
7. L'utilisation d'une émulsion lipidique intraveineuse à 20 % peut être efficace dans la réanimation d'une toxicité anesthésique locale menaçant le pronostic vital, en particulier à cause de la bupivacaïne.
8. Les patients présentant une agitation sévère due à un intoxication sympathomimétique nécessitent une sédation pour gérer l'hyperthermie et l'acidose, pour prévenir la rhabdomyolyse et les lésions, et pour permettre l'évaluation d'autres affections menaçant le pronostic vital.
9. Le flumazénil inverse la dépression du système nerveux central et la dépression respiratoire résultant d'une intoxication par les benzodiazépines, mais des risques et des contre-indications importants limitent son utilisation.

Commentaire : Suite de la traduction…
10. L'oxygénation par membrane extracorporelle veino-artérielle peut sauver la vie des patients présentant un choc cardiogénique ou des troubles du rythme réfractaires à d'autres mesures thérapeutiques. Comme la mise en œuvre de l'oxygénation par membrane extracorporelle veineuse prend du temps, le processus doit être entamé tôt chez les patients qui ne répondent pas bien aux autres thérapies.


Derivation of a HEAR Pathway for Emergency Department Chest Pain Patients to Safely Avoid a Second Troponin Test.
Chen C, Yu Y, Chen D, Cai C, Zhou Y, Liao F, Humarbek A, Li X, Song Z, Sun Z, Tong C, Yao C, Gu G. | Diagnostics. 2023 Oct 16;13(20):3217
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Keywords: HEAR pathway; chest pain; emergency department; high-sensitivity cardiac troponin; non-ST elevation myocardial infarction.


Editorial : The study aims to develop a decision pathway based on HEAR score and 0 h high-sensitivity cardiac troponin T (hs-cTnT) to safely avoid a second troponin test for suspected non-ST elevation myocardial infarction (NSTEMI) in emergency departments. A HEAR score consists of history, electrocardiogram, age, and risk factors. A HEAR pathway is established using a Bayesian approach based on a predefined safety threshold of NSTEMI prevalence in the rule-out group. In total, 7131 patients were retrospectively enrolled, 582 (8.2%) with index visit NSTEMI and 940 (13.2%) with 180-day major adverse cardiovascular events (MACE). For patients with a low-risk HEAR score (0 to 2) and low 0 h hs-cTnT (<14 ng/L), the HEAR pathway recommends early discharge without further testing. After the HEAR pathway had been applied to rule out NSTEMI, the negative predictive value of index visit NSTEMI was 100.0% (95% CI, 99.8% to 100.0%) and false-negative rate of 180-day MACE was 0.40% (95% CI, 0.18% to 0.87%). Compared with the 0 h hs-cTnT < limit of detection (LoD) strategy (<5 ng/L), the HEAR pathway could correctly reclassify 1298 patients without MACE as low risk and lead to a 18.2% decrease (95% CI, 17.4-19.1%) in the need for a second troponin test. The HEAR pathway may lead to a substantial and safe reduction in repeated troponin test for emergency department patients with suspected NSTEMI.

Conclusion : In conclusion, using the Bayesian approach, we derived a new clinical decision path- way, the HEAR pathway, to help ED physicians make decisions regarding patients with suspected NSTEMI. Applying the HEAR pathway may lead to a substantial and safe reduction in repeated troponin tests.

Conclusion (proposition de traduction) : En conclusion, en utilisant l'approche bayésienne, nous avons élaboré une nouvelle méthode de décision clinique, la méthode HEAR, pour aider les médecins urgentistes à prendre des décisions concernant les patients suspectés de présenter un infarctus du myocarde avec sus-décalage du segment ST. L'application de la méthode HEAR peut permettre une réduction substantielle et sûre des tests de troponine à répétition.

Commentaire : 

JAMA Network

Evaluation and Treatment of Knee Pain: A Review.
Duong V, Oo WM, Ding C, Culvenor AG, Hunter DJ. | JAMA. 2023 Oct 24;330(16):1568-1580
Keywords: Aucun


Introduction : Approximately 5% of all primary care visits in adults are related to knee pain. Osteoarthritis (OA), patellofemoral pain, and meniscal tears are among the most common causes of knee pain.

Méthode : Knee OA, affecting an estimated 654 million people worldwide, is the most likely diagnosis of knee pain in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness (95% sensitivity; 69% specificity). Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25%. The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain. Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma (eg, twisting injury) in people younger than 40 years. Alternatively, a meniscal tear may be a degenerative condition present in patients with knee OA who are aged 40 years or older. The McMurray test, consisting of concurrent knee rotation (internal or external to test lateral or medial meniscus, respectively) and extension (61% sensitivity; 84% specificity), and joint line tenderness (83% sensitivity; 83% specificity) assist diagnosis of meniscal tears. Radiographic imaging of all patients with possible knee OA is not recommended. First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition. Surgical referral for knee joint replacement can be considered for patients with end-stage OA (ie, no or minimal joint space with inability to cope with pain) after using all appropriate conservative options. For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery. Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears. For severe traumatic (eg, bucket-handle) tears, consisting of displaced meniscal tissue, surgery is likely required. For degenerative meniscal tears, exercise th

Conclusion : Knee OA, patellofemoral pain, and meniscal tears are common causes of knee pain, can be diagnosed clinically, and can be associated with significant disability. First-line treatment for each condition consists of conservative management, with a focus on exercise, education, and self-management.

Conclusion (proposition de traduction) : L'arthrose du genou, la douleur fémoro-patellaire et les déchirures méniscales sont des causes courantes de douleur au genou, peuvent être diagnostiquées cliniquement et peuvent être associées à une incapacité importante. Le traitement de première intention pour chacune de ces affections consiste en une prise en charge conservatrice, axée sur l'exercice, l'éducation et l'autogestion.

Journal of the American College of Cardiology

Comparison of Antiplatelet Monotherapies After Percutaneous Coronary Intervention According to Clinical, Ischemic, and Bleeding Risks.
Yang S, Kang J, Park KW, Hur SH, Lee NH, Hwang D, Yang HM, Ahn HS, Cha KS, Jo SH, Ryu JK, Suh IW, Choi HH, Woo SI, Han JK, Shin ES, Koo BK, Kim HS. | J Am Coll Cardiol. 2023 Oct 17;82(16):1565-1578
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Keywords: aspirin; bleeding; clopidogrel; ischemic events; percutaneous coronary intervention.


Introduction : Clopidogrel was superior to aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI).

Méthode : The purpose of this study was to evaluate the benefits of clopidogrel across high-risk subgroups METHODS: This was a post hoc analysis of the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy) trial that randomly assigned patients who were event free for 6 to 18 months post-PCI on dual antiplatelet therapy (DAPT) to clopidogrel or aspirin monotherapy. Two clinical risk scores were used for risk stratification: the DAPT score and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P) (the sum of age ≥75 years, diabetes, hypertension, current smoking, peripheral artery disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction). The primary composite endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission because of acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type ≥3) at 2 years after randomization.

Résultats : Among 5,403 patients, clopidogrel monotherapy showed a lower rate of the primary composite endpoint than aspirin monotherapy (HR: 0.73; 95% CI: 0.59-0.90). The benefit of clopidogrel over aspirin was consistent regardless of TRS 2°P (high TRS 2°P [≥3] group: HR: 0.65 [95% CI: 0.44-0.96]; and low TRS 2°P [<3] group: HR: 0.77 [95% CI: 0.60-0.99]) (P for interaction = 0.454) and regardless of DAPT score (high DAPT score [≥2] group: HR: 0.68 [95% CI: 0.46-1.00]; and low DAPT score [<2] group: HR: 0.75 [95% CI: 0.59-0.96]) (P for interaction = 0.662). The association was similar for the individual outcomes.

Conclusion : The beneficial effect of clopidogrel over aspirin monotherapy was consistent regardless of clinical risk or relative ischemic and bleeding risks compared with aspirin monotherapy.

Conclusion (proposition de traduction) : L'effet bénéfique du clopidogrel par rapport à l'aspirine en monothérapie était constant quel que soit le risque clinique ou les risques relatifs d'ischémie et de saignement par rapport à l'aspirine en monothérapie.


Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial.
Patterson T, Perkins GD, Perkins A, Clayton T, Evans R, Dodd M, Robertson S, Wilson K, Mellett-Smith A, Fothergill RT, McCrone P, Dalby M, MacCarthy P, Firoozi S, Malik I, Rakhit R, Jain A, Nolan JP, Redwood SR; ARREST trial collaborators. | Lancet. 2023 Oct 14;402(10410):1329-1337
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Keywords: Aucun


Introduction : The International Liaison Committee on Resuscitation has called for a randomised trial of delivery to a cardiac arrest centre. We aimed to assess whether expedited delivery to a cardiac arrest centre compared with current standard of care following resuscitated cardiac arrest reduces deaths.

Méthode : ARREST is a prospective, parallel, multicentre, open-label, randomised superiority trial. Patients (aged ≥18 years) with return of spontaneous circulation following out-of-hospital cardiac arrest without ST elevation were randomly assigned (1:1) at the scene of their cardiac arrest by London Ambulance Service staff using a secure online randomisation system to expedited delivery to the cardiac catheter laboratory at one of seven cardiac arrest centres or standard of care with delivery to the geographically closest emergency department at one of 32 hospitals in London, UK. Masking of the ambulance staff who delivered the interventions and those reporting treatment outcomes in hospital was not possible. The primary outcome was all-cause mortality at 30 days, analysed in the intention-to-treat (ITT) population excluding those with unknown mortality status. Safety outcomes were analysed in the ITT population. The trial was prospectively registered with the International Standard Randomised Controlled Trials Registry, 96585404.

Résultats : Between Jan 15, 2018, and Dec 1, 2022, 862 patients were enrolled, of whom 431 (50%) were randomly assigned to a cardiac arrest centre and 431 (50%) to standard care. 20 participants withdrew from the cardiac arrest centre group and 19 from the standard care group, due to lack of consent or unknown mortality status, leaving 411 participants in the cardiac arrest centre group and 412 in the standard care group for the primary analysis. Of 822 participants for whom data were available, 560 (68%) were male and 262 (32%) were female. The primary endpoint of 30-day mortality occurred in 258 (63%) of 411 participants in the cardiac arrest centre group and in 258 (63%) of 412 in the standard care group (unadjusted risk ratio for survival 1·00, 95% CI 0·90-1·11; p=0·96). Eight (2%) of 414 patients in the cardiac arrest centre group and three (1%) of 413 in the standard care group had serious adverse events, none of which were deemed related to the trial intervention.

Conclusion : In adult patients without ST elevation, transfer to a cardiac arrest centre following resuscitated cardiac arrest in the community did not reduce deaths.

Conclusion (proposition de traduction) : Chez les patients adultes sans élévation du segment ST, le transfert vers un centre d'arrêt cardiaque après un arrêt cardiaque réanimé dans la rue n'a pas réduit le nombre de décès.

Commentaire : Quand il n’y a pas de sus-décalage du segment ST, l’important c’est la stabilisation immédiate en réanimation, et pas autre chose.

C’est la suite logique de l’essai TOMAHAWK sur le thème (mêmes résultats) :
Desch S, Freund A, Akin Iand al; TOMAHAWK Investigators. Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial. JAMA Cardiol. 2023 Sep 1;8(9):827-834  .


Head-to-pelvis CT imaging after sudden cardiac arrest: Current status and future directions.
Branch KR, Nguyen ML, Kudenchuk PJ, Johnson NJ. | Resuscitation. 2023 Oct;191:109916
Keywords: Abdominopelvic computed tomography; Cardiac computed tomography; Cardiopulmonary resuscitation; Chest computed tomography; Computed tomography; Diagnostic testing; Head computed tomography; Out of hospital cardiac arrest; Standard of care.


Editorial : Causes for sudden circulatory arrest (SCA) can vary widely making early treatment and triage decisions challenging. Additionally, cardiopulmonary resuscitation (CPR), while a life-saving link in the chain of survival, can be associated with traumatic injuries. Computed tomography (CT) can identify many causes of SCA as well as its sequelae. However, the diagnostic and therapeutic impact of CT in survivors of SCA has not been reviewed to date. This general review outlines the rationale and potential applications of focused head, chest, and abdomen/pelvis CT as well as comprehensive head-to-pelvis CT imaging after SCA. CT has a diagnostic yield approaching 30% to identify causes of SCA while the addition of ECG-gated chest CT provides further information about coronary anatomy and cardiac function. Risks of CT include radiation exposure, contrast-induced kidney injury, and incidental findings. This review's findings suggest that routine head-to-pelvis CT can yield clinically actional findings with the potential to improve clinical outcome after SCA that merits further investigation.

Conclusion : CT imaging has emerged as an effective and efficient mode of assessing for causes and complications from resuscitation after SCA. With good diagnostic yield for causes of SCA and the evaluation of critical and actionable pathology in the post-arrest period, head and possible chest CT have been incorporated into guidelines for post-arrest care. More recent data suggest that a comprehensive approach with head-to-pelvis CT may provide substantial data on causes of the SCA event as well as resuscitation injuries, some of which could be life threatening. However, the number of studies and patients are modest leaving many questions as to the extent and the types of CT scanning one should perform. Further, the lack of data showing prognostic benefit is of concern that this may be incrementally diagnostic but not incrementally prognostic for post-arrest care. Further well-designed prospective studies are needed to answer these important questions.

Conclusion (proposition de traduction) : La tomodensitométrie s'est imposée comme un moyen efficace et efficient d'évaluer les causes et les complications de la réanimation après un arrêt cardiaque soudain. Avec un bon rendement diagnostique pour les causes de la mort subite et l'évaluation de la pathologie grave et traitable dans la période post-arrêt cardiaque, la tomodensitométrie crânienne et éventuellement thoracique a été incorporée dans les lignes directrices pour les soins post-arrêt cardiaque. Des données plus récentes suggèrent qu'une approche globale avec un scanner de la tête au bassin peut fournir des données substantielles sur les causes de l'arrêt cardiaque subit ainsi que sur les lésions liées à la réanimation, dont certaines peuvent menacer le pronostic vital. Toutefois, le nombre d'études et de patients étant modeste, de nombreuses questions se posent quant à l'étendue et aux types de tomodensitométrie à effectuer. En outre, l'absence de données montrant un avantage en termes de pronostic est préoccupante, car il pourrait s'agir d'un outil diagnostique supplémentaire, mais pas d'un outil de pronostic supplémentaire pour les soins après l'arrêt. D'autres études prospectives bien conçues sont nécessaires pour répondre à ces questions importantes.

Temperature control after adult cardiac arrest: An updated systematic review and meta-analysis.
Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW; International Liaison Committee on Resuscitation ILCOR Advanced Life Support Task Force. | Resuscitation. 2023 Oct;191:109928
Keywords: Cardiac arrest, Cooling, Hypothermia, Systematic review, Temperature control


Introduction : To perform an updated systematic review and meta-analysis on temperature control in adult patients with cardiac arrest.

Méthode : The review is an update of a previous systematic review published in 2021. An updated search including PubMed, Embase, and the Cochrane Central Register of Controlled Trials was performed on May 31, 2023. Controlled trials in humans were included. The population included adult patients with cardiac arrest. The review included all aspects of temperature control including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE.

Résultats : The updated systematic search identified six new trials. Risk of bias in the trials was assessed as intermediate for most of the outcomes. For temperature control with a target of 32–34 C vs. normothermia or 36 C, two new trials were identified, with seven trials included in an updated meta-analysis. Temperature control with a target of 32–34 C did not result in an improvement in survival (risk ratio: 1.06 [95%CI: 0.91, 1.23]) or favorable neurological outcome (risk ratio: 1.27 [95%CI: 0.89, 1.81]) at 90–180 days after the cardiac arrest (low certainty evidence). Subgroup anal- ysis according to location of cardiac arrest (in-hospital vs. out-of-hospital) found similar results. A sensitivity analysis of nine trials comparing tem- perature control at 32–34 C to normothermia or 36 C for favorable neurological outcome at any time point also did not show an improvement in outcomes (risk ratio: 1.14 [95%CI 0.98, 1.34]). New individual trials comparing a target of 31–34 C, temperature control for 12–24 hours to 36 hours, a rewarming rate of 0.25–0.5 C/hour, and the effect of temperature control with fever prevention found no differences in outcomes.

Conclusion : This updated systematic review showed no benefit from temperature control at 32–34 C compared with normothermia or 36 C, although the 95% confidence intervals cannot rule out a potential beneficial effect. Important knowledge gaps exist for topics such as hypother- mic temperature targets, rewarming rate, and fever control.

Conclusion (proposition de traduction) : Cette revue systématique actualisée n'a pas montré de bénéfice d'un contrôle de la température à 32-34 C par rapport à la normothermie ou à 36 C, bien que les intervalles de confiance à 95 % ne permettent pas d'exclure un effet bénéfique potentiel. Il existe d'importantes lacunes dans les connaissances sur des sujets tels que les cibles de température hypothermique, la vitesse de réchauffement et le contrôle de la fièvre.

Commentaire : Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW; International Liaison Committee on Resuscitation ILCOR Advanced Life Support Task Force. Corrigendum to "Temperature control after adult cardiac arrest: An updated systematic review and meta-analysis" [Resuscitation 191 (2023)109928]. Resuscitation. 2023 Nov 22;194:110052  .

Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis.
Ramaswamy VV, Dawson JA, de Almeida MF, Trevisanuto D, Nakwa FL, Kamlin COF, Trang J, Wyckoff MH, Weiner GM, Liley HG; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. | Resuscitation. 2023 Oct;191:109934
DOI:  | Télécharger l'article au format  
Keywords: Delivery room; Hyperthermia; Hypothermia; Plastic bag; Preterm newborn infants.


Introduction : To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation.

Méthode : Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines.

Résultats : DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient.

Conclusion : DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Conclusion (proposition de traduction) : Une température de ≥23 °C dans la salle d'accouchement, un chauffage radiant en mode manuel, l'utilisation d'un sac ou d'une enveloppe en plastique et d'un couvre-chef sont suggérés pour les nouveau-nés prématurés de moins de 34 semaines de gestation. Les gaz chauffés-humidifiés et le matelas thermique peuvent être envisagés en plus du sac ou de l'enveloppe en plastique, si les ressources le permettent, dans les environnements où l'incidence de l'hypothermie est élevée. Une surveillance attentive est nécessaire pour éviter l'hyperthermie.

Comparing strategies for prehospital transport to specialty care after cardiac arrest.
Elmer J, Dougherty M, Guyette FX, Martin-Gill C, Drake CD, Callaway CW, Wallace DJ. | Resuscitation. 2023 Oct;191:109943
DOI:  | Télécharger l'article au format  
Keywords: Cardiac arrest; Prehospital; Regionalization; Transport.

Clinical paper

Introduction : Outcomes are better when patients resuscitated from out-of-hospital cardiac arrest (OHCA) are treated at specialty centers. The best strategy to transport patients from the scene of resuscitation to specialty care is unknown.

Méthode : We performed a retrospective cohort study. We identified patients treated at a single specialty center after OHCA from 2010 to 2021 and used OHCA geolocations to develop a catchment area using a convex hull. Within this area, we identified short term acute care hospitals, OHCA receiving centers, adult population by census block group, and helicopter landing zones. We determined population-level times to specialty care via: (1) direct ground transport; (2) transport to the nearest hospital followed by air interfacility transfer; and (3) ground transport to air ambulance. We used an instrumental variable (IV) adjusted probit regression to estimate the causal effect of transport strategy on functionally favorable survival to hospital discharge.

Résultats : Direct transport to specialty care by ground to air ambulance had the shortest population-level times from OHCA to specialty care (median 56 [IQR 47-66] minutes). There were 1,861 patients included in IV regression of whom 395 (21%) had functionally favorable survival. Most (n = 1,221, 66%) were transported to the nearest hospital by ground EMS then to specialty care by air. Patient outcomes did not differ across transport strategies in our IV analysis.

Conclusion : We did not find strong evidence in favor of a particular strategy for transport to specialty care after OHCA. Population level time to specialty care was shortest with ground ambulance transport to the nearest helicopter landing zone.

Conclusion (proposition de traduction) : Nous n'avons pas trouvé de preuves solides en faveur d'une stratégie particulière pour le transport vers des soins spécialisés après un arrêt cardiaque extrahospitalier. Au niveau de la population, le temps d'accès aux soins spécialisés était le plus court avec le transport en ambulance terrestre vers la zone d'atterrissage d'hélicoptère la plus proche.

Association between the presence of an advanced airway and ventilation rate during pediatric CPR: A report from the Videography in Pediatric Resuscitation (VIPER) collaborative.
O'Connell KJ, Dutta A, Myers S, Neubrand T, Sandler A, Keane R, Kerrey B, Donoghue A. | Resuscitation. 2023 Oct;191:109923
DOI:  | Télécharger l'article au format  
Keywords: Assisted ventilation; Cardiopulmonary resuscitation; Pediatrics.

Clinical paper

Introduction : To determine the association between presence of an advanced airway during pediatric cardiopulmonary resuscitation (CPR) and ventilation rates.

Méthode : Prospective observational study, January 2017 to June 2020. Patients ≤18 years receiving CC for ≥2 minutes were enrolled. Ventilation rate and type of airway (advanced airway (AA), either endotracheal tube (ETT) or supraglottic airway (SGA); or natural airway (NA)) were collected from video review and analyzed in 'CPR segments' (periods of CPR by individual providers). Ventilation rate (breaths per minute, bpm) was calculated for each segment; hyperventilation was defined as >12 bpm according to 2015 American Heart Association guidelines. Univariate analysis between airway type was done by χ2 testing. Multivariate regression was used to determine the association between the presence of AA with hyperventilation while controlling for within-patient covariance.

Résultats : 779 CPR segments from 94 CPR event were analyzed. The mean ventilation rate per CPR segment across all events was 22 bpm (±16 bpm)). Mean ventilation rates were higher with AA, either ETT (24 ± 17 bpm) or SGA (34 ± 19 bpm), than with NA (17 ± 14, p < 0.001). Hyperventilation occurred more often with AA in place (ETT: 68%; SGA: 96%; NA: 43%; p < 0.001). The presence of AA was independently associated with hyperventilation (AOR 9.3, 95% CI 4.3-20.1).

Conclusion : During pediatric CPR, hyperventilation occurs more often with an advanced airway in place than during CPR with NA. Future research should focus on respiratory physiology during pediatric CPR to determine optimal ventilation rate(s) during pediatric cardiac arrest.

Conclusion (proposition de traduction) : Au cours de la RCP pédiatrique, l'hyperventilation est plus fréquente en présence d'une gestion spécialisée des voies aériennes qu'en présence d'une voie aérienne spontanée. Les recherches futures devraient se concentrer sur la physiologie respiratoire pendant la RCP pédiatrique afin de déterminer le(s) taux de ventilation optimal(s) pendant l'arrêt cardiaque pédiatrique.

The Journal of Emergency Medicine

Nonconvulsive Status Epilepticus: A Review for Emergency Clinicians.
Long B, Koyfman A. | J Emerg Med. 2023 Oct;65(4):e259-e271
DOI:  | Télécharger l'article au format  
Keywords: NCSE; neurology; nonconvulsive status epilepticus; seizures; status epilepticus.

Clinical Reviews

Introduction : Status epilepticus is associated with significant morbidity and mortality and is divided into convulsive status epilepticus and nonconvulsive status epilepticus (NCSE).

Méthode : This review provides a focused evaluation of NCSE for emergency clinicians.

Discussion : NCSE is a form of status epilepticus presenting with prolonged seizure activity. This disease is underdiagnosed, as it presents with nonspecific signs and symptoms, most commonly change in mental status without overt convulsive motor activity. Causes include epilepsy, cerebral pathology or injury, any systemic insult such as infection, and drugs or toxins. Mortality is primarily related to the underlying condition. Patients most commonly present with altered mental status, but other signs and symptoms include abnormal ocular movements and automatisms such as lip smacking or subtle motor twitches in the face or extremities. The diagnosis is divided into electrographic and electroclinical, and although electroencephalogram (EEG) is recommended for definitive diagnosis, emergency clinicians should consider this disease in patients with prolonged postictal state after a seizure with no improvement in mental status, altered mental status with acute cerebral pathology (e.g., stroke, hypoxic brain injury), and unexplained altered mental status. Assessment includes laboratory evaluation and neuroimaging with EEG. Management includes treating life-threatening conditions, including compromise of the airway, hypoglycemia, hyponatremia, and hypo- or hyperthermia, followed by rapid cessation of the seizure activity with benzodiazepines and other antiseizure medications.

Conclusion : An understanding of the presentation and management of NCSE can assist emergency clinicians in the care of these patients.

Conclusion (proposition de traduction) : La compréhension de la présentation et de la prise en charge de l'état de mal épileptique non convulsif peut aider les cliniciens d'urgence à soigner ces patients.

The New England Journal of Medicine

Extracorporeal Life Support in Infarct-Related Cardiogenic Shock.
Thiele H, Zeymer U, Akin I, Behnes M, Rassaf T, Mahabadi AA, Lehmann R, Eitel I, Graf T, Seidler T, Schuster A, Skurk C, Duerschmied D, Clemmensen P, Hennersdorf M, Fichtlscherer S, Voigt I, Seyfarth M, John S, Ewen S, Linke A, Tigges E, Nordbeck P, Bruch L, Jung C, Franz J, Lauten P, Goslar T, Feistritzer HJ, Pöss J, Kirchhof E, Ouarrak T, Schneider S, Desch S, Freund A; ECLS-SHOCK Investigators. | N Engl J Med. 2023 Oct 5;389(14):1286-1297
Keywords: Aucun


Introduction : Extracorporeal life support (ECLS) is increasingly used in the treatment of infarct-related cardiogenic shock despite a lack of evidence regarding its effect on mortality.

Méthode : In this multicenter trial, patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early ECLS plus usual medical treatment (ECLS group) or usual medical treatment alone (control group). The primary outcome was death from any cause at 30 days. Safety outcomes included bleeding, stroke, and peripheral vascular complications warranting interventional or surgical therapy.

Résultats : A total of 420 patients underwent randomization, and 417 patients were included in final analyses. At 30 days, death from any cause had occurred in 100 of 209 patients (47.8%) in the ECLS group and in 102 of 208 patients (49.0%) in the control group (relative risk, 0.98; 95% confidence interval [CI], 0.80 to 1.19; P = 0.81). The median duration of mechanical ventilation was 7 days (interquartile range, 4 to 12) in the ECLS group and 5 days (interquartile range, 3 to 9) in the control group (median difference, 1 day; 95% CI, 0 to 2). The safety outcome consisting of moderate or severe bleeding occurred in 23.4% of the patients in the ECLS group and in 9.6% of those in the control group (relative risk, 2.44; 95% CI, 1.50 to 3.95); peripheral vascular complications warranting intervention occurred in 11.0% and 3.8%, respectively (relative risk, 2.86; 95% CI, 1.31 to 6.25).

Conclusion : In patients with acute myocardial infarction complicated by cardiogenic shock with planned early revascularization, the risk of death from any cause at the 30-day follow-up was not lower among the patients who received ECLS therapy than among those who received medical therapy alone.

Conclusion (proposition de traduction) : Chez les patients souffrant d'un infarctus aigu du myocarde compliqué par un choc cardiogénique avec une revascularisation précoce planifiée, le risque de décès, quelle qu'en soit la cause, au bout de 30 jours, n'était pas plus faible chez les patients ayant reçu un traitement par ECLS que chez ceux ayant reçu un traitement médical seul.

Mois d'octobre 2023