Bibliographie de Médecine d'Urgence

Mois de janvier 2024


Academic Emergency Medicine

Trends in prehospital cervical collar utilization in trauma patients: Closer, but not there yet.
Muzyka L, Bradford JM, Teixeira PG, DuBose J, Cardenas TCP, Bach M, Ali S, Robert M, Brown CVR. | Acad Emerg Med. 2024 Jan;31(1):36-41
DOI: https://doi.org/10.1111/acem.14822
Keywords: EMS documentation; blunt trauma; cervical collar; cervical spine; prehospital trauma; spinal cord injury.

Original article

Introduction : This study aims to assess the change in cervical spine (C-spine) immobilization frequency in trauma patients over time. We hypothesize that the frequency of unnecessary C-spine immobilization has decreased.

Méthode : A retrospective chart review of adult trauma patients transported to our American College of Surgeons-verified Level I trauma center from January 1, 2014, to December 31, 2021, was performed. Emergency medical services documentation was manually reviewed to record prehospital physiology and the application of a prehospital cervical collar (c-collar). C-spine injuries were defined as cervical vertebral fractures and/or spinal cord injuries. Univariate and year-by-year trend analyses were used to assess changes in C-spine injury and immobilization frequency.

Résultats : Among 2906 patients meeting inclusion criteria, 12% sustained C-spine injuries, while 88% did not. Patients with C-spine injuries were more likely to experience blunt trauma (95% vs. 68%, p < 0.001), were older (46 years vs. 41 years, p < 0.001), and had higher Injury Severity Scores (31 vs. 18, p < 0.001). They also exhibited lower initial systolic blood pressures (108 mm Hg vs. 119 mm Hg, p < 0.001), lower heart rates (92 beats/min vs. 97 beats/min, p < 0.05), and lower Glasgow Coma Scale scores (9 vs. 11, p < 0.001). In blunt trauma, c-collars were applied to 83% of patients with C-spine injuries and 75% without; for penetrating trauma, c-collars were applied to 50% of patients with C-spine injuries and only 8% without. Among penetrating trauma patients with C-spine injury, all patients either arrived quadriplegic or did not require emergent neurosurgical intervention. The proportion of patients receiving a c-collar decreased in both blunt and penetrating traumas from 2014 to 2021 (blunt-82% in 2014 to 68% in 2021; penetrating-24% in 2014 to 6% in 2021).

Conclusion : Unnecessary C-spine stabilization has decreased from 2014 to 2021. However, c-collars are still being applied to patients who do not need them, both in blunt and in penetrating trauma cases, while not being applied to patients who would benefit from them.

Conclusion (proposition de traduction) : La stabilisation inutile du rachis cervical a diminué entre 2014 et 2021. Cependant, les colliers cervicaux sont encore posés à des patients qui n'en ont pas besoin, à la fois dans les cas de traumatismes contondants et pénétrants, alors qu'ils ne sont pas posés à des patients qui devraient en bénéficier.

Prehospital lung ultrasound in acute heart failure: Impact on diagnosis and treatment.
Russell FM, Supples M, Tamhankar O, Liao M, Finnegan P. | Acad Emerg Med. 2024 Jan;31(1):42-48
DOI: https://doi.org/10.1111/acem.14811  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Patients with acute heart failure (AHF) are commonly misdiagnosed and undertreated in the prehospital setting. These delays in diagnosis and treatment have a direct negative impact on patient outcomes. The goal of this study was to determine the diagnostic accuracy of paramedics with and without the use of lung ultrasound (LUS) for the diagnosis of AHF in patients with dyspnea in the prehospital setting. Secondarily, we assessed LUS impact on rate of and time to initiation of HF therapies.

Méthode : This was a prospective interventional study on a consecutive sample of patients transported to the hospital by one emergency medical services agency. Adult patients (>18 years) with a chief complaint of dyspnea were included. LUS was performed by trained paramedics and was defined as positive for AHF if both anterior-superior lung zones had greater than or equal to three B-lines or bilateral B-lines were visualized on a four-view protocol. Paramedic diagnosis was compared to hospital discharge diagnosis which served as the criterion standard.

Résultats : Of the 264 included patients, 94 (35%) had a final diagnosis of AHF. Forty total patients had a LUS performed; 17 of these patients had a final diagnosis of AHF. Sensitivity and specificity for AHF by paramedics were 23% (95% confidence interval [CI] 0.14-0.34) and 97% (95% CI 0.92-0.99) without LUS and 71% (95% CI 0.44-0.88) and 96% (95% CI 0.76-0.99) with the use of LUS. In the 94 patients with AHF, 14% (11/77) received HF therapy prehospital without the use of LUS and 53% (9/17) with the use of LUS. LUS improved frequency of treatment by 39%. Median time to treatment was 21 min with LUS and 169 min without.

Conclusion : LUS improved paramedic sensitivity and accuracy for diagnosing AHF in the prehospital setting. LUS use led to higher rates of prehospital HF therapy initiation and significantly decreased time to treatment.

Conclusion (proposition de traduction) : L'échographie pulmonaire a amélioré la sensibilité et la précision du diagnostic de l'insuffisance cardiaque aiguë en milieu préhospitalier. L'utilisation de l'échographie pulmonaire a permis d'augmenter les taux d'initiation du traitement de l'insuffisance cardiaque en préhospitalier et de réduire de manière significative le délai de traitement.

Oral analgesic for musculoskeletal injuries in children: A systematic review and network meta-analysis.
Utsumi S, Amagasa S, Moriwaki T, Uematsu S. | Acad Emerg Med. 2024 Jan;31(1):61-70
DOI: https://doi.org/10.1111/acem.14803
Keywords: analgesia; musculoskeletal; pain; pediatrics.

SYSTEMATIC REVIEWS

Introduction : Pain in pediatric musculoskeletal (MSK) injuries can lead to increased anxiety, fear, and avoidance of medical care, making analgesic management critical. Therefore, we evaluated analgesic efficacy and adverse effects to select the optimal analgesic agent in pediatric patients with MSK injuries.

Méthode : Four databases were searched from inception to March 2023 for peer-reviewed, open randomized controlled trials (RCTs). Inclusion criteria were: (1) trials with RCT design, (2) children aged 1 month-18 years with MSK injury, (3) outpatient setting, (4) interventions and control, (5) primary outcome of pain score at 60 and 120 min and secondary outcome of adverse effects, and (6) full-text and peer-reviewed articles. Two reviewers screened, extracted data, and assessed the risk of bias. A frequentist random-effects network meta-analysis (NMA) was performed. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation working group approach.

Résultats : We included eight trials comprising 1645 children. Ibuprofen was significantly associated with pain reduction at 120 min, compared with acetaminophen (SMD 0.31 [95% CI 0.11-0.51]; moderate certainty) and opioids (SMD 0.34 [95% CI 0.20-0.48]; moderate certainty). Compared with opioids alone, ibuprofen-opioid combination was significantly associated with pain reduction at 120 min (SMD 0.19 [95% CI 0.03-0.35]). No significant differences were found in pain interventions at 60 min. Ibuprofen had statistically fewer adverse events than opioids (RR, 0.54 [95% CI 0.33-0.90]; moderate certainty) and ibuprofen with opioids (RR 0.47 [95% CI 0.25-0.89]; moderate certainty). In terms of limitations, the eight RCTs included had relatively small sample sizes; only two were high-quality RCTs.

Conclusion : Our NMA found ibuprofen to be the most effective and least adverse analgesic in pediatric patients with MSK injuries.

Conclusion (proposition de traduction) : Notre méta-analyse en réseau a montré que l'ibuprofène était l'analgésique le plus efficace et le moins nocif chez les enfants souffrant de lésions musculo-squelettiques.

American Journal of Respiratory and Critical Care Medicine

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline.
Qadir N, Sahetya S, Munshi L, Summers C, Abrams D, Beitler J, Bellani G, Brower RG, Burry L, Chen JT, Hodgson C, Hough CL, Lamontagne F, Law A, Papazian L, Pham T, Rubin E, Siuba M, Telias I, Patolia S, Chaudhuri D, Walkey A, Rochwerg B, Fan E. | Am J Respir Crit Care Med. 2024 Jan 1;209(1):24-36
DOI: https://doi.org/10.1164/rccm.202311-2011st  | Télécharger l'article au format  
Keywords: acute respiratory distress syndrome; corticosteroids; extracorporeal membrane oxygenation; neuromuscular blockade; positive end-expiratory pressure.

American Thoracic Society Documents

Introduction : This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP).

Méthode : We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations.

Résultats : We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty).

Conclusion : We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

Conclusion (proposition de traduction) : Nous présentons des recommandations actualisées, fondées sur des données probantes, pour la prise en charge du syndrome de détresse respiratoire aiguë (SDRA). Les caractéristiques individuelles des patients et de la maladie doivent être prises en compte dans la prise de décision clinique et la mise en œuvre de ces recommandations pendant que des preuves supplémentaires sont générées à partir d'essais cliniques indispensables.

Anaesthesia and Intensive Care

Airway management of lingual tonsillar hypertrophy: A narrative review.
Wong P, Sleigh JW. | Anaesth Intensive Care. 2024 Jan;52(1):16-27
DOI: https://doi.org/10.1177/0310057x231196910
Keywords: Airway obstruction; complications; intubation; laryngoscopy; lingual tonsillar hypertrophy.

Review Article

Editorial : Lingual tonsillar hypertrophy is rarely identified on routine airway assessment but may cause difficulties in airway management. We conducted a narrative review of case reports of lingual tonsillar hypertrophy to examine associated patient factors, success rates of airway management techniques and complications. We searched the literature for anaesthetic management of cases with lingual tonsillar hypertrophy. We found 89 patients in various case reports, from which we derived 92 cases to analyse. 64% of cases were assessed as having a normal airway. Difficult and impossible face mask ventilation occurred in 29.6% and 1.4% of cases, respectively. Difficult intubation and failed intubation occurred in 89.1% and 21.7% of cases, respectively. Multiple attempts (up to six) at intubation were performed, with no successful intubation after the third attempt with direct laryngoscopy. Some 16.5% of patients were woken up and 4.3% required emergency front of neck access. Complications included oesophageal intubation (10.9%), bleeding (9.8%) and severe hypoxia (3.2%). Our findings show that severe cases of lingual hypertrophy may cause an unanticipated difficult airway and serious complications, including hypoxic brain damage and death. A robust airway strategy is required which includes limiting the number of attempts at laryngoscopy, and early priming and performance of emergency front of neck access if required. In patients with known severe lingual tonsillar hypertrophy, awake intubation should be considered.

Conclusion : The findings of this review indicate that LTH is rarely identified on routine airway assessment. Severe cases may lead to unanticipated difficult airways and associated morbidity and even mortality. Rescue techniques after failed intubation may fail due to their exacerbation of the space occupying effect of LTH. A robust airway strategy for managing patients with severe LTH includes consideration of awake tracheal intubation, which has a high success rate. The efficient use of upper airway resources is required including limiting the number of laryngoscopic attempts (more than three attempts at direct laryngoscopy may be futile and harmful), considering the use of straight blade laryngoscopy if experienced, and being mindful that rescue supraglottic airway ventilation may be difficult or fail in up to 30% of severe LTH cases. Finally, plan for success but ‘prepare for failure’ which may require early priming and implementation of eFONA.

Conclusion (proposition de traduction) : Les résultats de cette étude indiquent que l'hypertrophie de l'amygdale linguale est rarement identifiée lors d'une évaluation de routine des voies respiratoires. Les cas graves peuvent conduire à des difficultés imprévues d'accès aux voies aériennes et à la morbidité, voire à la mortalité, qui y est associée. Les techniques de sauvetage après une intubation ratée peuvent échouer en raison de l'exacerbation de l'effet d'occupation de l'espace de l'hypertrophie amygdalienne linguale. Une stratégie robuste de gestion des voies aériennes pour les patients atteints d'hypertrophie amygdalienne linguale sévère inclut l'intubation trachéale éveillée, qui a un taux de réussite élevé. L'utilisation efficace des ressources des voies aériennes supérieures est nécessaire, notamment en limitant le nombre de tentatives de laryngoscopie (plus de trois tentatives de laryngoscopie directe peuvent être futiles et nuisibles), en envisageant l'utilisation d'une laryngoscopie à lame droite en cas d'expérience, et en gardant à l'esprit que la ventilation de secours des voies aériennes supraglottiques peut être difficile ou échouer dans jusqu'à 30 % des cas d'hypertrophie amygdalienne linguale sévère. Enfin, il faut prévoir le succès mais se préparer à l'échec, qui peut nécessiter un amorçage précoce et la mise en œuvre d'un accès d'urgence par l'avant du cou (crycoïdotomie).

Commentaire : Il existe quatre types d’amygdales situées dans l’oropharynx et le nasopharynx, qui sont des parties de la gorge qu’on retrouve derrière la bouche (oro-) ou dans la cavité nasale (naso-).
Amygdale pharyngée (également appelée adénoïde), unique, située sur le toit du nasopharynx (la partie supérieure du pharynx). Amygdales tubaires, au nombre de 2, situées à l'ouverture de la trompe d’Eustache (tube qui relie le nasopharynx à l’oreille moyenne).
Amygdales palatines, au nombre de 2, situées aux côtés droit et gauche à l’arrière de la gorge, mais plus précisément entre les arcades palatoglosse et palatopharyngée.
Amygdale linguale, au nombre de 1, située à la partie la plus en arrière de la langue, plus précisément derrière le sulcus terminal de la langue. Tiré de : https://www.studiodentaire.com/fr/glossaire/amygdale.php

Naso-endoscopie flexible d'un patient présentant une hypertrophie amygdalienne linguale occupant la base de la langue. E : épiglotte ; LTH : hypertrophie amygdalienne linguale.

Annals of Emergency Medicine

Safety and Pain Reduction in Emergency Practitioner Ultrasound-Guided Nerve Blocks: A One-Year Retrospective Study.
Merz-Herrala J, Leu N, Anderson E, Lambeck A, Jefferson J, Sobrero M, Mantuani D, Mudda G, Nagdev A. | Ann Emerg Med. 2024 Jan;83(1):14-21
DOI: https://doi.org/10.1016/j.annemergmed.2023.08.482
Keywords: Aucun

Pain Management and Sedation

Introduction : Emergency practitioners use ultrasound-guided nerve blocks to alleviate pain. This study represents the largest registry of single-injection ultrasound-guided nerve blocks performed in an emergency department (ED) to date. We wished to assess the safety and pain score reductions associated with ED-performed ultrasound-guided nerve blocks. The main outcomes of interest were ultrasound-guided nerve block complication rates and change in patient-reported pain (0 to 10 on the VAS) pre and post ultrasound-guided nerve blocks. Other variables of interest were ultrasound-guided nerve block types and indications during the study period.

Méthode : This is a retrospective analysis of 420 emergency practitioner-performed ultrasound-guided nerve blocks through chart review over 1 year in the Highland ED. Four emergency physician abstractors reviewed all templated ultrasound-guided nerve block notes and nursing records over the study period. Inter-rater reliability was assessed using 10 randomly selected charts with 100% agreement for 70 key variables (Kappa=1, P<.001).

Résultats : Seventy-five unique emergency practitioners performed 420 ultrasound-guided nerve blocks. Ultrasound-guided nerve blocks were most often performed by emergency residents (61.9%), advanced practice practitioners (21.2%), ultrasound fellowship-trained faculty (8.3%), interns (3.6%), nonultrasound fellowship-trained faculty (3.3%), and not recorded (1.7%). One complication occurred during the study (arterial puncture recognized through syringe aspiration without further sequelae). Among the 261 ultrasound-guided nerve blocks with preblock and postblock pain scores, there was an improvement in postblock pain scores. The mean pain scores decreased from 7.4 to 2.8 after an ultrasound-guided nerve block (difference 4.6, 95% confidence interval 3.9 to 5.2).

Conclusion : This 1-year retrospective study supports that emergency practitioner-performed ultrasound-guided nerve blocks have a low complication rate and are associated with reduced pain.

Conclusion (proposition de traduction) : Cette étude rétrospective sur un an confirme que les blocs nerveux effectués par les praticiens des urgences sous guidage échographique présentent un faible taux de complications et sont associés à une réduction de la douleur.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023.
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Severe Agitation, Thiessen MEW, Godwin SA, Hatten BW, Whittle JA, Haukoos JS, Diercks DB; Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee); Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, V. | Ann Emerg Med. 2024 Jan;83(1):e1-e30
DOI: https://doi.org/10.1016/j.annemergmed.2023.09.010
Keywords: Aucun

Editorial : This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult out-of-hospital or emergency department patients presenting with severe agitation. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical question: Is there a superior parenteral medication or combination of medications for the acute management of adult out-of-hospital or emergency department patients with severe agitation? Evidence was graded, and recommendations were made based on the strength of the available data.

Conclusion : For patients with acute agitation in the ED, a combination of droperidol and midazolam is preferred given the improved time to sedation and side effect profile. If a single agent must be given, droperidol is preferred. If droperidol is not available, use an atypical antipsychotic. In cases where safety calls for the use of ketamine, it must be done in a setting where staff can institute immediate hemodynamic monitoring and advanced airway management when needed.
With respect to special populations, we were unable to make specific recommendations for sedating agents in older patients (more than the age of 65 years) because there was a lack of studies that looked specifically at this patient population. Out-of-hospital studies were included in our literature search; however, none of these studies were determined to be methodologically adequate to inform a specific recommendation, regardless of the agent(s) studied.

Conclusion (proposition de traduction) : Pour les patients présentant une agitation aiguë aux urgences, une combinaison de dropéridol et de midazolam est préférable en raison de l'amélioration du délai de sédation et du profil d'effets secondaires. Si un seul agent doit être administré, le dropéridol est préférable. Si le dropéridol n'est pas disponible, il convient d'utiliser un antipsychotique atypique. Dans les cas où la sécurité exige l'utilisation de la kétamine, celle-ci doit être administrée dans un environnement où le personnel peut mettre en place une surveillance hémodynamique immédiate et une gestion avancée des voies respiratoires en cas de besoin.
En ce qui concerne les populations particulières, nous n'avons pas été en mesure de formuler des recommandations spécifiques pour les agents sédatifs chez les patients âgés (plus de 65 ans) en raison du manque d'études portant spécifiquement sur cette population de patients. Des études extrahospitalières ont été incluses dans notre recherche documentaire ; cependant, aucune de ces études n'a été jugée méthodologiquement adéquate pour formuler une recommandation spécifique, quel que soit l'agent ou les agents étudiés.

Archives of Academic Emergency Medicine

A Clinical Score for Predicting Successful Weaning from Noninvasive Positive Pressure Ventilation in Emergency Department; a Retrospective Cohort Study.
Kattinanon N, Phontabtim M, Damdin S, Jermsiri K. | Arch Acad Emerg Med. 2024;12(1):e15-
DOI: https://doi.org/10.22037/aaem.v12i1.2173  | Télécharger l'article au format  
Keywords: Intermittent positive-pressure ventilation; Noninvasive ventilation; Ventilator weaning; Respiratory insuffi-ciency; Emergency service, hospital

Original/Research Article

Introduction : Noninvasive positive pressure ventilation (NIPPV ) is recognized as an efficient treatment for patientswith acute respiratory failure (ARF) in emergency department (ED). This study aimed to develop a scoring system forpredicting successful weaning from NIPPV in patients with ARF.

Méthode : In this retrospective cohort study patientswith ARF who received NIPPV in the ED of Ramathibodi Hospital, Thailand, between January 2020 and March 2022 wereevaluated. Factors associated with weaning from NIPPV were recorded and compared between cases with and withoutsuccessful weaning from NIPPV. Multivariable logistic regression analysis was used to develop a predictive model forweaning from NIPPV in ED.

Résultats : A total of 494 eligible patients were treated with NIPPV of whom 203(41.1%) weresuccessfully weaned during the study period. Based on the multivariate analysis the successful NIPPV weaning (SNOW )score was designed with six factors before discontinuation: respiratory rate, heart rate≤100 bpm, systolic blood pressure≥100 mmHg, arterial pH≥7.35, arterial PaCO2, and arterial lactate. The scores were classified into three groups: low,moderate, and high. A score of >14.5 points suggested a high probability of successful weaning from NIPPV with apositive likelihood ratio of 3.58 (95%CI: 2.56-4.99; p < 0.001). The area under the receiver operating characteristic (ROC)curve of the model in predicting successful weaning was 0.79 (95% confidence interval (CI): 0.75-0.83).

Conclusion : It seems that the SNOW score could be considered as a helpful tool for predicting successful weaning from NIPPV inED patients with ARF. A high predictive score, particularly one that exceeds 14.5, strongly suggests a high likelihood ofsuccessful weaning from NIPPV.

Conclusion (proposition de traduction) : Il semble que le score SNOW puisse être considéré comme un outil utile pour prédire la réussite du sevrage de la VNI chez les patients du service des urgences souffrant d'une insuffisance respiratoire aigüe. Un score prédictif élevé, en particulier un score supérieur à 14,5, suggère fortement une forte probabilité de réussite du sevrage de la VNI.

MONTH Score in Predicting Difficult Intubations in Emergency Department; a Prognostic Accuracy Study.
Hongthong N, Savatmongkorngul S, Yuksen C, Laksanamapune T. | Arch Acad Emerg Med. 2024;12(1):e17-
DOI: https://doi.org/10.22037/aaem.v12i1.2178  | Télécharger l'article au format  
Keywords: Laryngoscopy; Intubation; Emergency service, hospital; Validation study; Clinical decision rules

Original/Research Article

Introduction : MONTH Difficult Laryngoscopy Score was developed for effectively identifying difficult intubations inthe emergency department (ED). This study aimed to evaluate the accuracy of MONTH Score in predicting difficultintubations in ED.

Méthode : We prospectively collected data on all patients undergoing intubation in the ED of Ra-mathibodi Hospital, Bangkok, Thailand. The screening performance characteristics of the MONTH score in identifyingthe difficult intubation in ED were analyzed. All data were analyzed using STATA software version 18.0.

Résultats : 24intubated patients with the median age of 73 (63-82) years were studied (63.58% male). The proportion of difficult in-tubations was 19.44%. The sensitivity and specificity of MONTH in predicting difficult intubations were 74.6% (95% CI:61.6%-85.0%) and 92.8% (95% CI: 89.0%-95.6%), respectively. These measures in subgroup of patients with IntubationDifficulty Scale (IDS) score≥6 were 44.1% (95%CI: 31.2-57.6) and 98.5% (95% CI: 96.2%- 99.6%), respectively. The areaunder the receiver operation characteristic (ROC) curve of MONTH in predicting difficult intubations was 0.895 (95% CI:0.856- 0.926).

Conclusion : It seems that the MONTH Difficult Laryngoscopy Score could be considered as a tool withhigh specificity and positive predictive values in identifying cases with difficult intubations in ED.

Conclusion (proposition de traduction) : Il semble que le score MONTH de laryngoscopie difficile puisse être considéré comme un outil à haute spécificité et valeur prédictive positive pour identifier les cas d'intubation difficile aux urgences.

BMC Emergency Medicine

Prehospital ultrasound scanning for abdominal free fluid detection in trauma patients: a systematic review and meta-analysis.
Lin KT, Lin ZY, Huang CC, Yu SY, Huang JL, Lin JH, Lin YR. | BMC Emerg Med. 2024 Jan 7;24(1):7
DOI: https://doi.org/10.1186/s12873-023-00919-2  | Télécharger l'article au format  
Keywords: FAST; Prehospital; Trauma; Ultrasound.

Research

Introduction : Focused assessment with sonography for trauma helps detect abdominal free fluid. Prehospital ultrasound scanning is also important because the early diagnosis of hemoperitoneum may reduce the time to definitive treatment in the hospital. This study investigated whether prehospital ultrasound scanning can help detect abdominal free fluid.

Méthode : In this systematic review, relevant databases were searched for studies investigating prehospital ultrasound examinations for abdominal free fluid in trauma patients. The prehospital ultrasound results were compared with computed tomography, surgery, or hospital ultrasound examination data. The pooled sensitivity and specificity values were analyzed using forest plots. The overall predictive power was calculated by the summary receiver operating characteristic curve. The quality of the included studies was assessed using the quality assessment of diagnostic accuracy studies tool. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was performed to assess the certainty of evidence.

Résultats : This meta-analysis comprised six studies that included 1356 patients. The pooled sensitivity and specificity values were 0.596 (95% confidence interval [CI] = 0.345-0.822) and 0.970 (95% CI = 0.953-0.983), respectively. The pooled area under the summary receiver operating characteristic curve was 0.998. The quality assessment tool showed favorable results. In the GRADE analysis, the quality of evidence was very low for sensitivity and high for specificity when prehospital ultrasound was used for hemoperitoneum diagnosis.

Conclusion : The specificity of abdominal free fluid detection using prehospital ultrasound examinations in trauma patients was very high.

Conclusion (proposition de traduction) : La spécificité de la détection d'un épanchement abdominal à l'aide d'examens échographiques préhospitaliers chez les patients traumatisés était très élevée.

Commentaire : Lire sur le sujet, dans les traumatismes du bassin :
Schwed AC, Wagenaar A, Reppert AE, Gore A V., Pieracci FM, Platnick KB, et al. Trust the FAST: Confirmation that the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures. J Trauma Acute Care Surg. 2021;90(1):137–42  .

Comparing the efficacy of intravenous morphine versus ibuprofen or the combination of ibuprofen and acetaminophen in patients with closed limb fractures: a randomized clinical trial.
Nasr Isfahani M, Etesami H, Ahmadi O, Masoumi B. | BMC Emerg Med. 2024 Jan 25;24(1):15
DOI: https://doi.org/10.1186/s12873-024-00933-y  | Télécharger l'article au format  
Keywords: Acetaminophen; Fracture; Ibuprofen; Limb; Morphine; Pain.

Research

Introduction : This study aims to investigate the effectiveness of intravenous ibuprofen or intravenous ibuprofen plus acetaminophen compared to intravenous morphine in patients with closed extremity fractures.

Méthode : A triple-blinded randomized clinical trial was conducted at a tertiary trauma center in Iran. Adult patients between 15 and 60 years old with closed, isolated limb fractures and a pain intensity of at least 6/10 on the visual analog scale (VAS) were eligible. Patients with specific conditions or contraindications were not included. Participants were randomly assigned to receive intravenous ibuprofen, intravenous ibuprofen plus acetaminophen, or intravenous morphine. Pain scores were assessed using the visual analog scale at baseline and 5, 15, 30, and 60 min after drug administration. The primary outcome measure was the pain score reduction after one hour.

Résultats : Out of 388 trauma patients screened, 158 were included in the analysis. There were no significant differences in age or sex distribution among the three groups. The pain scores decreased significantly in all groups after 5 min, with the morphine group showing the lowest pain score at 15 min. The maximum effect of ibuprofen was observed after 30 min, while the ibuprofen-acetaminophen combination maintained its effect after 60 min. One hour after injection, pain score reduction in the ibuprofen-acetaminophen group was significantly more than in the other two groups, and pain score reduction in the ibuprofen group was significantly more than in the morphine group.

Conclusion : The study findings suggest that ibuprofen and its combination with acetaminophen have similar or better analgesic effects compared to morphine in patients with closed extremity fractures. Although morphine initially provided the greatest pain relief, its effect diminished over time. In contrast, ibuprofen and the ibuprofen-acetaminophen combination maintained their analgesic effects for a longer duration. The combination therapy demonstrated the most sustained pain reduction. The study highlights the potential of non-opioid analgesics in fracture pain management and emphasizes the importance of initiation of these medications as first line analgesic for patients with fractures. These findings support the growing trend of exploring non-opioid analgesics in pain management.

Conclusion (proposition de traduction) : Les résultats de l'étude suggèrent que l'ibuprofène et son association avec le paracétamol ont des effets analgésiques similaires ou supérieurs à ceux de la morphine chez les patients souffrant de fractures des membres fermés. Bien que la morphine ait initialement procuré le plus grand soulagement de la douleur, son effet a diminué avec le temps. En revanche, l'ibuprofène et l'association ibuprofène-paracétamol ont conservé leurs effets analgésiques plus longtemps. La bithérapie a démontré la réduction de la douleur la plus prolongée. L'étude met en évidence le potentiel des analgésiques non opioïdes dans la gestion de la douleur liée aux fractures et souligne l'importance de l'initiation de ces médicaments en tant qu'analgésiques de première intention pour les patients souffrant de fractures. Ces résultats confirment la tendance croissante à étudier les analgésiques non opioïdes dans la gestion de la douleur.

Commentaire : Consulter l'éditorial à propos de cet article :
Dahaba AA, Nannan Panday RS. Editorial: Optimizing opioid prescriptions in the emergency department. BMC Emerg Med. 2023 Sep 19;23(1):106   .

Burns & Trauma

Consensus on the treatment of second-degree burn wounds.
Ji S, Xiao S, Xia Z; Chinese Burn Association Tissue Repair of Burns and Trauma Committee, Cross-Straits Medicine Exchange Association of China. | Burns Trauma. 2024 Jan 30;12:tkad061
DOI: https://doi.org/10.1093/burnst/tkad061  | Télécharger l'article au format  
Keywords: Burns; Consensus; Debridement; First aid; Infection; Operative; Surgical procedures; Wound management.

Guideline

Editorial : Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.

Conclusion : Second-degree burn wounds are the most common type of burn in clinical practice and the most difficult to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age, and burn area. Standardized treatment can effectively prevent deepening of the wound in second-degree burn wounds while improving the quality of wound healing. However, there are no unified standards or specifications for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds, which seriously affects the development of clinical treatment programs. Based on evidence-based medicine and expert recommendations, this consensus gives recommendations for the treatment of second-degree burn wounds, aimed at forming a set of highly operable clinical practice guidelines for second-degree burn wounds. This consensus clarified and standardized the terminology related to second-degree burn wounds, including for the first time further dividing deep second-degree burn wounds into shallow deep second-degree and profound deep second- degree burn wounds, which provided a decision-making basis for standardizing the relevant diagnosis, classification, and treatment of second-degree burn wounds. However, given the current insufficient evidence from large-scale randomized controlled trials, many of the recommendations in this con- sensus are preliminary and still need to be supported by further evidence. In addition, considering the cultural traditions, economic levels, and patients’ educational backgrounds and religious beliefs in different geographic regions, clinical staff may adapt the recommendations in this consensus in light of local medical resources and health conditions.

Conclusion (proposition de traduction) : Les brûlures du deuxième degré sont le type de brûlure le plus courant dans la pratique clinique et le plus difficile à gérer. Leur traitement nécessite non seulement de prendre en compte les différents résultats qui peuvent découler des changements de pansements ou des traitements chirurgicaux eux-mêmes, mais aussi d'évaluer des facteurs tels que le site de la brûlure, l'âge du patient et la surface de la brûlure. Un traitement standardisé peut prévenir efficacement l'aggravation de la plaie dans le cas des brûlures du deuxième degré tout en améliorant la qualité de la cicatrisation. Cependant, il n'existe pas de normes ou de spécifications unifiées pour le diagnostic, la classification, la procédure chirurgicale, le diagnostic de l'infection et le classement des brûlures du deuxième degré, ce qui compromet gravement le développement des programmes de traitement clinique. Sur la base de la médecine factuelle et des recommandations d'experts, ce consensus propose des recommandations pour le traitement des brûlures du deuxième degré, dans le but de former un ensemble de directives de pratique clinique hautement opérationnelles pour les brûlures du deuxième degré. Ce consensus a clarifié et normalisé la terminologie relative aux brûlures au deuxième degré, y compris pour la première fois en divisant les brûlures du deuxième degré profond en brûlures du deuxième degré profond peu profondes et profondes, ce qui a fourni une base décisionnelle pour normaliser le diagnostic, la classification et le traitement des brûlures au deuxième degré. Cependant, compte tenu de l'insuffisance actuelle des preuves issues d'essais contrôlés randomisés à grande échelle, de nombreuses recommandations de ce consensus sont préliminaires et doivent encore être étayées par des preuves supplémentaires. En outre, compte tenu des traditions culturelles, des niveaux économiques, du niveau d'éducation et des croyances religieuses des patients dans différentes régions géographiques, le personnel clinique peut adapter les recommandations de ce consensus à la lumière des ressources médicales et des conditions sanitaires locales.

Canadian Journal of Emergency Medicine

POCUS literature primer: key papers on POCUS in cardiac arrest and shock.
Kim DJ, Atkinson P, Sheppard G, Chenkin J, Thavanathan R, Lewis D, Bell CR, Jelic T, Lalande E, Buchanan IM, Heslop CL, Burwash-Brennan T, Myslik F, Olszynski P. | CJEM. 2024 Jan;26(1):15-22
DOI: https://doi.org/10.1007/s43678-023-00611-1
Keywords: Aucun

Original Research

Introduction : The objective of this study is to identify the top five most influential papers published on the use of point-of-care ultrasound (POCUS) in cardiac arrest and the top five most influential papers on the use of POCUS in shock in adult patients.

Méthode : An expert panel of 14 members was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the panel are ultrasound fellowship trained or equivalent, are engaged in POCUS research, and are leaders in POCUS locally and nationally in Canada. A modified Delphi process was used, consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for the use of POCUS in cardiac arrest and shock.

Résultats : The panel identified 39 relevant papers on POCUS in cardiac arrest and 42 relevant papers on POCUS in shock. All panel members participated in all three rounds of the modified Delphi process, and we ultimately identified the top five most influential papers on POCUS in cardiac arrest and also on POCUS in shock. Studies include descriptions and analysis of safe POCUS protocols that add value from a diagnostic and prognostic perspective in both populations during resuscitation.

Conclusion : We have developed a reading list of the top five influential papers on the use of POCUS in cardiac arrest and shock to better inform residents, fellows, clinicians, and researchers on integrating and studying POCUS in a more evidence-based manner.

Conclusion (proposition de traduction) : Nous avons dressé une liste de lecture des cinq principaux articles influents sur l’utilisation du POCUS en cas d’arrêt cardiaque et de choc afin de mieux informer les résidents, les boursiers, les cliniciens et les chercheurs sur l’intégration et l’étude du POCUS d’une manière plus factuelle.

Commentaire : Fait partie d'une collection : L'échographie au point d'intervention (PoCUS) en médecine d'urgence  

Nitrous oxide use in Canadian pediatric emergency departments: a survey of physician's knowledge, attitudes, and practices.
Jain R, Hudson S, Osmond MH, Trottier ED, Poonai N, Ali S; Pediatric Emergency Research Canada. | CJEM. 2024 Jan;26(1):47-56
DOI: https://doi.org/10.1007/s43678-023-00602-2
Keywords: Anxiolysis; Emergency department; Nitrous oxide; Pain; Pediatric; Survey.

Original Research

Introduction : Nitrous oxide (N2O) is an inhaled analgesic/ anxiolytic gas with evidence supporting its safety and efficacy for distressing procedures in children. Despite this, its use is not consistent across Canadian pediatric emergency departments (EDs). We aimed to characterize a) physicians' knowledge and practices with N2O and b) site-specific N2O protocols in Canadian pediatric EDs to help optimize its use nationally.

Méthode : This cross-sectional survey was distributed to physician members of Pediatric Emergency Research Canada (PERC) in early 2021. Survey items addressed practice patterns, clinician comfort, and perceived barriers/ facilitators to use. Further, a representative from each ED completed a site-specific inventory of N2O policies and procedures.

Résultats : N2O was available in 40.0% of 15 pediatric EDs, with 83.3% of these sites having written policies in place. Of 230 distributed surveys, 67.8% were completed with mean (SD) attending experience of 14.7 (8.6) years and 70.1% having pediatric emergency subspecialty training. Of the 156 respondents, 48.7% used N2O in their clinical practice. The most common indications for use were digit fracture/ dislocation reduction (69.7%), wound closure (60.5%), and incision & drainage (59.2%). Commonly perceived facilitators were N2O equipment availability (73.0% of 156) and previous clinical experience (71.7% of 156). Of the 51.3% of physicians who reported not using N2O, 93.7% did not have availability at their site; importantly, the majority indicated a desire to acquire access. They identified concerns about ventilation/ scavenging systems (71.2% of 80) and unfamiliarity with equipment (52.5% of 80) as the most common barriers to use.

Conclusion : Despite evidence to support its use, only half of Canadian pediatric ED physicians surveyed use N2O in their clinical practice for treating procedure-related pain and distress. Increased availability of N2O equipment, protocols, and training may improve clinicians' abilities to better manage pediatric acute pain and distress in the ED.

Conclusion (proposition de traduction) : Malgré les données probantes à l'appui de son utilisation, seulement la moitié des médecins canadiens des urgences pédiatriques interrogés utilisent le N2O dans leur pratique clinique pour traiter la douleur et la détresse liées à l'intervention. Une plus grande disponibilité de l'équipement N2O, des protocoles et de la formation peut améliorer les capacités des cliniciens à mieux gérer la douleur aiguë et la détresse pédiatrique aux urgences.

Circulation

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. | Circulation. 2024 Jan 2;149(1):e1-e156
DOI: https://doi.org/10.1161/cir.0000000000001193
Keywords: AHA Scientific Statements; acute coronary syndrome; alcohol; anticoagulants; anticoagulation agents; antiplatelet agents; apixaban; atrial fibrillation; atrial flutter; cardioversion; catheter ablation; coronary artery disease; coronary heart disease; dabigatran; edoxaban; exercise; heart failure; hypertension; idarucizumab; left atrial appendage occlusion; myocardial infarction; obesity; percutaneous coronary intervention; pulmonary vein isolation; risk factors; rivaroxaban; sleep apnea; stents; stroke; surgical ablation; thromboembolism; warfarin.

Introduction : The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

Méthode : A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

Conclusion : Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Conclusion (proposition de traduction) : La fibrillation atriale est l'arythmie commune la plus répandue, et son incidence et sa prévalence augmentent aux États-Unis et dans le monde. Les recommandations des "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" et des "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" ont été mises à jour à l'aide de nouvelles données probantes pour guider les cliniciens. En outre, de nouvelles recommandations portant sur la fibrillation atriale et l'évaluation du risque thromboembolique, l'anticoagulation, fermeture de l'appendice auriculaire gauche, l'ablation chirurgicale ou par cathéter de la fibrillation atriale, ainsi que la modification des facteurs de risque et la prévention de la fibrillation atriale ont été élaborées.

Critical Care

Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial.
Obling LER, Beske RP, Meyer MAS, Grand J, Wiberg S, Mohr T, Damm-Hejmdal A, Forman JL, Frikke-Schmidt R, Folke F, Møller JE, Kjaergaard J, Hassager C. | Crit Care. 2024 Jan 22;28(1):28
DOI: https://doi.org/10.1186/s13054-024-04808-3  | Télécharger l'article au format  
Keywords: Hemodynamics; Inflammation; Intensive cardiovascular care; Out-of-hospital cardiac arrest; Post-cardiac arrest syndrome; Prehospital intervention; Vasopressor.

RESEARCH

Introduction : Following resuscitated out-of-hospital cardiac arrest (OHCA), inflammatory markers are significantly elevated and associated with hemodynamic instability and organ dysfunction. Vasopressor support is recommended to maintain a mean arterial pressure (MAP) above 65 mmHg. Glucocorticoids have anti-inflammatory effects and may lower the need for vasopressors. This study aimed to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients.

Méthode : The STEROHCA trial was a randomized, placebo-controlled, phase 2 trial comparing one prehospital injection of methylprednisolone 250 mg with placebo immediately after resuscitated OHCA. In this sub-study, we included patients who remained comatose at admission and survived until intensive care unit (ICU) admission. The primary outcome was cumulated norepinephrine use from ICU admission until 48 h reported as mcg/kg/min. Secondary outcomes included hemodynamic status characterized by MAP, heart rate, vasoactive-inotropic score (VIS), and the VIS/MAP-ratio as well as cardiac function assessed by pulmonary artery catheter measurements. Linear mixed-model analyses were performed to evaluate mean differences between treatment groups at all follow-up times.

Résultats : A total of 114 comatose OHCA patients were included (glucocorticoid: n = 56, placebo: n = 58) in the sub-study. There were no differences in outcomes at ICU admission. From the time of ICU admission up to 48 h post-admission, patients in the glucocorticoid group cumulated a lower norepinephrine use (mean difference - 0.04 mcg/kg/min, 95% CI - 0.07 to - 0.01, p = 0.02). Moreover, after 12-24 h post-admission, the glucocorticoid group demonstrated a higher MAP with mean differences ranging from 6 to 7 mmHg (95% CIs from 1 to 12), a lower VIS (mean differences from - 4.2 to - 3.8, 95% CIs from - 8.1 to 0.3), and a lower VIS/MAP ratio (mean differences from - 0.10 to - 0.07, 95% CIs from - 0.16 to - 0.01), while there were no major differences in heart rate (mean differences from - 4 to - 3, 95% CIs from - 11 to 3). These treatment differences between groups were also present 30-48 h post-admission but to a smaller extent and with increased statistical uncertainty. No differences were found in pulmonary artery catheter measurements between groups.

Conclusion : Prehospital treatment with high-dose glucocorticoid was associated with reduced norepinephrine use in resuscitated OHCA patients.

Conclusion (proposition de traduction) : Le traitement préhospitalier par une forte dose de glucocorticoïdes a été associé à une réduction de la consommation de norépinéphrine chez les patients réanimés à la suite d'un arrêt cardiaque extrahospitalier.

Commentaire : La methylprednisolone (Solumédrol) était administré à la posologie de 250 mg IVD.

Critical Care Medicine

The Predictive Validity of the Berlin Definition of Acute Respiratory Distress Syndrome for Patients With COVID-19-Related Respiratory Failure Treated With High-Flow Nasal Oxygen: A Multicenter, Prospective Cohort Study.
Busico M, Fuentes NA, Gallardo A, Vitali A, Quintana J, Olmos M, Burns KEA, Esperatti M; Argentine Collaborative Group on High Flow and Prone Positioning. | Crit Care Med. 2024 Jan 1;52(1):92-101
DOI: https://doi.org/10.1097/ccm.0000000000006056
Keywords: Aucun

CLINICAL INVESTIGATION

Introduction : The Berlin definition of acute respiratory distress syndrome (ARDS) was constructed for patients receiving invasive mechanical ventilation (IMV) with consideration given to issues related to reliability, feasibility, and validity. Notwithstanding, patients with acute respiratory failure (ARF) may be treated with high-flow nasal oxygen (HFNO) and may not fall within the scope of the original definition. We aimed to evaluate the predictive validity of the Berlin definition in HFNO-treated patients with COVID-19-related respiratory failure who otherwise met ARDS criteria.
Design: Multicenter, prospective cohort study.
Setting: Five ICUs of five centers in Argentina from March 2020 to September 2021.

Méthode : We consecutively included HFNO-treated patients older than 18 years with confirmed COVID-19-related ARF, a Pao2/Fio2 of less than 300 mm Hg, bilateral infiltrates on imaging, and worsening respiratory symptoms for less than 1 week.

Résultats : We evaluated the predictive validity of mortality at day 28 using the area under the receiver operating characteristics curve (AUC), compared the predictive validity across subgroups, and characterized relevant clinical outcomes. We screened 1,231 patients and included 696 ARDS patients [30 (4%) mild, 380 (55%) moderate, and 286 (41%) severe]. For the study cohort, the AUC for mortality at day 28 was 0.606 (95% CI, 0.561-0.651) with the AUC for subgroups being similar to that of the overall cohort. Two hundred fifty-six patients (37%) received IMV. By day 28, 142 patients (21%) had died, of whom 81 (57%) had severe ARDS. Mortality occurred primarily in patients who were transitioned to IMV.

Conclusion : The predictive validity of the Berlin ARDS definition was similar for HFNO-treated patients as compared with the original population of invasively ventilated patients. Our findings support the extension of the Berlin definition to HFNO-treated patients with ARDS.

Conclusion (proposition de traduction) : La validité prédictive de la définition de Berlin du SDRA était similaire pour les patients traités par HFNO par rapport à la population originale de patients sous ventilation invasive. Nos résultats plaident en faveur de l'extension de la définition de Berlin aux patients présentant un SDRA traités par HFNO.

Emergency Care Journal

Beyond the GCS: an integrative review of new tools for neurological assessment in the intensive care unit for adult patients.
Alessia Xhaferri, Nicola Ramacciati, Gian Domenico Giusti. | Emerg Care J. 2024;20(1):1-22
DOI: https://doi.org/10.4081/ecj.2024.12121  | Télécharger l'article au format  
Keywords: Glasgow Coma Scale, FOUR scale, automated pupillometry, impaired consciousness, neurological assessment

REVIEWS

Editorial : The Glasgow Coma Scale (GCS) is a widely used clinical tool for assessing impaired consciousness, but concerns arise when applied to intubated patients or those receiving analgesics, sedatives, and paralytics because verbal scores are not evaluable. Furthermore, the GCS does not differentiate the neurological status of the patient once intubated, resulting in poor reliability in neurological assessment, and clinical indicators that may reflect the severity of the coma are not included in the GCS. This study explores alternative tools for neurological assessment in Intensive Care Units (ICUs) when GCS is impractical. Conducting an integrative review of studies from 2018 to 2022, we identified seven relevant papers. Results indicate the FOUR score as a promising GCS alternative, particularly in cases where the GCS is unavailable. Automated pupillometry also demonstrated the potential for monitoring neurologically impaired ICU patients. These tools, independent of verbal responses and applicable to sedated patients, offer improved accuracy in assessing consciousness. The study emphasizes the importance of adopting such alternatives, and addressing GCS limitations, and highlights the need for further research and implementation to enhance patient care in ICU settings.

Conclusion : The purpose of this integrativereview is to describetools capable of making complete assessments of the neurological status of patients admitted to intensive care units and that are better predictors of mortality and morbidity in head injury. Two primary evaluation tools are proposed and analyzed: FOUR scoreand automated pupillometry, capable of exceeding the limits of GCS for a more calibrated and complete assessment of the neurological state and consciousness of the patient in the ICU. The FOUR scoreis not higher than GCS but the combination of visual and motor components is essential for an even more complete neurological assessment. The FOUR score can be used in multiple intensive settings, is easy to teach, learn,and administer,and also provides essential information for accurate assessment of patients with impaired states of consciousness. In contrast to GCS, where abnormal reflexes of the brain stem are not included among the clinical indicators evaluated, FOUR also includes pupillary and corneal reflex evaluation. The score showed a prognostic value comparable to that provided by GCS but offers indisputable advantages: it can be used in intubated patients, candistinguish vegetative states from minimally responsive states,and detect the "locked-in syndrome"

Conclusion (proposition de traduction) : L'objectif de cette revue intégrée est de décrire des outils capables de réaliser des évaluations complètes de l'état neurologique des patients admis dans les unités de soins intensifs et qui sont de meilleurs prédicteurs de la mortalité et de la morbidité en cas de traumatisme crânien. Deux outils d'évaluation primaires sont proposés et analysés : Le score FOUR et la pupillométrie automatisée, capables de dépasser les limites du GCS pour une évaluation plus calibrée et complète de l'état neurologique et de la conscience du patient dans l'unité de soins intensifs. Le score FOUR n'est pas plus élevé que le GCS mais la combinaison des composantes visuelles et motrices est essentielle pour une évaluation neurologique encore plus complète. Le score FOUR peut être utilisé dans de nombreux environnements intensifs, il est facile à enseigner, à apprendre et à réaliser, et il fournit également des informations essentielles pour une évaluation précise des patients présentant des états de conscience altérés. Contrairement au GCS, où les réflexes anormaux du tronc cérébral ne font pas partie des indicateurs cliniques évalués, le FOUR comprend également l'évaluation des réflexes pupillaires et cornéens. Le score a montré une valeur pronostique comparable à celle fournie par le GCS mais offre des avantages indiscutables : il peut être utilisé chez les patients intubés, distinguer les états végétatifs des états de réponse minimale, et détecter le "locked-in syndrome"

Commentaire :  Ce score, variant entre 0 (coma profond, voire état de mort encéphalique) à 16 (le meilleur), permet la mesure de la réponse oculaire, de la réponse motrice, des réflexes pupillaires, cornéens et de toux, ainsi que de la respiration des patients.

Emergency Medicine International

Point-of-Care Cardiac Ultrasound Training Programme: Experience from the University Hospital Hradec Králové.
Grenar P, Nový J, Mědílek K, Jakl M. | Emerg Med Int. 2024 Jan 6;2024:9974284
DOI: https://doi.org/10.1155/2024/9974284  | Télécharger l'article au format  
Keywords: Aucun

Review Article

Editorial : Point-of-care ultrasound examinations performed by physicians of different specialties are a rapidly growing phenomenon, which has led to a worldwide effort to create a standardised approach to ultrasound examination training. The implementation of emergency echocardiography by noncardiologists is mainly aimed at the standardisation of the procedure, a structured training system, and an agreement on competencies. This article summarises the current training programmes for nonechocardiographers at the University Hospital in Hradec Králové. In cooperation with cardiologists specialised in cardiac ultrasound (ECHO), an extended acute echo protocol dedicated to emergency department physicians was developed and validated in daily practice. According to our retrospective evaluation, after one year of clinical practice, we can confirm that point-of-care ultrasound examinations performed using the standardised limited echo protocol are safe and accurate. The observed concordance with comprehensive ECHO was 78%.

Conclusion : Our experience confrms that the concept of sonography training enables physicians of diferent specialties to perform standardised ultrasound examinations that, according to our retrospective evaluation, are accurate and reproducible and meet the requirements for safe use according to the ABCD approach. However, high accuracy alone does not justify the cost of a training programme, and there is currently little to no evidence of the clinical beneft of POCUS echocardiography by noncardiologists. To overcome this lack of evidence in patients with chest pain, the prospective, randomised ENDEMIC trial (NCT05306730) was initiated. Publication of the study results is anticipated in mid-2024. Abbreviations

Conclusion (proposition de traduction) : Notre expérience confirme que le concept de formation à l'échographie permet aux médecins de différentes spécialités de réaliser des examens échographiques standardisés qui, selon notre évaluation rétrospective, sont précis et reproductibles et répondent aux exigences d'une utilisation sûre selon l'approche ABCD. Cependant, une grande précision ne justifie pas à elle seule le coût d'un programme de formation, et il n'existe actuellement que peu ou pas de preuves des avantages cliniques de l'échocardiographie au point d'intervention pour les non-cardiologues. Pour pallier ce manque de preuves chez les patients souffrant de douleurs thoraciques, l'étude prospective et randomisée ENDEMIC (NCT05306730) a été lancée. La publication des résultats de l'étude est prévue pour la mi-2024.

Emergency Medicine Journal

A clinical decision rule to rule out bloodstream infection in the emergency department: retrospective multicentric observational cohort study.
Pehlivan J, Douillet D, Jérémie R, Perraud C, Niset A, Eveillard M, Chenouard R, Mahieu R. | Emerg Med J. 2024;41(1):20-26
DOI: https://doi.org/10.1136/emermed-2022-212987
Keywords: clinical medicine; diagnostic tests; emergency department; infections.

Original research

Introduction : We aimed to identify patients at low risk of bloodstream infection (BSI) in the ED.

Méthode : We derived and validated a prediction model to rule out BSI in the ED without the need for laboratory testing by determining variables associated with a positive blood culture (BC) and assigned points according to regression coefficients. This retrospective study included adult patients suspected of having BSI (defined by at least one BC collection) from two European ED between 1 January 2017 and 31 December 2019. The primary end point was the BSI rate in the validation cohort for patients with a negative Bacteremia Rule Out Criteria (BAROC) score. The effect of adding laboratory variables to the model was evaluated as a second step in a two-step diagnostic strategy.

Résultats : We analysed 2580 patients with a mean age of 64 years±21, of whom 46.1% were women. The derived BAROC score comprises 12 categorical clinical variables. In the validation cohort, it safely ruled out BSI without BCs in 9% (58/648) of patients with a sensitivity of 100% (95% CI 95% to 100%), a specificity of 10% (95% CI 8% to 13%) and a negative predictive value of 100% (95% CI 94% to 100%). Adding laboratory variables (creatinine ≥177 µmol/L (2.0 mg/dL), platelet count ≤150 000/mm3 and neutrophil count ≥12 000/mm3) to the model, ruled out BSI in 10.2% (58/570) of remaining patients who had been positive on the BAROC score. The BAROC score with laboratory results had a sensitivity of 100% (95% CI 94% to 100%), specificity of 11% (95% CI 9% to 14%) and negative predictive value of 100% (95% CI 94 to 100%). In the validation cohort, there was no evidence of a difference in discrimination between the area under the receiver operating characteristic for BAROC score with versus without laboratory testing (p=0.6).

Conclusion : The BAROC score safely identified patients at low risk of BSI and may reduce BC collection in the ED without the need for laboratory testing.

Conclusion (proposition de traduction) : Le score Bacteremia Rule Out Criteria (BAROC) a permis d'identifier en toute sécurité les patients à faible risque de bactériémie et peut réduire la collecte de sang dans le service des urgences sans qu'il soit nécessaire de procéder à des tests de laboratoire.

Commentaire : Le modèle final incluait :
l'âge de 65 ans ou plus, le sexe féminin, la BPCO, la cirrhose du foie, l'immunodéficience, le diabète, les frissons, la tension systolique ≤110 mm Hg, la température ≤36°C ou >38,5°C, les vomissements et la suspicion d'endocardite.

Le risque de bactériémie pour chaque patient a été facilement estimé à l'aide d'une application pour smartphone et ordinateur disponible sur :
BAROC (Bacteremia rule out criteria)  
Permettant de suggérer si une hémoculture doit être pratiquée ou non, selon le résultat.

Injury

Comparison of age-adjusted shock indices as predictors of injury severity in paediatric trauma patients immediately after emergency department triage: A report from the Korean multicentre registry.
Choi D, Park JW, Kwak YH, Kim DK, Jung JY, Lee JH, Jung JH, Suh D, Lee HN, Lee EJ, Kim JH. | Injury. 2024 Jan;55(1):111108
DOI: https://doi.org/10.1016/j.injury.2023.111108
Keywords: Child; Korea; Paediatric emergency medicine; Shock; Triage; Wounds and injuries.

RESEARCH ARTICLE

Introduction : Shock index paediatric-adjusted (SIPA) was presented for early prediction of mortality and trauma team activation in paediatric trauma patients. However, the derived cut-offs of normal vital signs were based on old references. We established alternative SIPAs based on the other commonly used references and compared their predictive values.

Méthode : We performed a retrospective review of all paediatric trauma patients aged 1-15 years in the Emergency Department (ED)-based Injury In-depth Surveillance (EDIIS) database from January 1, 2011 to December 31, 2019. A total of 4 types of SIPA values were obtained based on the references as follows: uSIPA based on the Nelson textbook of paediatrics 21st ed., SIATLS based on the ATLS 10th guideline, SIPALS based on the PALS 2020 guideline, and SIPA. In each SIPA group, the cut-off was established by dividing the group into 4 subgroups: toddler (age 1-3), preschooler (age 4-6), schooler (age 7-12), and teenager (age 13-15). We performed an ROC analysis and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to compare the predicted values of each SIPA in mortality, ICU admission, and emergent surgery or intervention.

Résultats : A total of 332,271 patients were included. The proportion of patients with an elevated shock index was 14.9 % (n = 49,347) in SIPA, 22.8 % (n = 75,850) in uSIPA, 0.3 % (n = 1058) in SIATLS, and 4.3 % (n = 14,168) in SIPALS. For mortality, uSIPA achieved the highest sensitivity (57.0 %; 95 % confidence interval 56.9 %-57.2 %) compared to SIPA (49.4 %, 95 % CI 49.2 %-49.5 %), SIATLS (25.5 %, 95 % CI 25.4 %-25.7 %), and SIPALS (43.8 %, 95 % CI 43.7 %-44.0 %), but there were no significant differences in the negative predictive value (NPV) or area under the curve (AUC). The positive predictive value (PPV) was highest in SIATLS (5.7 %, 95 % CI 5.6 %-5.8 %) compared to SIPA (0.2 %, 95 % CI 0.2 %-0.3 %), uSIPA (0.2 %, 95 % CI 0.2 %-0.2 %), and SIPALS (0.7 %, 95 % CI 0.7 %-0.8 %). The same findings were presented in ICU admission and emergent operation or intervention.

Conclusion : The ATLS-based shock index achieved the highest PPV and specificity compared to SIPA, uSIPA, and SIPALS for adverse outcomes in paediatric trauma.

Conclusion (proposition de traduction) : L'indice de choc basé sur l'ATLS a atteint la VPP et la spécificité les plus élevées par rapport au SIPA, à l'uSIPA et au SIPALS en ce qui concerne les conséquences négatives des traumatismes pédiatriques.

Vital signs among emergency department trauma patients in the setting of alcohol or drug use.
Marco CA, Sandelich S, Nelson E, Hu E, Locke D, Boehmer S. | Injury. 2024 Jan;55(1):111024
DOI: https://doi.org/10.1016/j.injury.2023.111024
Keywords: Alcohol; Drugs; Trauma; Vital signs.

RESEARCH ARTICLE

Introduction : The incidence of alcohol use among trauma patients has been estimated at 19-55%. This study was undertaken to identify any relationship between vital signs and alcohol and drug use among Emergency Department (ED) patients with trauma.

Méthode : In this retrospective case control study, eligible subjects included trauma patients ages 18 and over, with trauma and drug or alcohol use, between 2018 and 2022. The control group was comprised of trauma patients ages 18 and over, with trauma and no drug or alcohol use, who were matched by Injury Severity Score (ISS). Vital signs on ED arrival were compared among patients with and without alcohol use, and with and without recreational drug use.

Résultats : Among 16,159 eligible trauma subjects, 5,323 had tests available for drugs and alcohol of whom 2,750 had complete ISS and vital signs data. 684 subjects were identified with alcohol intoxication, 707 subjects were identified with recreational drug use. Patients with alcohol use had lower mean systolic blood pressure (Mean=133, SD=26.7), compared to patients without alcohol use (Mean=143, SD=29.4) (p < 0.001). Patients with alcohol use had higher mean heart rate (Mean=93, SD=19.9) compared to patients without alcohol use (Mean=91, SD=19.7) (p = 0.01). Patients with recreational drug use had lower mean systolic blood pressure (Mean=137, SD=28.5) compared to patients without drug use (Mean=143, SD=29.6) (p < 0.001). Patients with drug use had higher mean heart rate (Mean=94, SD=22.8), compared to patients without drug use (Mean=91, SD=20.0) (p = 0.002). Cannabinoids were associated with lower SBP (Case Mean=136 (25.4) vs. Control Mean=141 (31.0), p = 0.009). Opioids were associated with lower SBP (Case Mean=138 (28.0) vs. Control Mean=145 (29.4), p = 0.01). Benzodiazepines were associated with increased HR and decreased SBP and RR.

Conclusion : There appear to be no clinically relevant differences in vital signs among trauma patients with drug use and/or alcohol use, compared to patients without drug or alcohol use. Abnormal vital signs should not be prematurely attributed solely to acute substance intoxication before fully evaluating for associated traumatic injuries.

Conclusion (proposition de traduction) : Il ne semble pas y avoir de différences cliniquement pertinentes entre les signes vitaux des patients traumatisés ayant consommé de la drogue et/ou de l'alcool et ceux des patients n'ayant pas consommé de drogue ou d'alcool. Les signes vitaux anormaux ne doivent pas être prématurément attribués uniquement à une intoxication aiguë par une substance avant d'avoir procédé à une évaluation complète des lésions traumatiques associées.

Impact of accidental hypothermia in trauma patients: A retrospective cohort study.
Azarkane M, Rijnhout TWH, van Merwijk IAL, Tromp TN, Tan ECTH. | Injury. 2024 Jan;55(1):110973
DOI: https://doi.org/10.1016/j.injury.2023.110973  | Télécharger l'article au format  
Keywords: Accidental hypothermia; Injury; Intensive care unit; Mortality; Polytrauma; Transfusion.

RESEARCH ARTICLE

Introduction : Trauma patients with hypothermia have substantial increases in mortality and morbidity. In severely injured patients, hypothermia is common with a rate up to 50% in various geographic areas. This study aims to elucidate the incidence, predictors, and impact of hypothermia on outcomes in severely injured patients.

Méthode : This was a retrospective cohort study which included trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted to a level 1 trauma center in the Netherlands between January 1, 2015 and December 31, 2021. Primary outcome was incidence of hypothermia on arrival at the emergency department. Factors associated with hypothermia were identified. Secondary outcomes were transfusion requirement, mortality, and intensive care unit (ICU) admission. Logistic regression analysis was used to identify associations.

Résultats : A total of 2032 severely injured patients were included of which 257 (12.6%) were hypothermic on hospital arrival. Predictors for hypothermia on hospital arrival included higher ISS, prehospital intubation, cervical spine immobilization, winter months, systolic blood pressure (SBP) < 90 mmHg and Glasgow Coma Scale (GCS) ≤ 8. Hypothermia was independently associated with transfusion requirement (OR, 2.68; 95% CI, 1.94 - 3.73; p < 0.001), mortality (OR, 2.12; 95% CI, 1.40 - 3.19; p < 0.001) and more often ICU admission (OR, 1.81; 95% CI, 1.10 - 2.97, p = 0.019).

Conclusion : In this study, hypothermia was present in 12.6% of severely injured patients. Hypothermia was associated with increased transfusion requirement, mortality, and ICU admission. Identified predictors for hypothermia included the severity of injury, intubation, and immobilization, as well as winter season, SBP < 90 mmHg, and GCS ≤ 8.

Conclusion (proposition de traduction) : Dans cette étude, l'hypothermie était retrouvée chez 12,6 % des patients gravement blessés. L'hypothermie était associée à une augmentation des besoins en transfusion, de la mortalité et de l'admission aux soins intensifs. Les facteurs prédictifs identifiés de l'hypothermie étaient la sévérité des blessures, l'intubation et l'immobilisation, ainsi que la saison hivernale, une tension artérielle basse < 90 mmHg et un Glasgow ≤ 8.

Admission S100B fails as neuro-marker but is a good predictor for intrahospital mortality in major trauma patients.
Essl D, Schöchl H, Oberladstätter D, Lockie C, Islam M, Slezak C, Voelckel WG. | Injury. 2024 Jan;55(1):111187
DOI: https://doi.org/10.1016/j.injury.2023.111187
Keywords: Biomarker; Major trauma; Outcome; S100B; Traumatic brain injury.

Research article

Introduction : S100 B is an extensively studied neuro-trauma marker, but its specificity and subsequently interpretation in major trauma patients might be limited, since extracerebral injuries are known to increase serum levels. Thus, we evaluated the potential role of S100B in the assessment of severe traumatic brain injury (TBI) in multiple injured patients upon emergency room (ER) admission and the first days of intensive care unit (ICU) stay.

Méthode : Retrospective study employing trauma registry data derived from a level 1 trauma center. Four cohorts of patients were grouped: isolated TBI (iTBI), polytrauma patients with TBI (PT + TBI), polytrauma patients without TBI (PT-TBI) and patients without polytrauma or TBI (control). S100B-serum levels were assessed immediately after admission in the emergency room and during the subsequent ICU stay. Values were correlated with injury severity score (ISS), Glasgow Coma Score (GCS) and in-hospital mortality.

Résultats : 780 predominantly male patients (76 %) with a median age of 48 (30-63) and a median ISS of 24 (17-30) were enrolled in the study. Admission S100B correlated with ISS and TBI severity defined by the GCS (both p < 0.0001) but not with head abbreviated injury score (AIS) (p = 0.38). Compared with survivors, non-survivors had significantly higher median S100B levels in the ER (6.14 μg/L vs. 2.06 μg/L; p < 0.0001) and at ICU-day 1 (0.69 μg/L vs. 0.17 μg/L; p < 0.0001). S100B in the ER predicted mortality with an area under curve (AUC) of 0.77 (95 % CI 0,70-0,83, p < 0.0001), vs. 0.86 at ICU-day 1 (95 % CI 0,80-0,91, p < 0.0001).

Conclusion : In conclusion, S100B is a valid biomarker for prediction of mortality in major trauma patients with a higher accuracy when assessed at the first day of ICU stay vs. immediately after ER admission. Since S100B did not correlate with pathologic TBI findings in multiple injured patients, it failed as predictive neuro-marker because extracerebral injuries demonstrated a higher influence on admission levels than neurotrauma. Although S100B levels are indicative for injury severity they should be interpreted with caution in polytrauma patients.

Conclusion (proposition de traduction) : En conclusion, la S100B est un biomarqueur valide pour la prédiction de la mortalité chez les patients ayant subi un traumatisme majeur, avec une plus grande précision lorsqu'elle est évaluée au premier jour du séjour en USI par rapport à l'évaluation immédiatement après l'admission aux urgences. La S100B n'étant pas en corrélation avec les résultats pathologiques des traumatismes crâniens chez les patients souffrant de lésions multiples, elle n'a pas réussi à être un neuro-marqueur prédictif car les lésions extracérébrales ont eu une plus grande influence sur les niveaux d'admission que les traumatismes crâniens. Bien que les taux de S100B soient indicatifs de la gravité des lésions, ils doivent être interprétés avec prudence chez les patients polytraumatisés.

Intensive Care Medicine

Status epilepticus in the ICU.
Rossetti AO, Claassen J, Gaspard N. | Intensive Care Med. 2024 Jan;50(1):1-16
DOI: https://doi.org/10.1007/s00134-023-07263-w
Keywords: Mortality; Outcome; Second-line; Status epilepticus; Treatment.

Review

Editorial : Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.

Conclusion : Status epilepticus is a potentially dangerous condition; mortality ranges from 10 to 15% in the short term, and additional long-term effects such as development of epilepsy, cognitive decline, and long-term mortality have been reported. Status epilepticus needs to be managed urgently, with initial therapy including rapid administration of a benzodiazepine and one among (fos-)phenytoin, levetiracetam, or valproate. Refractory generalized convulsive status epilepticus, including subtle post-convulsive status epilepticus, is managed with continuous infusions of propofol or midazolam and barbiturates, or other non-pharmacologic treatments; in case of focal status epilepticus without major consciousness impairment, general anesthetics may be differed. More important than the choice of treatment is the adherence to existing guidelines. EEG is required for the detection of nonconvulsive seizures and crucial in the management of patients with refractory status epilepticus, as these seizures are almost exclusively nonconvulsive. Addressing the underlying cause of status epilepticus is crucial, particularly for patients with treatable conditions such as autoimmune encephalitis. Given the several current knowledge gaps, future studies should focus especially on refractory status epilepticus and super-refractory status epilepticus patients, for example testing innovative pharmacological compounds including the timing and type of immunomodulatory interventions, addressing optimal EEG targets and weaning strategies (ideally conducted as randomized trials), and exploring early biomarkers and potential biological targets of pharmacological interventions (as cohort studies).

Conclusion (proposition de traduction) : L'état de mal épileptique est un état potentiellement dangereux ; la mortalité varie de 10 à 15 % à court terme, et des effets à long terme supplémentaires tels que le développement de l'épilepsie, le déclin cognitif et la mortalité à long terme ont été rapportés. L'état de mal épileptique doit être pris en charge de toute urgence, le traitement initial comprenant l'administration rapide d'une benzodiazépine et d'un médicament parmi la (fos-)phénytoïne, le lévetiracétam ou le valproate. L'état de mal épileptique convulsif généralisé réfractaire, y compris l'état de mal épileptique infra-clinique post-convulsif, est traité par des perfusions continues de propofol ou de midazolam et de barbituriques, ou par d'autres traitements non pharmacologiques ; en cas d'état de mal épileptique focal sans altération majeure de la conscience, on peut différer les anesthésiques généraux. Plus que le choix du traitement, c'est le respect des directives existantes qui est important. L'EEG est nécessaire pour détecter les crises non convulsives et est crucial pour la prise en charge des patients présentant un état de mal épileptique réfractaire, car ces crises sont presque exclusivement non convulsives. Il est essentiel de s'attaquer à la cause sous-jacente de l'état de mal épileptique, en particulier pour les patients atteints de maladies traitables telles que l'encéphalite auto-immune. Compte tenu de plusieurs lacunes dans les connaissances actuelles, les études futures devraient se concentrer en particulier sur les patients atteints d'état de mal épileptique réfractaire et d'état de mal épileptique super-réfractaire, par exemple en testant des composés pharmacologiques innovants, y compris le moment et le type d'interventions immunomodulatrices, en examinant les cibles EEG optimales et les stratégies de sevrage (idéalement sous forme d'essais randomisés), et en explorant les biomarqueurs précoces et les cibles biologiques potentielles des interventions pharmacologiques (sous forme d'études de cohortes).

Commentaire :  Proposed pharmacologic treatment flow of status epilepticus. BRV brivaracetam, CI contraindicated, CK creatinine phosphokinase, CLZ clonazepam, KET ketamine, IGE idiopathic generalized epilepsy, LZP lorazepam, MDZ midazolam, LAC lactate, LCM lacosamide, LEV levetiracetam, PER perampanel, PGB pregabalin, (f )PHT (fosph-)phenytoin, PRIS propofol infusion syndrome, PRO propofol, PTB pentobarbital, SE status epilepticus; THP thiopental, TPM topiramate, VPA valproate Complications of status epilepticus and management of status epilepticus in the intensive care setting. Complications in the blue boxes are related to SE or prolonged unconsciousness, while complications in the orange boxes are drug related (please refer to Tables 4 and 5 for details). *Propofol infusion syndrome typically presents as severe rhabdomyolysis, acute kidney injury, hyperkalemia, metabolic acidosis, hypertriglyceridemia, and hepatomegaly. **Propylene glycol toxicity includes hyperosmolarity and lactic acidosis, cardiac arrhythmias, hemolysis, renal failure and, ultimately, refractory hypotension and multiple organ failure

International Journal of Emergency Medicine

The diagnostic accuracy of point-of-care ultrasound parameters for airway assessment in patients undergoing intubation in emergency department-an observational study.
Pillai A, Arora P, Kabi A, Chauhan U, Asokan R, Akhil P, Shankar T, Lalneiruol DJ, Baid H, Chawang H. | Int J Emerg Med. 2024 Jan 29;17(1):12
DOI: https://doi.org/10.1186/s12245-024-00585-6  | Télécharger l'article au format  
Keywords: Airway ultrasound; Difficult intubation; Emergency department.

Research

Introduction : Endotracheal intubation is an essential resuscitative procedure in the emergency setting. Airway assessment parameters such as the Mallampati classification are difficult to perform in an emergency setting. As point-of-care ultrasound (POCUS) assessment of airway parameters does not require patients to perform any mandatory action, ultrasound may become the potential first-line noninvasive airway assessment tool in the emergency department (ED). The use of POCUS in the ED has not been sufficiently studied. Using POCUS in airway assessment for predicting difficult intubation may be the next step in successful airway management.

Méthode : The study was an observational study conducted at the ED of the All India Institute of Medical Sciences (Rishikesh). The treating emergency physician recorded the patient history and systemic examination along with an indication for intubation. The POCUS assessment of airway parameters pre-epiglottis to epiglottic vocal cord ratio (Pre-E/E-VC), tongue thickness, hyomental distance, and distance from skin to the hyoid bone was performed by the study investigator. During laryngoscopy, Cormack-Lehane (CL) grading was assessed. The data was entered and analyzed.

Résultats : Seventy patients who required intubation in the ED were enrolled in the study. Among the study population, 48.6%, 28.6%, 14.3%, 1.4%, and 7.1% were classified with the following CL grading: 1, 2a, 2b, 3a, and 3b, respectively. At a cutoff of ≥ 1.86, Pre-E/E-VC predicts difficult laryngoscopy (AUC 0.835) with a sensitivity of 83% and a specificity of 94%. At a cutoff of ≥ 5.98 cm, tongue thickness predicts difficult laryngoscopy (AUC 0.78) with a sensitivity of 83% and a specificity of 88%. At a cutoff of hyomental distance ≤ 6 cm, it predicts difficult laryngoscopy with a sensitivity of 83% and a specificity of 88%. All parameters can act as a promising tool for predicting difficult laryngoscopy, with the single best parameter being Pre-E/E-VC.

Conclusion : Assessment of the airway with POCUS may be helpful to the emergency physician when the clinical airway assessment parameters fail to predict difficult laryngoscopy as most patients requiring intubation are uncooperative. Assessment of the parameters in our study Pre-E/E-VC, tongue thickness, and hyomental distance can act as a promising tool for predicting difficult laryngoscopy in the emergency scenario.

Conclusion (proposition de traduction) : L'évaluation des voies aériennes à l'aide de l'échographie au point d'intervention peut être utile au médecin urgentiste lorsque les paramètres cliniques d'évaluation des voies aériennes ne permettent pas de prédire une laryngoscopie difficile, car la plupart des patients nécessitant une intubation ne sont pas coopératifs. L'évaluation des paramètres de notre étude - le rapport pré-épiglotte/corde vocale épiglottique (Pre-E/E-VC), l'épaisseur de la langue et la distance hyomentale - peut constituer un outil prometteur pour prédire une laryngoscopie difficile dans un scénario d'urgence.

Journal of Burn Care & Research

Comparing the Efficacy of Diluted Lidocaine Solution and Placebo in Reducing Pain Perception During Burn Wound Dressing Change.
Yousefnezhad O, Meskar H, Abdollahi A, Frouzanian M, Pahnabi A, Faghani-Makrani N. | J Burn Care Res. 2024 Jan 5;45(1):200-204
DOI: https://doi.org/10.1093/jbcr/irad167  | Télécharger l'article au format  
Keywords: bandages; burns; lidocaine; wounds and injuries.

ORIGINAL ARTICLE

Introduction : The aim of this study was to evaluate the effectiveness of 0.08% diluted lidocaine solution during and after wound dressing procedures for patients with burn injuries. Fifty burn patients aged 18-60 years, with burns ranging from 30% to 60%, were divided into intervention and control groups.

Méthode : The intervention group received dressings diluted with 0.08% lidocaine solution, while the control group received a placebo. Vital signs were continuously monitored before, during, and after the application of new dressings. Pain was assessed using the Visual Analog Scale (VAS) checklist before and after the dressing change in both groups.

Résultats : The study included 25 participants in the intervention group with a mean age of 40.2 ± 6.5 and 25 participants in the control group with a mean age of 39.1 ± 6.8. The groups were comparable in terms of baseline characteristics, including gender, age, weight, height, body mass index, percentage and degree of burns, as well as average morphine intake. No significant differences were observed in vital signs or pain scores before and after dressing changes between the 2 groups. However, the intervention group reported significantly lower pain scores during the dressing change compared to the control group (P < .001).

Conclusion : Diluted lidocaine solution during wound dressing procedures can reduce pain in burn patients. Further research with larger sample sizes is needed to establish the safety and efficacy of this technique. This study suggests that lidocaine can be a useful tool in the management of pain during dressing changes for burn patients.

Conclusion (proposition de traduction) : La solution de lidocaïne diluée pendant les procédures de pansement peut réduire la douleur chez les patients brûlés. D'autres recherches avec des échantillons plus importants sont nécessaires pour établir la sécurité et l'efficacité de cette technique. Cette étude suggère que la lidocaïne peut être un outil utile dans la gestion de la douleur pendant les changements de pansements chez les patients brûlés.

Journal of Education and Teaching in Emergency Medicine

E-FAST Ultrasound Training Curriculum for Prehospital Emergency Medical Service (EMS) Clinicians.
Nguyen CM, Hartmann K, Goodmurphy C, Flamm A. | J Educ Teach Emerg Med. 2024 Jan 31;9(1):C41-C97
DOI: https://doi.org/10.21980/j8s060  | Télécharger l'article au format  
Keywords: Aucun

CURRICULUM

Introduction : The extended-focused assessment with sonography in trauma (E-FAST) exam can identify intrathoracic and intraabdominal free fluid, as well as pneumothoraces. The E-FAST ultrasound exam has previously been taught to clinicians of various backgrounds in healthcare including emergency medical service (EMS). However, an open-access, systemized curriculum for teaching E-FAST exams to EMS clinicians has not been published.

Méthode : An online 13-question pre-test was administered prior to the study. An online post-test and in-person scanning OSCEs were administered at least eight weeks after their scheduled workshop consisting of an online 13-question multiple-choice post-test, a confidence survey, and a hands-on E-FAST Objectively Structured Clinical Exam (OSCE) session. A non-parametric Wilcoxon signed-rank test was performed between each pre-test and post-test metric to examine the statistical differences of paired data.

Résultats : Post-test scores demonstrated statistically significant improvement in both image interpretation exams and ultrasound self-efficacy from the pre-test. The mean pre-test and post-test scores were 55.46% (7.21 ± 1.99) and 84.23% (10.89 ± 1.59) correct out of 13 questions, respectively (p < 0.0001). Participants surveyed an increase in self-efficacy reflected by a Likert scale for ultrasound usage and image interpretation (p < 0.005). The average post-test OSCE E-FAST exam score was 37.89 ± 2.76 out of 42 points (90.21%).

Discussion : This 4.5-hour hybrid asynchronous model demonstrates an effective curriculum for teaching E-FAST ultrasound to prehospital clinicians.

Conclusion (proposition de traduction) : Ce modèle hybride asynchrone de 4,5 heures propose un programme efficace pour enseigner l'échographie E-FAST aux cliniciens préhospitaliers.

Journal of Emergency Nursing

Triage Accuracy of Emergency Nurses: An Evidence-Based Review.
Suamchaiyaphum K, Jones AR, Markaki A. | J Emerg Nurs. 2024 Jan;50(1):44-54
DOI: https://doi.org/10.1016/j.jen.2023.10.001  | Télécharger l'article au format  
Keywords: Accuracy; Emergency department; Nurses; Triage.

TRI A GE DECISIONS TRIAGE

Introduction : Accurate triage assessment by emergency nurses is essential for prioritizing patient care and providing appropriate treatment. Undertriage and overtriage remain an ongoing issue in care of patients who present to the emergency department. The purpose of this literature review was to examine factors associated with triage accuracy in the emergency department.

Méthode : We conducted an evidence-based literature review using the Cumulative Index to Nursing and Allied Health Literature, PubMed, and Embase. The search focused on peer-reviewed articles in English, available in full text, published between January 2011 and December 2021.

Résultats : A total of 14 articles met inclusion criteria and revealed the following 3 themes for triage accuracy: triage nurse characteristics, patient characteristics, and work environment. Triage nurses' accuracy rates ranged from 59.3% to 82%, with experience in triage associated with higher accuracy. Patient characteristics influenced triage accuracy, with nontrauma patients being undertriaged and trauma patients often overtriaged. The work environment played a role, as accuracy rates varied based on shift time and patient volume. Competing systems between prehospital and ED triage posed challenges and affected accuracy during fluctuations in patient volumes.

Conclusion : This review underscores the complex nature of ED triage accuracy. It highlights the importance of nurse experience, training programs, patient characteristics, and the work environment in enhancing triage decision making. Enhanced understanding of these factors can inform strategies to optimize triage accuracy and improve patient outcomes.

Conclusion (proposition de traduction) : Cette étude souligne la nature complexe de la précision du triage aux urgences. Elle met en évidence l'importance de l'expérience des infirmières, des programmes de formation, des caractéristiques des patients et de l'environnement de travail dans l'amélioration de la prise de décision en matière de triage. Une meilleure compréhension de ces facteurs peut permettre d'élaborer des stratégies visant à optimiser la précision du trie et à améliorer les résultats pour les patients.

Journal of the American College of Cardiology

Clopidogrel vs Aspirin Monotherapy Beyond 1 Year After Percutaneous Coronary Intervention.
Watanabe H, Morimoto T, Natsuaki M, Yamamoto K, Obayashi Y, Nishikawa R, Ando K, Ono K, Kadota K, Suwa S, Morishima I, Yoshida R, Hata Y, Akao M, Yagi M, Suematsu N, Morino Y, Yokomatsu T, Takamisawa I, Noda T, Doi M, Okayama H, Nakamura Y, Hibi K, Sakamoto H, Noguchi T, Kimura T; STOPDAPT-2 Investigators. | J Am Coll Cardiol. 2024 Jan 2;83(1):17-31
DOI: https://doi.org/10.1016/j.jacc.2023.10.013
Keywords: P2Y(12) inhibition; antiplatelet therapy; bleeding; coronary stent; percutaneous coronary intervention.

Research article

Introduction : It remains unclear whether clopidogrel is better suited than aspirin as the long-term antiplatelet monotherapy following dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI).

Méthode : This study compared clopidogrel monotherapy following 1 month of DAPT (clopidogrel group) with aspirin monotherapy following 12 months of DAPT (aspirin group) after PCI for 5 years.
Methods: STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy 2) is a multicenter, open-label, adjudicator-blinded, randomized clinical trial conducted in Japan. Patients who underwent PCI with cobalt-chromium everolimus-eluting stents were randomized in a 1-to-1 fashion either to clopidogrel or aspirin groups. The primary endpoint was a composite of cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke, or definite stent thrombosis) or major bleeding (TIMI major or minor bleeding).

Résultats : Among 3,005 study patients (age: 68.6 ± 10.7 years; women: 22.3%; acute coronary syndrome: 38.3%), 2,934 patients (97.6%) completed the 5-year follow-up (adherence to the study drugs at 395 days: 84.7% and 75.9%). The clopidogrel group compared with the aspirin group was noninferior but not superior for the primary endpoint (11.75% and 13.57%, respectively; HR: 0.85; 95% CI: 0.70-1.05; Pnoninferiority < 0.001; Psuperiority = 0.13), whereas it was superior for the cardiovascular outcomes (8.61% and 11.05%, respectively; HR: 0.77; 95% CI: 0.61-0.97; P = 0.03) and not superior for major bleeding (4.44% and 4.92%, respectively; HR: 0.89; 95% CI: 0.64-1.25; P = 0.51). By the 1-year landmark analysis, clopidogrel was numerically, but not significantly, superior to aspirin for cardiovascular events (6.79% and 8.68%, respectively; HR: 0.77; 95% CI: 0.59-1.01; P = 0.06) without difference in major bleeding (3.99% and 3.32%, respectively; HR: 1.23; 95% CI: 0.84-1.81; P = 0.31).

Conclusion : Clopidogrel might be an attractive alternative to aspirin with a borderline ischemic benefit beyond 1 year after PCI.

Conclusion (proposition de traduction) : Le clopidogrel pourrait être une alternative intéressante à l'aspirine avec un bénéfice ischémique limité au-delà d'un an après une intervention coronarienne percutanée.

Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism.
Kobayashi T, Pugliese S, Sethi SS, Parikh SA, Goldberg J, Alkhafan F, Vitarello C, Rosenfield K, Lookstein R, Keeling B, Klein A, Gibson CM, Glassmoyer L, Khandhar S, Secemsky E, Giri J. | J Am Coll Cardiol. 2024 Jan 2;83(1):35-43
DOI: https://doi.org/10.1016/j.jacc.2023.10.026
Keywords: ECMO; catheter-directed embolectomy; catheter-directed thrombolysis; high-risk pulmonary embolism; pulmonary embolism; systemic thrombolysis.

Research article

Introduction : Contemporary care patterns/outcomes in high-risk pulmonary embolism (PE) patients are unknown.

Méthode : This study sought to characterize the management of high-risk PE patients and identify factors associated with poor outcomes.
Methods: A retrospective analysis of the PERT (Pulmonary Embolism Response Team) Consortium Registry was performed. Patients presenting with intermediate-risk PE, high-risk PE, and catastrophic PE (those with hemodynamic collapse) were identified. Patient characteristics were compared with chi-square testing for categorical covariates and Student's t-test for continuous covariates. Multivariable logistic regression was used to assess associations between clinical characteristics and outcomes in the high-risk population.

Résultats : Of 5,790 registry patients, 2,976 presented with intermediate-risk PE and 1,442 with high-risk PE. High-risk PE patients were more frequently treated with advanced therapies than intermediate-risk PE patients (41.9% vs 30.2%; P < 0.001). In-hospital mortality (20.6% vs 3.7%; P < 0.001) and major bleeding (10.5% vs. 3.5%; P < 0.001) were more common in high-risk PE. Multivariable regression analysis demonstrated vasopressor use (OR: 4.56; 95% CI: 3.27-6.38; P < 0.01), extracorporeal membrane oxygenation use (OR: 2.86; 95% CI: 1.12-7.30; P = 0.03), identified clot-in-transit (OR: 2.26; 95% CI: 1.13-4.52; P = 0.02), and malignancy (OR: = 1.70; 95% CI: 1.13-2.56; P = 0.01) as factors associated with in-hospital mortality. Catastrophic PE patients (n = 197 [13.7% of high-risk PE patients]) had higher in-hospital mortality (42.1% vs 17.2%; P < 0.001) than those presenting with noncatastrophic high-risk PE. Extracorporeal membrane oxygenation (13.3% vs. 4.8% P < 0.001) and systemic thrombolysis (25% vs 11.3%; P < 0.001) were used more commonly in catastrophic PE.

Conclusion : In the largest analysis of high-risk PE patients to date, mortality rates were high with the worst outcomes among patients with hemodynamic collapse.

Conclusion (proposition de traduction) : Dans la plus grande analyse de patients présentant une embolie pulmonaire à haut risque réalisée à ce jour, les taux de mortalité étaient élevés, les pires résultats étant enregistrés chez les patients présentant un collapsus hémodynamique.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Writing Committee Members, Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. | J Am Coll Cardiol. 2024 Jan 2;83(1):109-279
DOI: https://doi.org/10.1016/j.jacc.2023.08.017  | Télécharger l'article au format  
Keywords: Aucun

Practice guideline

Introduction : The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

Méthode : A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

Conclusion : Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Conclusion (proposition de traduction) : La fibrillation auriculaire est l'arythmie commune la plus répandue, et son incidence et sa prévalence augmentent aux États-Unis et dans le monde. Les recommandations des "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" et des "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" ont été mises à jour à l'aide de nouvelles données probantes pour guider les cliniciens. En outre, de nouvelles recommandations portant sur la fibrillation auriculaire et l'évaluation du risque thromboembolique, l'anticoagulation, l'occlusion de l'appendice auriculaire gauche, l'ablation chirurgicale ou par cathéter de la fibrillation auriculaire, la modification des facteurs de risque et la prévention de la fibrillation auriculaire ont été élaborées.

Commentaire : Consulter le document :
Les lignes directrices en bref  .
Retrouver dans ce document, les dix principaux messages à retenir des lignes directrices de l'ACC/AHA/ACCP/HRS sur la fibrillation auriculaire, afin de fournir un cadre pour la diffusion.

Journal of the American Medical Association

Intranasal Naloxone for Opioid Overdose.
Taylor JL, Lasser KE. | JAMA. 2024 Jan 16;331(3):250-251
DOI: https://doi.org/10.1001/jama.2023.23248
Keywords: Aucun

JAMA Insights

Editorial : In 2021, opioid overdose deaths exceeded 80 000 in the US. Naloxone, a competitive opioid receptor antagonist that reverses symptoms of opioid intoxication and overdose by displacing opioids from μ-opioid receptors, is a safe and effective medication for preventing opioid overdose death. Naloxone meets US Food and Drug Administration (FDA) criteria for approval without a prescription: its benefits outweigh risks, it treats a condition that can be identified by people in the com- munity, it has a low potential for misuse, and it can be labeled to fa- cilitate correct administration. In 2015, the FDA approved a 4-mg/0.1 mL intranasal naloxone formulation available by prescription. In March 2023, the FDA ap- proved 4-mg/0.1 mL intranasal naloxone for availability without pre- scription. In July 2023, a generic form of naloxone 4-mg/0.1 mL na- sal spray and a 3-mg/0.1 mL naloxone formulation became available without prescription.

Conclusion : Intranasal naloxone is safe and effective for reversing opioid overdose and is now available without prescription. Physicians and other licensed clinicians should prescribe naloxone to those who may benefit.

Conclusion (proposition de traduction) : La naloxone intranasale est sûre et efficace pour inverser une overdose d'opioïdes et est désormais disponible sans ordonnance. Les médecins et autres cliniciens agréés doivent prescrire la naloxone aux personnes qui peuvent en bénéficier.

Pediatric Critical Care Medicine

Performance of Tools and Measures to Predict Fluid Responsiveness in Pediatric Shock and Critical Illness: A Systematic Review and Meta-Analysis.
Walker SB, Winters JM, Schauer JM, Murphy P, Fawcett A, Sanchez-Pinto LN. | Pediatr Crit Care Med. 2024 Jan 1;25(1):24-36
DOI: https://doi.org/10.1097/pcc.0000000000003320  | Télécharger l'article au format  
Keywords: Aucun

Feature Review Article

Introduction : In this systematic review and meta-analysis we asked: Do predictors of fluid responsiveness in children perform comparably: 1) in the PICU as in non-PICU settings? 2) in shock states compared with nonshock states? Additionally, 3) is there an association between preload responsiveness and clinical response?

Méthode : Ovid Medline, PubMed, and Embase databases were searched from inception through May 2022.
Study selection: Included studies reported physiological response to IV fluid administration in humans less than 18 years. Only studies reporting an area under the receiver operating characteristic curve (AUROC) were included for descriptive analysis. Only studies for which a se could be estimated were included for meta-analysis.
Data extraction: Title, abstract, full text screening, and extraction were completed by two authors (S.B.W., J.M.W.). Variables extracted included predictors ("tools") and outcome measures ("reference tests") of fluid responsiveness, demographic, and clinical variables.

Résultats : We identified 62 articles containing 204 AUROCs for 55 tools, primarily describing mechanically ventilated children in an operating room or PICU. Meta-analysis across all tools showed poor predictive performance (AUROC, 0.66; 95% CI, 0.63-0.69), although individual performance varied greatly (range, 0.49-0.87). After controlling for PICU setting and shock state, PICU setting was associated with decreased predictive performance (coefficient, -0.56; p = 0.0007), while shock state was associated with increased performance (0.54; p = 0.0006). Effect of PICU setting and shock state on each tool was not statistically significant but analysis was limited by sample size. The association between preload responsiveness and clinical response was rarely studied but results did not suggest an association. Ultrasound measurements were prone to inherent test review and incorporation biases.

Conclusion : We suggest three opportunities for further research in fluid responsiveness in children: 1) assessing predictive performance of tools during resuscitation in shock states; 2) separating predictive tool from reference test when using ultrasound techniques; and 3) targeting decreasing time in a shock state, rather than just increase in preload.

Conclusion (proposition de traduction) : Nous suggérons trois possibilités pour poursuivre la recherche de la réponse au remplissage vasculaire chez les enfants : 1) évaluer la performance prédictive des outils pendant la réanimation de l'état de choc ; 2) séparer l'outil prédictif du test de référence lors de l'utilisation des techniques d'échographie ; et 3) cibler la diminution de la durée de l'état de choc, plutôt que la seule augmentation de la précharge.

Pediatric Emergency Care

Does Immobilization of Distal Radius Torus Fractures Affect Treatment Outcome?.
Kazez M, Key S, Agar A. | Pediatr Emerg Care. 2024 Jan 1;40(1):6-9
DOI: https://doi.org/10.1097/pec.0000000000003101
Keywords: Aucun

Original Article

Introduction : The aim of this study is to compare the clinical results of splint, short arm circular plaster, and soft bandage immobilization methods applied in the treatment of wrist torus fractures in a single center.

Méthode : Patients treated for torus fractures at a tertiary trauma hospital between January 2018 and January 2022 were analyzed retrospectively. According to the physician's preference, a splint, short arm circular plaster, or soft bandage was applied to each patient. The treatment modalities, the number of hospital admissions during the treatment, the number of radiological imaging procedures used during the treatment, immobilization time, and the follow-up periods of the patients were checked and noted on the hospital data processing system.

Résultats : Six hundred ten patients were included in the study. It was determined that 351 patients were treated with a short arm splint, 155 with a short arm circular cast, and 104 with soft bandaging. The number of radiological imaging procedures, the number of hospital admissions during the treatment, the duration of the pain complaint, and the complication rate of the patients treated with splint were significantly lower than the groups treated with short arm circular plaster and soft bandage (P < 0.001).

Conclusion : It was observed that patients who were immobilized with a short arm splint required less follow-up time and fewer imaging procedures and hospital admissions and experienced earlier pain relief and lower complication rates. We think that the use of short arm splints in the treatment of torus fractures is sufficient, safe, and advantageous.

Conclusion (proposition de traduction) : Il a été observé que les patients immobilisés avec une attelle de bras courte nécessitaient moins de temps de suivi, moins de procédures d'imagerie et d'admissions à l'hôpital, et qu'ils bénéficiaient d'un soulagement plus rapide de la douleur et d'un taux de complication plus faibles. Nous pensons que l'utilisation d'attelles de bras courtes dans le traitement des fractures en motte de beurre est suffisante, sûre et avantageuse.

Resuscitation

The impact of double sequential shock timing on outcomes during refractory out-of-hospital cardiac arrest.
Rahimi M, Drennan IR, Turner L, Dorian P, Cheskes S. | Resuscitation. 2024 Jan;194:110082
DOI: https://doi.org/10.1016/j.resuscitation.2023.110082  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Defibrillation; Double sequential external defibrillation; Prehospital care; Resuscitation.

Clinical paper

Introduction : Animal studies suggest the efficacy of double sequential external defibrillation (DSED) may depend on the interval between the two shocks, or "DSED interval". No human studies have examined this concept.

Méthode : To determine the relationship between DSED interval and termination of ventricular fibrillation (VFT), return of spontaneous circulation (ROSC), survival to hospital discharge, and favourable neurological status (MRS ≤ 2) for patients in refractory VF. Methods: We performed a retrospective review of adult (≥18 years) out-of-hospital cardiac arrest between January 2015 and May 2022 with refractory VF who received ≥1 DSED shock. DSED interval was divided into four pre-defined categories. We examined the association between DSED interval and patient outcomes using general estimated equation logistic regression or Fisher's exact test.

Résultats : Among 106 included patients, 303 DSED shocks were delivered (median 2, IQR 1-3). DSED intervals of 75-125 ms (OR 0.39, 95% CI 0.16-0.98), 125-500 ms (OR 0.36, 95% CI 0.16-0.82), and >500 ms (OR 0.27, 95% CI 0.11-0.63) were associated with lower probability of VF termination compared to <75 ms interval. DSED interval of >75 ms was associated with lower probability of ROSC compared to <75 ms interval (OR 0.37, 95% CI 0.14-0.98). No association was noted between DSED interval and survival to hospital discharge or neurologic outcome.

Conclusion : Among patients in refractory VF a DSED interval of less than 75 ms was associated with improved rates of VF termination and ROSC. No association was noted between DSED interval and survival to hospital discharge or neurologic outcome.

Conclusion (proposition de traduction) : Chez les patients en FV réfractaire, un intervalle de réalisation de la double défibrillation séquentielle externe inférieur à 75 ms a été associé à de meilleurs taux d'arrêt de la FV et de retour à une circulation spontanée. Aucune association n'a été observée entre l'intervalle de réalisation de la double défibrillation séquentielle et la survie jusqu'à la sortie de l'hôpital ou l'issue neurologique.

Exerted force on the face mask in preterm infants at birth is associated with apnoea and bradycardia.
Kuypers KLAM, Cramer SJE, Dekker J, Visser R, Hooper SB, Te Pas AB. | Resuscitation. 2024 Jan;194:110086
DOI: https://doi.org/10.1016/j.resuscitation.2023.110086  | Télécharger l'article au format  
Keywords: Apnoea; Bradycardia; Face mask; Force; Preterm infants.

Clinical paper

Introduction : During stabilisation of preterm infants at birth, a face mask is used to provide respiratory support. However, application of these masks may activate cutaneous stretch receptors of the trigeminal nerve, causing apnoea and bradycardia. This study investigated the amount of force exerted on the face mask during non-invasive ventilation of preterm infants at birth and whether the amount of exerted force is associated with apnoea and bradycardia.

Méthode : A prospective observational study was performed in preterm infants born <32 weeks of gestation who were stabilised at birth. During the first 10 minutes of respiratory support, we measured breathing and heart rate as well as the amount of force exerted on a face mask using a custom-made pressure sensor placed on top of the face mask.

Résultats : Thirty infants were included (median (IQR) gestational age(GA) 28+3 (27+0-30+0) weeks, birthweight 1104 (878-1275) grams). The median exerted force measured was 297 (198-377) grams, ranging from 0 to 1455 grams. Significantly more force was exerted on the face mask during positive pressure ventilation when compared to CPAP (410 (256-556) vs 286 (190-373) grams, p = 0.009). In a binary logistic regression model, higher forces were associated with an increased risk of apnoea (OR = 1.607 (1.556-1.661), p < 0.001) and bradycardia (OR = 1.140 (1.102-1.180), p < 0.001) during the first 10 minutes of respiratory support at birth.

Conclusion : During mask ventilation, the median exerted force on a face mask was 297 grams with a maximum of 1455 grams. Higher exerted forces were associated apnoea and bradycardia during the first 10 minutes of respiratory support at birth.

Conclusion (proposition de traduction) : Pendant la ventilation au masque, la force médiane exercée sur un masque facial était de 297 grammes avec un maximum de 1455 grammes. Des forces exercées plus élevées étaient associées à l'apnée et à la bradycardie pendant les 10 premières minutes de l'assistance respiratoire à la naissance.

Impact of blood pressure targets on central hemodynamics during intensive care after out-of-hospital cardiac arrest.
Grand J, Møller JE, Hassager C, Schmidt H, Mølstrøm S, Boesgaard S, Meyer MAS, Josiassen J, Højgaard HF, Frydland M, Dahl JS, Obling LER, Bak M, Lind Jørgensen V, Thomsen JH, Wiberg S, Madsen SA, Nyholm B, Kjaergaard J. | Resuscitation. 2024 Jan;194:110094
DOI: https://doi.org/10.1016/j.resuscitation.2023.110094  | Télécharger l'article au format  
Keywords: Cardiac Arrest; Hemodynamic parameters; Post-cardiac arrest syndrome; Vasopressors.

Clinical paper

Introduction : The aim was to investigate the advanced hemodynamic effects of the two MAP-targets during intensive care on systemic hemodynamics in comatose patients after cardiac arrest.

Méthode : Secondary analysis of a randomized controlled trial.
Setting: Primary vasopressor used was per protocol norepinephrine. Hemodynamic monitoring was done with pulmonary artery catheters (PAC) and measurements were made on predefined time points. The primary endpoint of this substudy was the difference in cardiac index within 48 h from a repeated measurements-mixed model. Secondary endpoints included systemic vascular resistance index (SVRI), heart rate, and stroke volume index.
Patients: Comatose survivors after out-of-hospital cardiac arrest.
Interventions: The "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial was a randomized, controlled, double-blinded, multicenter-study comparing targeted mean arterial pressure (MAP) of 63 mmHg (MAP63) vs 77 mmHg (MAP77).

Résultats : Among 789 randomized patients, 730 (93%) patients were included in the hemodynamic substudy. From PAC-insertion (median 1 hours after ICU-admission) and the next 48 hours, the MAP77-group received significantly higher doses of norepinephrine (mean difference 0.09 µg/kg/min, 95% confidence interval (CI) 0.07-0.11, pgroup < 0.0001). Cardiac index was significantly increased (0.20 L/min/m2 (CI 0.12-0.28), pgroup < 0.0001) as was SVRI with an overall difference of (43 dynes m2/s/cm5 (CI 7-79); pgroup = 0.02). Heart rate was increased in the MAP77-group (4 beats/minute; CI 2-6, pgroup < 0.003), but stroke volume index was not (pgroup = 0.10).

Conclusion : Targeted MAP at 77 mmHg compared to 63 mmHg resulted in a higher dose of norepinephrine, increased cardiac index and SVRI. Heart rate was also increased, but stroke volume index was not affected by a higher blood pressure target.

Conclusion (proposition de traduction) : Une PAM ciblée à 77 mmHg par rapport à 63 mmHg a entraîné une dose plus élevée de norépinéphrine, une augmentation de l'index cardiaque et de l'index de résistance vasculaire systémique. La fréquence cardiaque a également augmenté, mais l'indice de volume cérébral n'a pas été affecté par une cible de pression artérielle plus élevée.

Early extracorporeal CPR for refractory out-of-hospital cardiac arrest - A pre-planned per-protocol analysis of the INCEPTION-trial.
Ubben JFH, Suverein MM, Delnoij TSR, Heuts S, Winkens B, Gabrio A, van der Horst ICC, Maessen JG, Lorusso R, van de Poll MCG; INCEPTION-investigators. | Resuscitation. 2024 Jan;194:110033
DOI: https://doi.org/10.1016/j.resuscitation.2023.110033  | Télécharger l'article au format  
Keywords: Extracorporeal membrane oxygenation; Out-of-hospital cardiac arrest; Randomized controlled trial, per-protocol analysis.

Clinical pape

Introduction : Evidence for extracorporeal cardiopulmonary resuscitation (CPR) in refractory out-of-hospital cardiac arrest (OHCA) remains inconclusive. Recently, the INCEPTION-trial, comparing extracorporeal with conventional CPR, found no statistically significant difference in neurologically favorable survival. Since protocol deviations were anticipated, a pre-specified per-protocol analysis was foreseen.

Méthode : The per-protocol analysis of the INCEPTION trial excluded patients not meeting inclusion or exclusion criteria, amongst which time-to-cannulation of >60 minutes, and achieving a return of spontaneous circulation before hospital arrival. Crossovers were excluded as well. The primary outcome (30-day survival in a neurologically favorable condition; cerebral performance category [CPC] 1-2) was primarily analyzed under a frequentist statistical framework. In addition, Bayesian analysis under a minimally informative prior was performed.

Résultats : Eighty-one patients were included in the per-protocol analysis (extracorporeal CPR n = 33, conventional CPR n = 48). Thirty-day survival with CPC1-2 was 15% in the extracorporeal CPR group versus 9% in the conventional CPR group (adjusted OR 1.9; 95% CI 0.4-9.3; p-value 0.393). Bayesian analysis showed an 84% posterior probability of any ECPR benefit and a 61% posterior probability of a 5% absolute risk reduction for the primary outcome.

Conclusion : A pre-planned, pre-specified per-protocol analysis of the INCEPTION-trial, found a higher survival with favorable neurological in patients undergoing ECPR versus CCPR for refractory shockable OHCA. This difference did not reach statistical significance, but results should be interpreted with care, in the light of the small remaining sample size.

Conclusion (proposition de traduction) : Une analyse per-protocole pré-planifiée et pré-spécifiée de l'essai INCEPTION a révélé un taux de survie plus élevé et un état neurologique favorable chez les patients ayant bénéficié d'une réanimation cardio-pulmonaire extracorporelle par rapport à une réanimation cardio-pulmonaire conventionnelle en cas d'arrêt cardiaque extrahospitalier réfractaire avec chocs. Cette différence n'est pas statistiquement significative, mais les résultats doivent être interprétés avec prudence, compte tenu de la petite taille de l'échantillon restant.

Performances and limits of Bag-Valve-Device for pre-oxygenation and manual ventilation: A comparative bench and cadaver study.
Broc A, Morin F, Schmit H, Taillantou-Candau M, Vuillermoz A, Drouet A, Hutin A, Polard L, Lamhaut L, Brisset U, Charbonney E, Delisle S, Beloncle F, Richard JC, Savary D; CAVIAR Cardiac Arrest, Ventilation International Association for Research Group. | Resuscitation. 2024 Jan;194:109999
DOI: https://doi.org/10.1016/j.resuscitation.2023.109999  | Télécharger l'article au format  
Keywords: Bag-Valve-Device; Cardiopulmonary Resuscitation; Manual ventilation; Pre-oxygenation

Experimental paper

Introduction : Bag-Valve-Device (BVD) is the most frequently used device for pre-oxygenation and ventilation during cardiopulmonary resuscitation (CPR). A minimal expired fraction of oxygen (FeO2) above 0.85 is recommended during pre-oxygenation while insufflated volume (VTi) should be reduced during manual ventilation. The objective was to compare the performances of different BVD in simulated conditions.

Méthode : Nine BVD were evaluated during pre-oxygenation: spontaneous breathing patients were simulated on a test lung (mild and severe conditions). FeO2 was measured with and without positive end-expiratory pressure (PEEP). CO2 rebreathing was evaluated. Then, manual ventilation was performed by 36 caregivers (n = 36) from three hospitals on a specific manikin; same procedure was repeated by 3 caregivers (n = 3) on two human cadavers with three of the nine BVD: In non-CPR scenario and during mechanical CPR with Interrupted Chest Compressions strategy (30:2).

Résultats : Pre-oxygenation: FeO2 was lower than 0.85 for three BVD in severe condition and for two BVD in mild condition. FeO2 was higher than 0.85 in eight of nine BVD with an additional PEEP valve (PEEP 5 cmH2O). One BVD induced CO2 rebreathing. Manual ventilation: For non-CPR manual ventilation, mean VTi was within the predefined lung protective range (4-8 mL/kg PBW) for all BVD on the bench. For CPR manual ventilation, mean VTi was above the range for three BVD on the bench. Similar results were observed on cadavers.

Conclusion : Several BVD did not reach the FeO2 required during pre-oxygenation. Manual ventilation was significantly less protective in three BVD. These observations are related to the different BVD working principles.

Conclusion (proposition de traduction) : Plusieurs BAVU n'ont pas atteint le niveau de FeO2 requis pendant la préoxygénation. La ventilation manuelle s'est avérée nettement moins protectrice avec trois BAVU. Ces observations sont liées aux différents principes de fonctionnement des BAVU.

Hemodynamics, survival and neurological function with early versus delayed automated head-up CPR in a porcine model of prolonged cardiac arrest.
Pourzand P, Moore J, Metzger A, Salverda B, Suresh M, Arango S, Rosenhagen H, Kaizer A, Duval S, Debaty G, Lurie K. | Resuscitation. 2024 Jan;194:110067
DOI: https://doi.org/10.1016/j.resuscitation.2023.110067  | Télécharger l'article au format  
Keywords: Active compression-decompression CPR; Cardiac arrest; Cardiopulmonary resuscitation; Epinephrine; Head and thorax elevation; Head-Up CPR; Impedance threshold device.

Introduction : To determine if controlled head and thorax elevation, active compression-decompression cardiopulmonary resuscitation (CPR), and an impedance threshold device combined, termed automated head-up positioning CPR (AHUP-CPR), should be initiated early, as a basic (BLS) intervention, or later, as an advanced (ALS) intervention, in a severe porcine model of cardiac arrest.To determine if controlled head and thorax elevation, active compression-decompression cardiopulmonary resuscitation (CPR), and an impedance threshold device combined, termed automated head-up positioning CPR (AHUP-CPR), should be initiated early, as a basic (BLS) intervention, or later, as an advanced (ALS) intervention, in a severe porcine model of cardiac arrest.

Méthode : Yorkshire pigs (n = 22) weighing ∼40 kg were anesthetized and ventilated. After 15 minutes of untreated ventricular fibrillation, pigs were randomized to AHUP-CPR for 25 minutes (BLS group) or conventional CPR for 10 minutes, followed by 15 minutes of AHUP-CPR (ALS group). Thereafter, epinephrine, amiodarone, and defibrillation were administered. Neurologic function, the primary endpoint, was assessed 24-hours later with a Neurological Deficit Score (NDS, 0 = normal and 260 = worst deficit score or death). Secondary outcomes included return of spontaneous circulation (ROSC), cumulative survival, hemodynamics and epinephrine responsivity. Data, expressed as mean ± standard deviation, were compared using Fisher's Exact, log-rank, Mann-Whitney U and unpaired t-tests.

Résultats : ROSC was achieved in 10/11 pigs with early AHUP-CPR versus 6/11 with delayed AHUP-CPR (p = 0.14), and cumulative 24-hour survival was 45.5% versus 9.1%, respectively (p < 0.02). The NDS was 203 ± 80 with early AHUP-CPR versus 259 ± 3 with delayed AHUP-CPR (p = 0.035). ETCO2, rSO2, and responsiveness to epinephrine were significantly higher in the early versus delayed AHUP-CPR.

Conclusion : When delivered early rather than late, AHUP-CPR resulted in significantly increased hemodynamics, 24-hour survival, and improved neurological function in pigs after prolonged cardiac arrest. Based on these findings, AHUP-CPR should be considered a BLS intervention.

Conclusion (proposition de traduction) : Lorsqu'elle est pratiquée précocement plutôt que tardivement, la RCP automatisée tête haute entraîne une augmentation significative de l'hémodynamique, une survie de 24 heures et une amélioration de la fonction neurologique chez les porcs ayant subi un arrêt cardiaque prolongé. Sur la base de ces résultats, la RCP automatisée tête haute devrait être considérée comme une intervention technique de réanimation de base.

Commentaire : Sur le sujet, lire l'article :
Huang CC, Chen KC, Lin ZY, Chou YH, Chen WL, Lee TH, Lin KT, Hsieh PY, Chen CH, Chou CC, Lin YR. The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care. 2021 Oct 30;25(1):376  .



Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Imposter or knight in shining armor? Pelvic circumferential compression devices (PCCD) for severe pelvic injuries in patients with multiple trauma: a trauma-registry analysis.
Trentzsch H, Lefering R, Schweigkofler U; TraumaRegister DGU (TraumaRegister DGU of the German Trauma Society). | Scand J Trauma Resusc Emerg Med. 2024 Jan 16;32(1):2
DOI: https://doi.org/10.1186/s13049-023-01172-z  | Télécharger l'article au format  
Keywords: Advanced trauma life support care; Emergency medical services; Emergency treatment; Multiple trauma; Pelvic binder; Pelvic ring injury; Registries.

ORIGINAL RESEARCH

Introduction : Pelvic Circumferential Compression Devices (PCCD) are standard in hemorrhage-control of unstable pelvic ring fractures (UPF). Controversial data on their usefulness exists. Aim of the study was to investigate whether prehospital application of PCCD can reduce mortality and transfusion requirements in UPF.

Méthode : Retrospective cohort study. From 2016 until 2021, 63,371 adult severely injured patients were included into TraumaRegister DGU® of the German Trauma Society (TR-DGU). We analyzed PCCD use over time and compared patients with multiple trauma patients and UPF, who received prehospital PCCD to those who did not (noPCCD). Groups were adjusted for risk of prehospital PCCD application by propensity score matching. Primary endpoints were hospital mortality, standardized mortality rate (SMR) and transfusion requirements.

Résultats : Overall UPF incidence was 9% (N = 5880) and PCCD use increased over time (7.5% to 20.4%). Of all cases with UPF, 40.2% received PCCD and of all cases with PCCD application, 61% had no pelvic injury at all. PCCD patients were more severely injured and had higher rates of shock or transfusion. 24-h.-mortality and hospital mortality were higher with PCCD (10.9% vs. 9.3%; p = 0.033; 17.9% vs. 16.1%, p = 0.070). Hospital mortality with PCCD was 1% lower than predicted. SMR was in favor of PCCD but failed statistical significance (0.95 vs. 1.04, p = 0.101). 1,860 propensity score matched pairs were analyzed: NoPCCD-patients received more often catecholamines (19.6% vs. 18.5%, p = 0.043) but required less surgical pelvic stabilization in the emergency room (28.6% vs. 36.8%, p < 0.001). There was no difference in mortality or transfusion requirements.

Conclusion : We observed PCCD overuse in general and underuse in UPF. Prehospital PCCD appears to be more a marker of injury severity and less triggered by presence of UPF. We found no salutary effect on survival or transfusion requirements. Inappropriate indication and technical flaw may have biased our results. TR-DGU does not contain data on these aspects. Further studies are necessary. Modular add-on questioners to the registry could offer one possible solution to overcome this limitation. We are concerned that PCCD use may be unfairly discredited by misinterpretation of the available evidence and strongly vote for a prospective trial.

Conclusion (proposition de traduction) : Nous avons observé une surutilisation des ceintures pelviennes en général et une sous-utilisation dans les fractures instables de l'anneau pelvien. Les dispositifs de ceintures pelviennes préhospitaliers semblent être davantage un marqueur de la gravité des blessures et moins déclenchés par la présence de fractures instables de l'anneau pelvien. Nous n'avons pas trouvé d'effet bénéfique sur la survie ou les besoins en transfusion. Le TR-DGU ne dispose pas de données sur ces aspects. D'autres études sont nécessaires. L'ajout de questions complémentaires au registre pourrait être une solution possible pour surmonter cette limitation. Nous craignons que l'utilisation des ceintures pelviennes ne soit injustement discréditée par une mauvaise interprétation des preuves disponibles et nous plaidons fortement en faveur d'un essai prospectif.

The American Journal of Emergency Medicine

Low-flow time and outcomes in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation.
Shoji K, Ohbe H, Kudo D, Tanikawa A, Kobayashi M, Aoki M, Hamaguchi T, Nagashima F, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Kushimoto S; SAVE-J II study group. | Am J Emerg Med. 2024 Jan;75:37-41
DOI: https://doi.org/10.1016/j.ajem.2023.10.024
Keywords: Extracorporeal cardiopulmonary resuscitation; Favorable neurological outcome; Low-flow time; Out-of-hospital cardiac arrest; Registry.

Research article

Introduction : In out-of-hospital cardiac arrest (OHCA) patients with extracorporeal cardiopulmonary resuscitation (ECPR), the association between low-flow time, the duration between the initiation of conventional cardiopulmonary resuscitation and the establishment of ECPR, and outcomes has not been clearly determined.

Méthode : This was a secondary analysis of the retrospective multicenter registry in Japan. This study registered patients ≥18 years old who were admitted to the emergency department for OHCA and underwent ECPR between January, 2013 and December, 2018. Low-flow time was defined as the time from initiation of conventional cardiopulmonary resuscitation to the establishment of ECPR, and patients were categorized into two groups according to the visualized association of the restricted cubic spline curve. The primary outcome was survival discharge. Cubic spline analyses and multivariable logistic regression analyses were performed to assess the nonlinear associations between low-flow time and outcomes.

Résultats : A total of 1,524 patients were included. The median age was 60 years, and the median low-flow time was 52 (42-53) mins. The overall survival at hospital discharge and favorable neurological outcomes were 27.8% and 14.2%, respectively. The cubic spline analysis showed a decreased trend of survival discharge rates and favorable neurological outcomes with shorter low-flow time between 20 and 60 mins, with little change between the following 60 and 80 mins. The multivariable logistic regression analyses showed that patients with long low-flow time (>40 mins) compared to those with short low-flow time (0-40 mins) had significantly worse survival (adjusted odds ratio 0.42; 95% confidence intervals, 0.31-0.57) and neurological outcomes (0.65; 0.45-0.95, respectively).

Conclusion : The survival discharge and neurological outcomes of patients with low-flow time shorter than 40 min are better than those of patients with longer low-flow time.

Conclusion (proposition de traduction) : La survie à la sortie de l'hôpital et les résultats neurologiques des patients dont le temps de low-flow est inférieur à 40 minutes sont meilleurs que ceux des patients dont le temps de low-flow est plus long.

Prediction of the neurological outcomes post-cardiac arrest: A prospective validation of the CAST and rCAST.
Kikutani K, Nishikimi M, Matsui K, Sakurai A, Hayashida K, Kitamura N, Tagami T, Nakada TA, Matsui S, Ohshimo S, Shime N; SOS-KANTO 2017 Study Group. | Am J Emerg Med. 2024 Jan;75:46-52
DOI: https://doi.org/10.1016/j.ajem.2023.10.028
Keywords: Cardiopulmonary resuscitation; Post-cardiac arrest syndrome; Targeted temperature management; Therapeutic hypothermia.

Research article

Introduction : The neurologic prognosis of out-of-hospital cardiac arrest (OHCA) patients in whom return of spontaneous circulation (ROSC) is achieved remains poor. The aim of this study was to externally and prospectively validate two scoring systems developed by us: the CAST score, a scoring system to predict the neurological prognosis of OHCA patients undergoing targeted temperature management (TTM), and a simplified version of the same score developed for improved ease of use in clinical settings, the revised CAST (rCAST) score.

Méthode : This study was a prospective, multicenter, observational study conducted using the SOS KANTO 2017 registry, an OHCA registry involving hospitals in the Kanto region (including Tokyo) of Japan. The primary outcome was favorable neurological outcome (defined as Cerebral Performance Category score of 1 or 2) at 30 days and the secondary outcomes were favorable neurological outcome at 90 days and survival at 30 and 90 days. The predictive accuracies of the original CAST (oCAST) and rCAST scores were evaluated by using area under the receiver operating characteristic curve (AUC).

Résultats : Of 9909 OHCA patients, 565 showed ROSC and received TTM. Of these, we analyzed the data of 259 patients in this study. The areas under the receiver operating characteristic curve (AUCs) of the oCAST and rCAST scores for predicting a favorable neurological outcome at 30 days were 0.86 and 0.87, respectively, and those for predicting a favorable neurological outcome at 90 days were 0.87 and 0.88, respectively. The rCAST showed a higher predictive accuracy for the neurological outcome as compared with the NULL-PLEASE score. The patients with a favorable neurological outcome who had been classified into the high severity group based on the rCAST tended to have hypothermia at hospital arrival and to not show any signs of loss of gray-white matter differentiation on brain CT. Neurological function at 90 days was correlated with the rCAST (r = 0.63, p < 0.001).

Conclusion : rCAST showed high predictive accuracy for the neurological prognosis of OHCA patients managed by TTM, comparable to that of the oCAST score. The scores on the rCAST were strongly correlated with the neurological functions at 90 days, implying that the rCAST is a useful scale for assessing the severity of brain injury after cardiac arrest.

Conclusion (proposition de traduction) : Le score CAST révisé a montré une grande précision prédictive pour le pronostic neurologique des patients ayant présenté un arrêt cardiaque extrahospitalier et ayant bénéficié d'une prise en charge ciblée de la température, comparable à celle du score CAST original. Les scores du CAST révisé étaient fortement corrélés avec les fonctions neurologiques à 90 jours, ce qui implique que le score CAST révisé est une échelle utile pour évaluer la gravité des lésions cérébrales après un arrêt cardiaque.

Commentaire : CAST : un nouveau score pour la prédiction précoce des résultats neurologiques après un arrêt cardiaque avant l'hypothermie thérapeutique avec une grande précision.

Respiratory rate‑oxygenation (ROX) index for predicting high-flow nasal cannula failure in patients with and without COVID-19.
Kwon H, Ha SW, Kim B, Chae B, Kim SM, Hong SI, Kim JS, Kim YJ, Ryoo SM, Kim WY. | Am J Emerg Med. 2024 Jan;75:53-58
DOI: https://doi.org/10.1016/j.ajem.2023.09.036
Keywords: Acute hypoxemic respiratory failure; COVID-19; Discriminative power; Endotracheal intubation; High-flow nasal cannula; ROX index.

Research article

Introduction : The predictive value of the respiratory rate‑oxygenation (ROX) index for a high-flow nasal cannula (HFNC) in patients with COVID-19 with acute hypoxemic respiratory failure (AHRF) may differ from patients without COVID-19 with AHRF, but these patients have not yet been compared. We compared the diagnostic accuracy of the ROX index for HFNC failure in patients with AHRF with and without COVID-19 during acute emergency department (ED) visits.

Méthode : We performed a retrospective analysis of patients with AHRF treated with an HFNC in an ED between October 2020 and April 2022. The ROX index was calculated at 1, 2, 4, 6, 12, and 24 h after HFNC placement. The primary outcome was the failure of the HFNC, which was defined as the need for subsequent intubation or death within 72 h. A receiver operating characteristic (ROC) curve was used to evaluate discriminative power of the ROX index for HFNC failure.

Résultats : Among 448 patients with AHRF treated with an HFNC in an ED, 78 (17.4%) patients were confirmed to have COVID-19. There was no significant difference in the HFNC failure rates between the non-COVID-19 and COVID-19 groups (29.5% vs. 33.3%, p = 0.498). The median ROX index was higher in the non-COVID-19 group than in the COVID-19 group at all time points. The prognostic power of the ROX index for HFNC failure as evaluated by the area under the ROC curve was generally higher in the COVID-19 group (0.73-0.83) than the non-COVID-19 group (0.62-0.75). The timing of the highest prognostic value of the ROX index for HFNC failure was at 4 h for the non-COVID-19 group, whereas in the COVID-19 group, its performance remained consistent from 1 h to 6 h. The optimal cutoff values were 6.48 and 5.79 for the non-COVID-19 and COVID-19 groups, respectively.

Conclusion : The ROX index had an acceptable discriminative power for predicting HFNC failure in patients with AHRF with and without COVID-19 in the ED. However, the higher ROX index thresholds than those in previous publications involving intensive care unit (ICU) patients suggest the need for careful monitoring and establishment of a new threshold for patients admitted outside the ICU.

Conclusion (proposition de traduction) : L'indice ROX avait un pouvoir discriminant acceptable pour prédire l'échec des canules nasales à haut débit chez les patients souffrant d'insuffisance respiratoire hypoxémique aiguë avec ou sans COVID-19 aux urgences. Cependant, les seuils de l'indice ROX plus élevés que ceux des publications précédentes concernant les patients de l'unité de soins intensifs (USI) suggèrent la nécessité d'une surveillance attentive et l'établissement d'un nouveau seuil pour les patients admis en dehors de l'USI.

Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets.
Sanchez T, Coisy F, Grau-Mercier L, Occelli C, Ajavon F, Claret PG, Markarian T, Bobbia X. | Am J Emerg Med. 2024 Jan;75:59-64
DOI: https://doi.org/10.1016/j.ajem.2023.10.026
Keywords: Animal model; Experimental model; Hemorrhagic; Shock; Shock index.

Research article

Introduction : The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase.

Méthode : We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly.

Résultats : The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively.

Conclusion : In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.

Conclusion (proposition de traduction) : Dans un modèle de choc hémorragique contrôlé chez le porcelet, la corrélation entre le Shock Index (SI) et le volume de perte sanguine semble forte.

Utility of nicardipine in the management of hypertensive crises in adults with reduced ejection fractions.
Ibarra F Jr, Holzmann S, Shah S, Fountain C, Saleh S, Kapoor V, Dang T. | Am J Emerg Med. 2024 Jan;75:79-82
DOI: https://doi.org/10.1016/j.ajem.2023.10.041
Keywords: Heart failure; Hypertensive crises; Nicardipine; Pulmonary congestion; Reduced ejection fraction.

Research article

Introduction : Nicardipine is commonly used in the management of hypertensive crises, except those involving cardiac contractility defects despite its ability to reduce afterload and pulmonary congestion. Consequently, there is limited literature evaluating nicardipine's role for this indication. The purpose of this study was to evaluate the efficacy and safety of nicardipine in adults with reduced ejection fractions presenting with acute heart failure with hypertension (AHF-H).

Méthode : This was a retrospective study conducted at an academic Level 1 trauma center with an annual Emergency Department (ED) volume surpassing 100,000. The purpose of this study was to determine the efficacy and safety of nicardipine in adults with reduced ejection fractions presenting to the ED with AHF-H. Efficacy was determined by achievement of the physician prescribed blood pressure target range. The primary safety endpoints included the number of individuals who experienced bradycardia (< 60 beats per minute, bpm) or hypotension (systolic blood pressure, SBP, < 90 mmHg) while receiving nicardipine and for up to 15 min after its discontinuation. Patients were included if they were ≥ 18 years of age, received a continuous intravenous nicardipine infusion within six hours of presenting to the ED, and had an ejection fraction ≤ 40% per an echocardiogram obtained within three months of the study visit. Pregnant and incarcerated patients were excluded.

Résultats : Of the 500 patient charts reviewed, 38 met inclusion criteria. The median (interquartile, IQR) ejection fraction and brain natriuretic peptide (BNP) were 35% (25-40) and 731 pg/nL (418-3277), respectively. The median baseline heart rate and SBP were 90 bpm and 193 mmHg, respectively. The median physician specified SBP goal was 160 mmHg and all patients met this endpoint in a median time of 18 min. One (2.6%) patient in the total population developed both hypotension and bradycardia. This patient had an ejection fraction of 20%, was intubated, and received nicardipine in addition to esmolol for an aortic dissection without experiencing an adverse event until 30 min after dexmedetomidine was initiated.

Conclusion : In this non-interventional study evaluating the use of nicardipine in patients with reduced ejection fractions presenting to the ED with AHF-H, nicardipine was found to be safe and effective. To our knowledge this is the largest study to date evaluating nicardipine in this patient population and positively contributes to the existing literature.

Conclusion (proposition de traduction) : Cette étude non interventionnelle évaluant l'utilisation de la nicardipine chez les patients présentant une fraction d'éjection réduite et se présentant aux urgences avec une HTA a montré que la nicardipine était sûre et efficace. À notre connaissance, il s'agit de la plus grande étude à ce jour évaluant la nicardipine dans cette population de patients et elle apporte une contribution positive à la littérature existante.

Efficacy and safety of corticosteroid therapy in patients with cardiac arrest: A meta-analysis of randomized controlled trials.
Zhou FW, Liu C, Li DZ, Zhang Y, Zhou FC. | Am J Emerg Med. 2024 Jan;75:111-118
DOI: https://doi.org/10.1016/j.ajem.2023.10.031  | Télécharger l'article au format  
Keywords: Cardiac arrest; Corticosteroid; Meta-analysis; Steroid; Survival; Systematic review.

Research article

Introduction : The clinical benefits of steroid therapy during cardiac arrest (CA) are unclear. Several recent clinical trials have shown that administering corticosteroid therapy during CA may improve patient outcomes. The purpose of the present study was to determine whether providing corticosteroids improves outcomes for patients following CA.

Méthode : We searched the PubMed, Embase, Cochrane Library, Web of Science and CNKI databases for randomized controlled trials comparing corticosteroid therapy to placebo during CA.

Résultats : Eleven relevant studies involving a total of 2273 patients were included in the meta-analysis. The statistical analysis showed that corticosteroid treatment during CA was significantly associated with an increased rate of sustained return of spontaneous circulation (ROSC) (OR: 2.05, 95% CI: 1.24 to 3.37, P < 0.01). Corticosteroid treatment during CA did not show a significant benefit in favorable neurological outcomes (OR: 1.13, 95% CI: 0.81 to 1.58, P = 0.49) or overall survival rate at hospital discharge (OR: 1.29, 95% CI: 0.74 to 2.26, P = 0.38). However, in the subgroup analysis, we found that patients had a significantly increased survival rate and ROSC if the dose of corticosteroid therapy above 100 mg methylprednisolone. The statistical analysis revealed no significant differences in adverse events.

Conclusion : High-dose corticosteroid treatment (above 100 mg methylprednisolone) is associated with better overall survival rate at hospital discharge and ROSC outcomes. However, there is uncertainty regarding whether this treatment results in a benefit or harm to the favorable neurological outcomes at hospital discharge.

Conclusion (proposition de traduction) : La corticothérapie à forte dose (plus de 100 mg de méthylprednisolone) est associée à un meilleur taux de survie globale à la sortie de l'hôpital et à de meilleurs résultats en matière de réanimation cardio-pulmonaire. Cependant, il n'est pas certain que ce traitement ait un effet bénéfique ou néfaste sur les résultats neurologiques favorables à la sortie de l'hôpital.

Effect of no-flow period on the vasopressor effect of initial epinephrine administration in cardiac arrest.
Song NE, Kim KH, Hong KJ. | Am J Emerg Med. 2024 Jan;75:154-159
DOI: https://doi.org/10.1016/j.ajem.2023.10.053
Keywords: Animal experimentation; Epinephrine; Out-of-hospital cardiac arrest; Vasoconstriction.

Research article

Introduction : Whether a longer no-flow (NF) interval affects the magnitude of response to epinephrine in the resuscitation has not been well studied. Therefore, this study aimed to evaluate the effect of NF interval on the vasopressor effect of initial epinephrine administration in a porcine model.

Méthode : We enrolled 20 pigs from two randomized porcine experimental studies using a ventricular fibrillation (VF) cardiac arrest model. The first experiment subjects were resuscitated after 4 min of NF (Short NF group), followed by three cycles (6 min) of chest compression using a mechanical cardiopulmonary resuscitation device before epinephrine administration. Second experiment subjects received 6 min of NF (Long NF group), two cycles (4 min) of chest compressions, and administration of epinephrine. Defibrillation for VF was delivered 8 and 10 min after VF induction in the Short NF and Long NF groups, respectively. The mean arterial pressure (MAP) and cerebral perfusion pressure (CePP) in the 2-min resuscitation period after epinephrine administration were compared between the study groups using the Wilcoxon rank-sum test. The mean differences in the parameters between phases were also compared.

Résultats : Seven pigs in the Short NF group and 13 pigs in the Long NF group were included in the analysis. All 2-min resuscitation phases from 6 to 16 min after VF induction were compared between the study groups. The Short NF group showed higher MAP and CePP in all phases (p < 0.01). Change of mean MAP after the epinephrine administration was significantly different between the study groups: mean difference (95% confidence interval) of 16.6 (15.8-17.4) mmHg in the Short NF group and 4.2 (3.9-4.5) mmHg in the Long NF group.

Conclusion : In the porcine VF cardiac arrest model, 6 min of NF before resuscitation may affect the vasopressor effect of the initial epinephrine administered compared to 4 min of NF. A short NF may play a role in maximizing the effect of epinephrine in advanced cardiovascular life support.

Conclusion (proposition de traduction) : Dans le modèle porcin d'arrêt cardiaque par FV, 6 minutes de no-flow avant la réanimation semblent affecter l'effet vasopresseur de l'épinéphrine initiale administrée par rapport à 4 minutes de no-flow. Un no-flow courte peut jouer un rôle dans l'optimisation de l'effet de l'adrénaline dans le cadre d'une réanimation cardio-vasculaire avancée.

The British Medical Journal

Efficacy and safety of tranexamic acid in acute haemorrhage.
Franchini M, Focosi D, Zaffanello M, Mannucci PM. | BMJ. 2024 Jan 4;384:e075720
DOI: https://doi.org/10.1136/bmj-2023-075720
Keywords: Aucun

Practice

Editorial : What you need to know
• Tranexamic acid is a synthetic haemostatic drug that inhibits fibrinolysis
• It is effective in reducing bleeding and mortality, although to different extents in trauma, peripartum, and surgical settings
• It is generally safe and inexpensive with few adverse reactions, although further studies are needed to assess its safety in settings of high thromboembolic risk

Conclusion : Trials of tranexamic acid have been conducted in acute trauma, surgery, gastrointestinal bleeding, and peripartum haemorrhage. Key points are presented in the following sections and major trials summarised in table 2. This article primarily focuses on the use of intravenous tranexamic acid in the acute inpatient setting

Conclusion (proposition de traduction) : Des essais sur l'acide tranexamique ont été menés dans les cas de traumatismes aigus, chirurgie, les hémorragies gastro-intestinales et les hémorragies du péripartum. Les points clés sont présentés dans les sections suivantes et les principaux essais sont résumés dans le tableau 2. Cet article se concentre principalement sur l'utilisation de l'acide tranexamique intraveineux dans le cadre d'une hospitalisation en phase aiguë.

Commentaire : Tableau 2. Résultats cliniques des plus grands essais contrôlés randomisés sur l'utilisation de l'acide tranexamique pour le traitement des hémorragies aiguës

The Journal of Trauma and Acute Care Surgery

Delayed tranexamic acid after traumatic brain injury impedes learning and memory: Early tranexamic acid is favorable but not in sham animals.
Culkin MC, Coons M, Bele P, Thaploo A, Georges AP, Anderson E, Browne KD, Jacovides C, Santos P, Kaplan LJ, Meaney DF, Smith DH, Pascual JL. | J Trauma Acute Care Surg. 2024 Jan 1;96(1):26-34
DOI: https://doi.org/10.1097/ta.0000000000004155
Keywords: Aucun

AAST PODIUM 2023

Introduction : Early but not late tranexamic acid (TXA) after TBI preserves blood-brain-barrier integrity, but it is unclear if and how dose timing affects cognitive recovery beyond hours postinjury. We hypothesized that early (1 hour post-TBI) but not late (24 hours post-TBI) TXA administration improves cognitive recovery for 14 days.

Méthode : CD1 male mice (n = 25) were randomized to severe TBI (injury [I], by controlled cortical impact) or sham craniotomy (S) followed by intravenous saline at 1 hour (placebo [P1]) or 30 mg/kg TXA at 1 hour (TXA1) or 24 hours (TXA24). Daily body weights, Garcia Neurological Test scores, brain/lung water content, and Morris water maze exercises quantifying swimming traffic in the platform quadrant (zone [Z] 1) and platform area (Z5) were recorded for up to 14 days.

Résultats : Among injured groups, I-TXA1 demonstrated fastest weight gain for 14 days and only I-TXA1 showed rapid (day 1) normalization of Garcia Neurological Test ( p = 0.01 vs. I-P1, I-TXA24). In cumulative spatial trials, compared with I-TXA1, I-TXA24 hindered learning (distance to Z5 and % time in Z1, p < 0.05). Compared with I-TXA1, I-TXA24 showed poorer memory with less Z5 time (0.51 vs. 0.16 seconds, p < 0.01) and Z5 crossing frequency. Unexpectedly, TXA in uninjured animals (S-TXA1) displayed faster weight gain but inferior learning and memory.

Conclusion : Early TXA appears beneficial for cognitive and behavioral outcomes following TBI, although administration 24 hours postinjury consistently impairs cognitive recovery. Tranexamic acid in sham animals may lead to adverse effects on cognition.

Conclusion (proposition de traduction) : L'acide tranexamique administré précocement semble bénéfique sur les résultats cognitifs et comportementaux après une lésion cérébrale traumatique, bien que l'administration 24 heures après la lésion nuise systématiquement à la récupération cognitive. L'acide tranexamique administré à des animaux fictifs peut avoir des effets négatifs sur la cognition.

The Lancet

Conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU): a UK multicentre, open, parallel-group, randomised clinical trial.
Peters MJ, Gould DW, Ray S, Thomas K, Chang I, Orzol M, O'Neill L, Agbeko R, Au C, Draper E, Elliot-Major L, Giallongo E, Jones GAL, Lampro L, Lillie J, Pappachan J, Peters S, Ramnarayan P, Sadique Z, Rowan KM, Harrison DA, Mouncey PR; Oxy-PICU Investigators of the Paediatric Critical Care Society Study Group (PCCS-SG). | Lancet. 2024 Jan 27;403(10424):355-364
DOI: https://doi.org/10.1016/s0140-6736(23)01968-2  | Télécharger l'article au format  
Keywords: UK National Institute for Health and Care Research Health Technology Assessment Programme.

Article

Introduction : The optimal target for systemic oxygenation in critically ill children is unknown. Liberal oxygenation is widely practiced, but has been associated with harm in paediatric patients. We aimed to evaluate whether conservative oxygenation would reduce duration of organ support or incidence of death compared to standard care.

Méthode : Oxy-PICU was a pragmatic, multicentre, open-label, randomised controlled trial in 15 UK paediatric intensive care units (PICUs). Children admitted as an emergency, who were older than 38 weeks corrected gestational age and younger than 16 years receiving invasive ventilation and supplemental oxygen were randomly allocated in a 1:1 ratio via a concealed, central, web-based randomisation system to conservative peripheral oxygen saturations ([SpO2] 88-92%) or liberal (SpO2 >94%) targets. The primary outcome was the duration of organ support at 30 days following random allocation, a rank-based endpoint with death either on or before day 30 as the worst outcome (a score equating to 31 days of organ support), with survivors assigned a score between 1 and 30 depending on the number of calendar days of organ support received. The primary effect estimate was the probabilistic index, a value greater than 0·5 indicating more than 50% probability that conservative oxygenation is superior to liberal oxygenation for a randomly selected patient. All participants in whom consent was available were included in the intention-to-treat analysis. The completed study was registered with the ISRCTN registry (ISRCTN92103439).

Résultats : Between Sept 1, 2020, and May 15, 2022, 2040 children were randomly allocated to conservative or liberal oxygenation groups. Consent was available for 1872 (92%) of 2040 children. The conservative oxygenation group comprised 939 children (528 [57%] of 927 were female and 399 [43%] of 927 were male) and the liberal oxygenation group included 933 children (511 [56%] of 920 were female and 409 [45%] of 920 were male). Duration of organ support or death in the first 30 days was significantly lower in the conservative oxygenation group (probabilistic index 0·53, 95% CI 0·50-0·55; p=0·04 Wilcoxon rank-sum test, adjusted odds ratio 0·84 [95% CI 0·72-0·99]). Prespecified adverse events were reported in 24 (3%) of 939 patients in the conservative oxygenation group and 36 (4%) of 933 patients in the liberal oxygenation group.

Conclusion : Among invasively ventilated children who were admitted as an emergency to a PICU receiving supplemental oxygen, a conservative oxygenation target resulted in a small, but significant, greater probability of a better outcome in terms of duration of organ support at 30 days or death when compared with a liberal oxygenation target. Widespread adoption of a conservative oxygenation saturation target (SpO2 88-92%) could help improve outcomes and reduce costs for the sickest children admitted to PICUs.

Conclusion (proposition de traduction) : Parmi les enfants sous ventilation invasive admis en urgence dans une unité de soins intensifs pédiatriques et recevant un supplément d'oxygène, un objectif d'oxygénation conservateur a entraîné une probabilité faible, mais significative, de meilleurs résultats en termes de durée du soutien d'organe à 30 jours ou de décès, par rapport à un objectif d'oxygénation libéral. L'adoption généralisée d'un objectif conservateur de saturation en oxygène (SpO2 88-92 %) pourrait contribuer à améliorer les résultats et à réduire les coûts pour les enfants les plus malades admis dans les unités de soins intensifs pédiatriques.

The Ultrasound Journal

The role of point-of-care ultrasound (POCUS) imaging in clinical outcomes during cardiac arrest: a systematic review.
Zaki HA, Iftikhar H, Shaban EE, Najam M, Alkahlout BH, Shallik N, Elnabawy W, Basharat K, Azad AM. | Ultrasound J. 2024 Jan 24;16(1):4
DOI: https://doi.org/10.1186/s13089-023-00346-1  | Télécharger l'article au format  
Keywords: Aucun

Review

Introduction : Cardiac arrest in hospital and out-of-hospital settings is associated with high mortality rates. Therefore, a bedside test that can predict resuscitation outcomes of cardiac arrest patients is of great value. Point-of-care ultrasound (POCUS) has the potential to be used as an effective diagnostic and prognostic tool during cardiac arrest, particularly in observing the presence or absence of cardiac activity. However, it is highly susceptible to "self-fulfilling prophecy" and is associated with prolonged cardiopulmonary resuscitation (CPR), which negatively impacts the survival rates of cardiac arrest patients. As a result, the current systematic review was created to assess the role of POCUS in predicting the clinical outcomes associated with out-of-hospital and in-hospital cardiac arrests.

Méthode : The search for scientific articles related to our study was done either through an electronic database search (i.e., PubMed, Medline, ScienceDirect, Embase, and Google Scholar) or manually going through the reference list of the relevant articles. A quality appraisal was also carried out with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2), and the prognostic test performance (sensitivity and sensitivity) was tabulated.

Résultats : The search criteria yielded 3984 articles related to our topic, of which only 22 were eligible for inclusion. After reviewing the literature, we noticed a wide variation in the definition of cardiac activity, and the statistical heterogeneity was high; therefore, we could not carry out meta-analyses. The tabulated clinical outcomes based on initial cardiac rhythm and definitions of cardiac activity showed highly inconsistent results.

Conclusion : POCUS has the potential to provide valuable information on the management of cardiac arrest patients; however, it should not be used as the sole predictor for the termination of resuscitation efforts.

Conclusion (proposition de traduction) : L'échographie au point de service peut fournir des informations précieuses sur la prise en charge des patients en arrêt cardiaque ; cependant, elle ne doit pas être utilisée comme seul facteur prédictif de l'arrêt des efforts de réanimation.

Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging.
Zaki HA, Albaroudi B, Shaban EE, Shaban A, Elgassim M, Almarri ND, Basharat K, Azad AM. | Ultrasound J. 2024 Jan 23;16(1):3
DOI: https://doi.org/10.1186/s13089-023-00356-z  | Télécharger l'article au format  
Keywords: Chest X-ray; Diagnostic imaging; Emergency medicine; Meta-analysis; Pleural effusion; Point-of-care systems; Sensitivity; Specificity; Systematic review; Ultrasound.

REVIEW

Introduction : Pleural effusion is a fluid buildup in the pleural space that mostly result from congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolism. The diagnosis of this condition can be challenging as it presents symptoms that may overlap with other conditions; therefore, imaging diagnostic tools such as chest x-ray/radiograph (CXR), point-of-care ultrasound (POCUS), and computed tomography (CT) have been employed to make an accurate diagnosis. Although POCUS has high diagnostic accuracy, it is yet to be considered a first-line diagnostic tool as most physicians use radiography. Therefore, the current meta-analysis was designed to compare POCUS to chest radiography.

Méthode : n extended search for studies related to our topic was done on five electronic databases, including PubMed, Medline, Embase, Scopus, and Google Scholar. A quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was performed on all eligible articles obtained from the databases. Moreover, the diagnostic accuracy of POCUS and CXR was performed using STATA 16 software.

Résultats : Our search yielded 1642 articles, of which only 18 were eligible for inclusion and analysis. The pooled analysis showed that POCUS had a higher diagnostic accuracy compared to CXR (94.54% (95% CI 91.74-97.34) vs. 67.68% (95% CI 58.29-77.08) and 97.88% (95% CI 95.77-99.99) vs. 85.30% (95% CI 80.06-90.54) sensitivity and specificity, respectively). A subgroup analysis based on the position of patients during examinations showed that POCUS carried out in supine and upright positions had higher specificity than other POCUS positions (99%). In comparison, lateral decubitus CXR had higher sensitivity (96%) and specificity (99%) than the other CXR positions. Further subgroup analyses demonstrated that CXR had higher specificity in studies that included more than 100 patients (92.74% (95% CI 85.41-100). Moreover, CXR tends to have a higher diagnostic accuracy when other CXR positions are used as reference tests (93.38% (95% CI 86.30-100) and 98.51% (95% CI 94.65-100) sensitivity and specificity, respectively).

Conclusion : POCUS as an imaging modality has higher diagnostic accuracy than CXR in detecting pleural effusion. Moreover, the accuracy is still high even when performed by physicians with less POCUS training. Therefore, we suggest it is considered a first-line imaging tool for diagnosing pleural effusion at the patients' bedside.

Conclusion (proposition de traduction) : L'échographie au point d'intervention en tant que modalité d'imagerie présente une précision diagnostique supérieure à celle de la radiographie thoracique dans la détection de l'épanchement pleural. En outre, la précision reste élevée même lorsqu'elle est réalisée par des médecins moins formés à l'échographie au chevet du patient. Par conséquent, nous suggérons qu'il soit considéré comme un outil d'imagerie de première ligne pour le diagnostic de l'épanchement pleural au chevet du patient.

Turkish Journal of Emergency Medicine

Family opinions on resuscitation and participation in end-of-life care in the emergency department: A cross-sectional study.
Akman U, Koyuncu A. | Turk J Emerg Med. 2024 Jan 8;24(1):48-54
DOI: https://doi.org/10.4103/tjem.tjem_164_23  | Télécharger l'article au format  
Keywords: End-of-life; emergency nursing; family presence during resuscitation; family-centered care; nursing.

Original Article

Introduction : The study looked into emergency department family members' (FMs) views on being present during resuscitation and contributing to end-of-life care.

Méthode : A cross-sectional study with 467 FM volunteers of mildly injured or ill patients was conducted at a research hospital between October 2021 and May 2022. Data were collected using a questionnaire administered by a clinical psychologist. The analysis employed SPSS 22.0 with a significance threshold of P < 0.05. The study was conducted according to the STROBE criteria. Statistical significance was set at P < 0.05.

Résultats : The mean FMs' age was 34.3 ± 10.43; 64.2% were male, 62.1% were married, and 76.9% had nuclear families. About 61% wanted the option of being present during resuscitation, with 47.5% desiring participation in both resuscitation and end-of-life care. Significant differences were observed in opinions based on education, work status, and resuscitation training (P = 0.015, P = 0.001, P = 0.002).

Conclusion : Many FMs sought the choice to be present during resuscitation, and nearly half preferred participation in both resuscitation and end-of-life care.

Conclusion (proposition de traduction) : De nombreux membres de la famille ont demandé à être présents pendant la réanimation, et près de la moitié ont préféré participer à la fois à la réanimation et aux soins de fin de vie.

World Journal of Emergency Medicine

Efficacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury.
Yi Shan, Yang Zhao, Chengcheng Li, Jianxin Gao, Guogeng Song, Tanshi Li. | World J Emerg Med. 2024;15(1):10-15
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2024.001  | Télécharger l'article au format  
Keywords: Non-compressible torso hemorrhage; Liver injury; Ischemia-reperfusion injury; Resuscitative endovascular balloon occlusion of the aorta

Original Article

Introduction : Resuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control traumatic bleeding. However, its prolonged use potentially leads to ischemia-reperfusion injury (IRI). Partial REBOA (pREBOA) can alleviate ischemic burden; however, its security and effectiveness prior to operative hemorrhage control remains unknown. Hence, we aimed to estimate the efficacy of pREBOA in a swine model of liver injury using an experimental sliding-chamber ballistic gun.

Méthode : Twenty Landrace pigs were randomized into control (no aortic occlusion) (n=5), intervention with complete REBOA (cREBOA) (n=5), continuous pREBOA (C-pREBOA) (n=5), and sequential pREBOA (S-pREBOA) (n=5) groups. In the cREBOA and C-pREBOA groups, the balloon was inflated for 60 min. The hemodynamic and laboratory values were compared at various observation time points. Tissue samples immediately after animal euthanasia from the myocardium, liver, kidneys, and duodenum were collected for histological assessment using hematoxylin and eosin staining.

Résultats : Compared with the control group, the survival rate of the REBOA groups was prominently improved (all P<0.05). The total volume of blood loss was markedly lower in the cREBOA group (493.14±127.31 mL) compared with other groups (P<0.01). The pH was significantly lower at 180 min in the cREBOA and S-pREBOA groups (P<0.05). At 120 min, the S-pREBOA group showed higher alanine aminotransferase (P<0.05) but lower blood urea nitrogen compared with the cREBOA group (P<0.05).

Conclusion : In this trauma model with liver injury, a 60-minute pREBOA resulted in improved survival rate and was effective in maintaining reliable aortic pressure, despite persistent hemorrhage. Extended tolerance time for aortic occlusion in Zone I for non-compressible torso hemorrhage was feasible with both continuous partial and sequential partial measures, and the significant improvement in the severity of acidosis and distal organ injury was observed in the sequential pREBOA.

Conclusion (proposition de traduction) : Dans ce modèle de traumatisme avec lésions hépatiques, un pREBOA de 60 minutes a permis d'améliorer le taux de survie et de maintenir une pression aortique fiable, malgré une hémorragie persistante. Un temps de tolérance prolongé pour l'occlusion aortique dans la zone I en cas d'hémorragie non compressible du torse était possible avec des mesures partielles continues et successives, et l'amélioration significative de la sévérité de l'acidose et des lésions des organes distaux a été observée dans le cadre du pREBOA continu.

A novel predictor of unsustained return of spontaneous circulation in cardiac arrest patients through a combination of capnography and pulse oximetry: a multicenter observational study.
Jing Yang, Hanqi Tang, Shihuan Shao, Feng Xu, Yangyang Fu, Shengyong Xu, Chen Li, Yan Li, Yang Liu, Joseph Harold Walline, Huadong Zhu, Yuguo Chen, Xuezhong Yu, Jun Xu. | World J Emerg Med. 2024;15(1):16–22
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2023.186  | Télécharger l'article au format  
Keywords: Return of spontaneous circulation; Pulse oximetry photoplethysmogram; End-tidal carbon dioxide; Cardiac arrest; Cardiopulmonary resuscitation

Original Article

Introduction : Unsustained return of spontaneous circulation (ROSC) is a critical barrier to survival in cardiac arrest patients. This study examined whether end-tidal carbon dioxide (ETCO2) and pulse oximetry photoplethysmogram (POP) parameters can be used to identify unsustained ROSC.

Méthode : We conducted a multicenter observational prospective cohort study of consecutive patients with cardiac arrest from 2013 to 2014. Patients’ general information, ETCO2, and POP parameters were collected and statistically analyzed.

Résultats : The included 105 ROSC episodes (from 80 cardiac arrest patients) comprised 51 sustained ROSC episodes and 54 unsustained ROSC episodes. The 24-hour survival rate was significantly higher in the sustained ROSC group than in the unsustained ROSC group (29.2% vs. 9.4%, P<0.05). The logistic regression analysis showed that the difference between after and before ROSC in ETCO2 (ΔETCO2) and the difference between after and before ROCS in area under the curve of POP (ΔAUCp) were independently associated with sustained ROSC (odds ratio [OR]=0.931, 95% confidence interval [95% CI] 0.881–0.984, P=0.011 and OR=0.998, 95% CI 0.997– 0.999, P<0.001). The area under the receiver operating characteristic curve of ΔETCO2, ΔAUCp, and the combination of both to predict unsustained ROSC were 0.752 (95% CI 0.660–0.844), 0.883 (95% CI 0.818–0.948), and 0.902 (95% CI 0.842–0.962), respectively.

Conclusion : Patients with unsustained ROSC have a poor prognosis. The combination of ΔETCO2 and ΔAUCp showed significant predictive value for unsustained ROSC.

Conclusion (proposition de traduction) : Les patients dont la RACS n'est pas prolongée ont un mauvais pronostic. La combinaison de l'ETCO2 avant et après la RACS et de l'aire sous la courbe du photopléthysmogramme de l'oxymétrie de pouls a montré une valeur prédictive significative pour le ROSC non soutenu.

World Journal of Emergency Surgery

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).
Picetti E, Demetriades AK, Catena F, Aarabi B, Abu-Zidan FM, Alves OL, Ansaloni L, Armonda RA, Badenes R, Bala M, Balogh ZJ, Barbanera A, Bertuccio A, Biffl WL, Bouzat P, Buki A, Castano-Leon AM, Cerasti D, Citerio G, Coccolini F, Coimbra R, Coniglio C, Costa F, De Iure F, Depreitere B, Fainardi E, Fehlings MJ, Gabrovsky N, Godoy DA, Gruen P, Gupta D, Hawryluk GWJ, Helbok R, Hossain I, Hutchinson PJ, Iaccarino C, Inaba K, Ivanov M, Kaprovoy S, Kirkpatrick . | World J Emerg Surg. 2024 Jan 18;19(1):4
DOI: https://doi.org/10.1186/s13017-023-00525-4  | Télécharger l'article au format  
Keywords: Management; Polytrauma; Traumatic spinal cord injury

RESEARCH

Introduction : The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies.

Méthode : A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted.

Résultats : A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak).

Conclusion : This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Conclusion (proposition de traduction) : Ce consensus fournit des recommandations pratiques pour aider le clinicien à prendre des décisions dans la prise en charge des patients polytraumatisés présentant une lésion de la moelle épinière traumatique.


Mois de janvier 2024