Dexmedetomidine in the emergency department: A prospective observational cohort study.
Baumgartner K, Joseph M, Lothet E, Fuller BM. | Acad Emerg Med. 2024 Mar;31(3):263-272
DOI: https://doi.org/10.1111/acem.14842
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Dexmedetomidine (DEX) is a centrally acting sympatholytic sedative. Abundant evidence from the intensive care unit and other settings demonstrates that the use of DEX is associated with improved sedation-related outcomes. There is a paucity of data on the use and efficacy of DEX in the emergency department (ED).

Méthode : We performed a prospective single-center observational cohort study of patients treated with intravenous DEX for any indication in the ED. We performed serial bedside evaluations of sedation depth and delirium and administered standardized questionnaires to ED physicians about their use of DEX. We assessed the incidence of hemodynamic adverse events (HAEs; bradycardia or hypotension), clinically significant HAEs (HAEs accompanied by clinical intervention or discontinuation of DEX), sedation-related ED outcomes, and clinician perception of DEX effectiveness.

Résultats : We enrolled 75 patients treated with DEX in the ED during our study period. The most common indication for DEX was noninvasive positive pressure ventilation (32 patients, 43%). DEX was administered in the ED for a median of 2.6 h (interquartile range [IQR] 1.6-4.9 h), with a median infusion rate of 0.3 μg/kg/h (IQR 0.2-0.4 μg/kg/h). Clinically significant HAE occurred in nine patients (12%, 95% CI 6%-22%). Other sedative or analgesic infusions were administered in the ED to 21 patients (28%). Clinicians felt DEX was highly effective (median [IQR] effectiveness score of 5 [3-5] on a 5-point Likert scale). The median (IQR) ED Richmond Agitation Sedation Scale post-DEX was -1 (-4 to 0).

Conclusion : DEX is used in the ED for diverse indications. Additional data from larger cohorts and comparative studies are required to determine the precise incidence of clinically significant HAE associated with DEX use in the ED. ED clinicians have a positive perception of the effectiveness of DEX.

Conclusion (proposition de traduction) : La dexmédétomidine est utilisée aux urgences dans diverses indications. Des données supplémentaires issues de cohortes plus importantes et d'études comparatives sont nécessaires pour déterminer la fréquence précise des effets indésirables hémodynamiques cliniquement significatifs associés à l'utilisation de la dexmédétomidine dans les services d'urgence. Les médecins urgentistes ont une perception positive de l'efficacité de la dexmédétomidine.

Higher versus lower oxygenation targets in adult ICU patients: A rapid practice guideline.
Møller MH, Granholm A, Al Duhailib Z, Alhazzani W, Belley-Cote E, Oczkowski S, Vijayaraghavan BKT, Sjövall F, Butler E, Zampieri FG, Mac Sweeney R, Derde LPG, Ruzycki-Chadwick A, Mer M, Burns KEA, Ergan B, Al-Fares A, Sjoding MW, Valley TS, Rasmussen BS, Schjørring OL, Prescott HC. | Acta Anaesthesiol Scand. 2024 Mar;68(3):302-310
DOI: https://doi.org/10.1111/aas.14366  | Télécharger l'article au format  
Keywords: ICM-RPG; Intensive Care Medicine Rapid Practice Guideline; clinical practice guideline; oxygenation target.

Review article

Introduction : he aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) was to provide evidence-based clinical guidance about the use of higher versus lower oxygenation targets for adult patients in the intensive care unit (ICU).

Méthode : The guideline panel comprised 27 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines, including the use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and used the Evidence-to-Decision framework to generate recommendations.

Résultats : A recently published updated systematic review and meta-analysis constituted the evidence base. Through teleconferences and web-based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, equity, feasibility, acceptability, and research priorities. The updated systematic review and meta-analysis included data from 17 randomized clinical trials with 10,248 participants. There was little to no difference between the use of higher versus lower oxygenation targets for all outcomes with available data, including all-cause mortality, serious adverse events, stroke, functional outcomes, cognition, and health-related quality of life (very low certainty of evidence).

Conclusion : The panel felt that values and preferences, costs and resources, and equity favored the use of lower oxygenation targets. The ICM-RPG panel issued one conditional recommendation against the use of higher oxygenation targets: "We suggest against the routine use of higher oxygenation targets in adult ICU patients (conditional recommendation, very low certainty of evidence). Remark: an oxygenation target of SpO2 88%-92% or PaO2 8 kPa/60 mmHg is relevant and safe for most adult ICU patients."

Conclusion (proposition de traduction) : Le groupe a estimé que les valeurs et les préférences, les coûts et les ressources, ainsi que l'équité favorisaient l'utilisation d'objectifs d'oxygénation plus bas. Le groupe ICM-RPG a émis une recommandation conditionnelle contre l'utilisation de cibles d'oxygénation plus élevées : « Nous suggérons de ne pas utiliser systématiquement des objectifs d'oxygénation plus élevés chez les patients adultes en USI (recommandation conditionnelle, certitude de preuve très faible). Remarque : un objectif d'oxygénation de SpO2 88%-92% ou de PaO2 8 kPa/60 mmHg est pertinent et sûr pour la plupart des patients adultes des soins intensifs ».

Ultrasound-guided femoral nerve block versus fascia iliaca compartment block for femoral fractures in emergency department: A randomized controlled trial.
Rukerd MRZ, Erfaniparsa L, Movahedi M, Mirkamali H, Alizadeh SD, Ilaghi M, Sadeghifar A, Barazandehpoor S, Hashemian M, Pourzand P, Mirafzal A. | Acute Med Surg. 2024 Mar 6;11(1):e936
DOI: https://doi.org/10.1002/ams2.936  | Télécharger l'article au format  
Keywords: emergency department; fascia iliaca compartment block; femoral nerve block; femur fracture.

ORIGINAL ARTICLE

Introduction : Femoral fractures are one of the most debilitating injuries presenting to the emergency departments (EDs). The pain caused by these fractures is typically managed with opioids and adjunctive regional analgesia. These approaches are often associated with adverse side effects. Thus, appropriate alternative methods should be thoroughly investigated. To evaluate ultrasound-guided femoral nerve block (FNB) with ultrasound-guided fascia iliaca compartment block (FICB) in femoral fractures, to determine which provides better analgesia and less opioid requirement.

Méthode : This study was a randomized clinical trial performed on adult patients presenting to the ED within 3 h of isolated femoral fracture with initial numerical pain rating scale (NRS-0) score of more than 5. The patients were randomized to receive FNB or FICB. The outcomes were block success rates, pain at 20 (NRS-20) and 60 (NRS-60) min after the end of the procedures, as well as the number and total dose of fentanyl administration during ED stay.

Résultats : Eighty-seven patients were recruited (40 FNB and 47 FICB). Success rates were 82.5% in FNB and 83.0% in FICB group, with no significant difference between the groups. NRS-20, NRS-60, the number of patients who received supplemental fentanyl, and the total dose of administered fentanyl were significantly lower following FNB. However, the length of the procedure was significantly lower in the FICB group.

Conclusion : Both FNB and FICB are effective in pain reduction for fractures of femur, but FNB provides more pain relief and less need for supplemental fentanyl.

Conclusion (proposition de traduction) : emergency department; fascia iliaca compartment block; femoral nerve block; femur fracture.

Relationship between extravascular leakage and clinical outcome on computed tomography of isolated traumatic brain injury.
Ito H, Nakamura Y, Togami Y, Onishi S, Nakao S, Ogura H, Oda J. | Acute Med Surg. 2024 Feb 20;11(1):e931
DOI: https://doi.org/10.1002/ams2.931  | Télécharger l'article au format  
Keywords: contrast extravasation; head injury; mortality; surgery.

ORIGINAL ARTICLE

Introduction : This study investigated whether contrast extravasation on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with death or surgical procedures.

Méthode : Patients over 18 years old, directly brought in by ambulance with an isolated head injury and confirmed to have acute intracranial hemorrhage on a CT scan upon admission between 2010 and 2020, were included. The primary outcome was mortality, and the secondary outcome was neurosurgical procedures performed from admission to discharge from the intensive care unit. Multivariable logistic regression analyses were performed to evaluate the association between these outcomes and contrast extravasation.

Résultats : The analysis included 188 patients with a median age of 65 years, 123 men (65.4%), 34 deaths (18.1%), and 91 surgeries (48.4%). Among the 66 patients with contrast extravasation, 22 (33.3%) died and 47 (71.2%) required surgery. Among the 122 patients with no contrast extravasation, 12 (9.8%) died, and 44 (36.1%) required surgery. The presence or absence of extravascular leakage was associated with death (odds ratio, 3.6 [95% CI: 1.2-12.2]) and surgery (odds ratio, 7.6 [95% CI: 2.5-22.7]).

Conclusion : Contrast extravasation was associated with mortality and performance of surgery in patients with an isolated head injury.

Conclusion (proposition de traduction) : L'extravasation de produit de contraste a été associée à la mortalité et à la réalisation d'une intervention chirurgicale chez des patients souffrant d'un traumatisme crânien isolé.

Morphine (10, 20 mg) in a Postoperative Dressing Used with Patients After Surgical Debridement of Burn Wounds: A Prospective, Double-Blinded, Randomized Controlled Trial.
Kowalski G, Domagalska M, Słowiński K, Grochowicka M, Zawadzki M, Kropińska S, Leppert W, Wieczorowska-Tobis K. | Adv Wound Care (New Rochelle). 2024 Mar;13(3):115-122
DOI: https://doi.org/10.1089/wound.2023.0037
Keywords: analgesia; dressing; morphine; opioids; pain management.

Discovery Express

Introduction : This is the first clinical trial to evaluate the analgesic effect of 10 and 20 mg of morphine used in a postoperative dressing with patients after surgical debridement of burn wounds.

Méthode : In this randomized controlled trial, 20 adult patients with third-degree flame burns, who had undergone surgical debridement under general anesthesia, were randomly assigned to either group A, whose members were treated with a burn dressing that contained 10 mg of morphine, or group B, whose members were treated with a burn dressing that contained 20 mg of morphine; the dressing was also soaked with octenidine and phenoxyethanol in the case of both groups. The plasma morphine concentrations were measured 1, 2, 3, and 6 h after surgery, while the level of pain intensity was determined on the Numeric Pain Rating Scale (NRS), and the occurrence of side effects was observed. Results: The serum morphine concentration levels were very low, but statistically different between the two groups at all time points. The NRS value was similar in both groups at all time points (p > 0.05). Despite this, in group B, the NRS value was 0 in all patients in postoperative hours 1, 2, and 3. No adverse effect of morphine sulfate was observed in any patient.

Résultats : This project is the first clinical study to have demonstrated that morphine administered in dressings in concentrations of 0.02-0.08 mg/mL significantly reduces the occurrence of pain.

Conclusion : The use of morphine in dressings after surgical treatment of burn wounds is very effective when it comes to pain management and is safe for the patient.

Conclusion (proposition de traduction) : L'utilisation de la morphine pour les pansements après le traitement chirurgical des brûlures est très efficace pour la gestion de la douleur et est sans danger pour le patient.

Emergency care drugs' chemical stability after eight weeks' deployment in the prehospital setting.
Sobuwa S, Singh T, Kalicharan K. | Afr J Emerg Med. 2024 Mar;14(1):7-10
DOI: https://doi.org/10.1016/j.afjem.2023.11.009  | Télécharger l'article au format  
Keywords: Drugs; Environmental exposure; Out-of-hospital; Prehospital drug storage.

Research article

Introduction : Temperature conditions vary in emergency service vehicles, which may pose a risk to the integrity of the drugs on board, possibly rendering them ineffective and increasing morbidity and mortality in patients.
Aim: This study assessed the stability of four emergency care drugs (adrenaline, etomidate, ketamine, and rocuronium) after eight weeks of deployment in the prehospital context.

Méthode : The study adopted a longitudinal quantitative design to evaluate the chemical stability of emergency care drugs. The study was conducted at four emergency medical service bases in Ballito, Durban and Pietermaritzburg, South Africa. The primary outcome was the relative reduction in drug concentration from the labelled concentration after four and eight weeks. High-performance liquid chromatography-mass spectrometry (HPLC-MS) analysed samples to determine the concentration of active ingredients in the drug samples.

Résultats : HPLC analysis was done on 176 samples. The ambient temperature ranged from 18.7 to 44 °C in the first four weeks, averaging 26.8 °C ± 3.0. At 4 and 8 weeks, Adrenaline decreased 24.93 % and 22.73 %, respectively. Etomidate's control had 3.06 mg/ml, not the 2 mg/ml on the bottle. After 4 and 8 weeks, the samples had 3.10 and 3.15 mg/ml active components, respectively. Ketamine degraded over 30 % after four weeks but not beyond that. The Ketamine package states 10 mg/ml. However, we found 17.46 mg/ml. Rocuronium was 6.45 mg/ml in the control, although the manufacturer specified 10 mg/ml. At four weeks, the concentration was 6.70 mg/ml; at eight weeks, 6.56.

Conclusion : This study suggests that adrenaline and ketamine degrade by more than 20 % within four weeks of deployment in the prehospital field, whereas etomidate and rocuronium remain stable after eight weeks.

Conclusion (proposition de traduction) : Cette étude suggère que l'adrénaline et la kétamine se dégradent de plus de 20 % dans les quatre semaines suivant leur utilisation en milieu préhospitalier, alors que l'étomidate et le rocuronium restent stables après huit semaines.

Multicenter, Randomized, Placebo-controlled Crossover Trial Evaluating Topical Lidocaine for Mechanical Cervical Pain.
Cohen SP, Larkin TM, Weitzner AS, Dolomisiewicz E, Wang EJ, Hsu A, Anderson-White M, Smith MS, Zhao Z. | Anesthesiology. 2024 Mar 1;140(3):513-523
DOI: https://doi.org/10.1097/aln.0000000000004857  | Télécharger l'article au format  
Keywords: Aucun

Pain Medicine

Introduction : There are few efficacious treatments for mechanical neck pain, with controlled trials suggesting efficacy for muscle relaxants and topical nonsteroidal anti-inflammatory drugs. Although studies evaluating topical lidocaine for back pain have been disappointing, the more superficial location of the cervical musculature suggests a possible role for topical local anesthetics.

Méthode : This study was a randomized, double-blind, placebo-controlled crossover trial performed at four U.S. military, Veterans Administration, academic, and private practice sites, in which 76 patients were randomized to receive either placebo followed by lidocaine patch for 4-week intervals (group 1) or a lidocaine-then-placebo patch sequence. The primary outcome measure was mean reduction in average neck pain, with a positive categorical outcome designated as a reduction of at least 2 points in average neck pain coupled with at least a 5-point score of 7 points on the Patient Global Impression of Change scale at the 4-week endpoint.

Résultats : For the primary outcome, the median reduction in average neck pain score was -1.0 (interquartile range, -2.0, 0.0) for the lidocaine phase versus -0.5 (interquartile range, -2.0, 0.0) for placebo treatment (P = 0.17). During lidocaine treatment, 27.7% of patients experienced a positive outcome versus 14.9% during the placebo phase (P = 0.073). There were no significant differences between treatments for secondary outcomes, although a carryover effect on pain pressure threshold was observed for the lidocaine phase (P = 0.015). A total of 27.5% of patients in the lidocaine group and 20.5% in the placebo group experienced minor reactions, the most common of which was pruritis (P = 0.36).

Conclusion : The differences favoring lidocaine were small and nonsignificant, but the trend toward superiority of lidocaine suggests more aggressive phenotyping and applying formulations with greater penetrance may provide clinically meaningful benefit.

Conclusion (proposition de traduction) : Les différences en faveur de la lidocaïne étaient faibles et non significatives, mais la tendance à la supériorité de la lidocaïne suggère qu'un phénotypage plus agressif et l'application de formulations ayant une plus grande pénétration pourraient apporter un bénéfice cliniquement significatif.

Commentaire : Les emplâtres médicamenteux contenant de la lidocaïne sont indiqués pour traiter les douleurs neuropathiques post-zostériennes chez l’adulte. Ils sont dosés à 700 mg de lidocaïne, appliqué une fois par jour, pendant une période maximale de 12 heures par 24 heures.
Le mécanisme d’action serait lié à une stabilisation des membranes neuronales entraînant une diminution d’activité des canaux sodiques aboutissant ainsi à une diminution de la douleur (traitement dit « neuromodulateur »).
De nombreuses études ont montré leur intérêt dans le cadre d’autres types de douleurs neuropathiques telles que les neuropathies diabétiques, les douleurs postopératoires, les lombalgies, les névralgies post-traumatiques, les névralgies faciales (névralgie du trijumeau, neuropathie trigéminale…), les douleurs neuropathiques liées au cancer ou encore l’algodystrophie et la douleur liée aux crises vaso-occlusives drépanocytaires.
Compte tenu de la faible efficacité de la plupart des traitements habituels dans ces indications, il semble intéressant de pouvoir intégrer ce médicament topique dans l'arsenal thérapeutique.

Early Versus Late Advanced Airway Management for Pediatric Patients With Out-of-Hospital Cardiac Arrest.
Amagasa S, Iwamoto S, Kashiura M, Yasuda H, Kishihara Y, Uematsu S. | Ann Emerg Med. 2024 Mar;83(3):185-195
DOI: https://doi.org/10.1016/j.annemergmed.2023.09.023  | Télécharger l'article au format  
Keywords: Aucun

Research article Pediatrics

Introduction : To determine the association between early versus late advanced airway management and improved outcomes in pediatric out-of-hospital cardiac arrest.

Méthode : We performed a retrospective cohort study using data from the out-of-hospital cardiac arrest registry in Japan. We included pediatric patients (<18 years) with out-of-hospital cardiac arrest who had received advanced airway management (tracheal intubation, supraglottic airway, and esophageal obturator). The main exposure was early (≤20 minutes) versus late (>20 minutes) advanced airway management. The primary and secondary outcome measurements were survival and favorable neurologic outcomes at 1 month, respectively. To address resuscitation time bias, we performed risk-set matching analyses using time-dependent propensity scores.

Résultats : Out of the 864 pediatric patients with both out-of-hospital cardiac arrest and advanced airway management over 67 months (2014 to 2019), we included 667 patients with adequate data (77%). Of these 667 patients, advanced airway management was early for 354 (53%) and late for 313 (47%) patients. In the risk-set matching analysis, the risk of both survival (risk ratio 0.98 for early versus late [95% confidence interval 0.95 to 1.02]) and favorable 1-month neurologic outcomes (risk ratio 0.99 [95% confidence interval 0.97 to 1.00]) was similar between early and late advanced airway management groups. In sensitivity analyses, with time to early advanced airway management defined as ≤10 minutes and ≤30 minutes, both outcomes were again similar.

Conclusion : In pediatric out-of-hospital cardiac arrest, the timing of advanced airway management may not affect patient outcomes, but randomized controlled trials are needed to address this question further.

Conclusion (proposition de traduction) : Dans le cas d'un arrêt cardiaque pédiatrique extrahospitalier, le moment choisi pour la prise en charge avancée des voies aériennes (précoce ou tardive, chez 667 patients) n'a peut-être pas d'incidence sur les résultats des patients, mais des essais contrôlés randomisés sont nécessaires pour approfondir cette question.

Diagnostic Accuracy of Point-of-Care Ultrasound Versus Radiographic Imaging for Pediatric Distal Forearm Fractures: A Randomized Controlled Trial.
Snelling PJ, Jones P, Bade D, Bindra R, Davison M, Gillespie A, McEniery J, Moore M, Keijzers G, Ware RS. | Ann Emerg Med. 2024 Mar;83(3):198-207
DOI: https://doi.org/10.1016/j.annemergmed.2023.10.008  | Télécharger l'article au format  
Keywords: Aucun

Research article Pediatriccs

Introduction : In patients aged 5 to 15 years with a clinically nondeformed distal forearm injury presenting to the emergency department (ED), we examined whether point-of-care ultrasound or radiographic imaging had better diagnostic accuracy, with the reference diagnosis determined by an expert panel review.

Méthode : This multicenter, open-label, diagnostic randomized controlled trial was conducted in South East Queensland, Australia. Eligible patients were randomized to receive initial imaging through point-of-care ultrasound performed by an ED clinician or radiograph. Images were defined as "no," "buckle," or "other" fracture by the treating clinician. The primary outcome was the diagnostic accuracy of the treating clinician's interpretation compared against the reference standard diagnosis, which was determined retrospectively by an expert panel consisting of an emergency physician, pediatric radiologist, and pediatric orthopedic surgeon, who reviewed all imaging and follow-up.

Résultats : Two-hundred and seventy participants were enrolled, with 135 randomized to each initial imaging modality. There were 132 (97.8%) and 112 (83.0%) correctly diagnosed participants by ED clinicians in the point-of-care ultrasound and radiograph groups, respectively (absolute difference [AD]=14.8%; 95% confidence interval [CI] 8.0% to 21.6%; P<.001). Point-of-care ultrasound had better accuracy for participants with "buckle" fractures (AD=18.5%; 95% CI 7.1% to 29.8%) and "other" fractures (AD=17.1%; 95% CI 2.7% to 31.6%). No clinically important fractures were missed in either group.

Conclusion :  In children and adolescents presenting to the ED with a clinically nondeformed distal forearm injury, clinician-performed (acquired and interpreted) point-of-care ultrasound more accurately identified the correct diagnosis than clinician-interpreted radiographic imaging.

Conclusion (proposition de traduction) : hez les enfants et les adolescents se présentant aux urgences avec une lésion de l'avant-bras distal non déformée cliniquement, l'échographie réalisée par le clinicien (acquise et interprétée) a permis d'identifier le bon diagnostic avec plus de précision que l'imagerie radiographique interprétée par le clinicien.

Management of cardiogenic shock: a narrative review.
Laghlam D, Benghanem S, Ortuno S, Bouabdallaoui N, Manzo-Silberman S, Hamzaoui O, Aissaoui N. | Ann Intensive Care. 2024 Mar 30;14(1):45
DOI: https://doi.org/10.1186/s13613-024-01260-y  | Télécharger l'article au format  
Keywords: Cardiogenic shock; ECMO; Hemodynamic monitoring; Mechanical ventilation; Myocardial infarction; Shock.

Review

Editorial : Cardiogenic shock (CS) is characterized by low cardiac output and sustained tissue hypoperfusion that may result in end-organ dysfunction and death. CS is associated with high short-term mortality, and its management remains challenging despite recent advances in therapeutic options. Timely diagnosis and multidisciplinary team-based management have demonstrated favourable effects on outcomes. We aimed to review evidence-based practices for managing patients with ischemic and non-ischemic CS, detailing the multi-organ supports needed in this critically ill patient population.

Conclusion : The management of CS has seen significant advances in recent decades, but the mortality remains dramatically high. As for other types of shock, rapid recognition with multimodal evaluation by ECG, biological and echocardiographic tests allows early and appropriate management and may improve survival. Recent classifications allowing better stratification of mortality risk may be useful to guide the management. The cornerstone of CS patient management is the treatment of the cause of the cardiac insult including coronary revascularization by PCI of the culprit lesion in case of AMI. Symptomatic management aims to restore perfusion with noradrenaline and increase cardiac output with inotropic therapies. The management of other organs failure is based on optimization of mechanical ventilation and appropriate initiation of RRT. Mechanical assist devices may have an important role in CS patients but, pending the results of further clinical trials, the type and implantation timing of such techniques remain to be defined according to the expertise of the Heart Team.

Conclusion (proposition de traduction) : La prise en charge du choc cardiogénique a connu des avancées significatives au cours des dernières décennies, mais la mortalité reste dramatiquement élevée. Comme pour les autres types de chocs, une reconnaissance rapide avec une évaluation multimodale par ECG, tests biologiques et échocardiographiques permet une prise en charge précoce et appropriée et peut améliorer la survie. Des classifications récentes permettant une meilleure stratification du risque de mortalité peuvent être utiles pour guider la prise en charge. La pierre angulaire de la prise en charge des patients en choc cardiogénique est le traitement de la cause de l'atteinte cardiaque, y compris la revascularisation coronaire par intervention coronaire percutanée de la lésion coupable en cas d'infarctus aigu du myocarde. La prise en charge symptomatique vise à rétablir la perfusion par la noradrénaline et à augmenter le débit cardiaque par des thérapies inotropes. La prise en charge de la défaillance d'autres organes repose sur l'optimisation de la ventilation mécanique et l'instauration appropriée d'une dialyse rénale. Les dispositifs d'assistance mécanique peuvent jouer un rôle important chez les patients en état de choc cardiogénique mais, dans l'attente des résultats d'autres essais cliniques, le type et le moment de l'implantation de ces techniques restent à définir en fonction de l'expertise de l'équipe de cardiologie.

As loud as a construction site: Noise levels in the emergency department.
Adams C, Walsan R, McDonnell R, Schembri A. | Australas Emerg Care. 2024 Mar;27(1):26-29
DOI: https://doi.org/10.1016/j.auec.2023.07.004  | Télécharger l'article au format  
Keywords: Environment; Hospitals; Noise; Patient experience; Patients; Safety.

Full length article

Introduction : The Emergency Department (ED), while being an integral part of healthcare systems, frequently experiences noise levels surpassing the World Health Organization's recommended thresholds. These excessive noise levels could considerably compromise the safety and wellbeing of both patients and staff.

Méthode : To evaluate noise levels throughout the ED environment, this study utilized dosimeters to measure noise levels over a 24-hour period in six distinct locations, including the ED Waiting Room and Treatment areas.

Résultats : The study found that noise exceeded the WHO recommendations in all six areas of the ED for the entire 24-hour period. Peak noise levels were recorded up to 102.8 dB, which is as loud as noise levels at a construction site. The ED Waiting Room exhibited high peak and average noise levels, indicating the urgent need for quality improvement efforts. These findings align with the results of previous research, thereby suggesting that noise levels in the ED have remained problematic for more than a decade.

Conclusion : The findings of this study underscore the importance of addressing excessive noise levels in the ED to create a safe and therapeutic hospital environment for both patients and staff. Healthcare organizations must implement proactive measures to address excessive noise levels in the ED.

Conclusion (proposition de traduction) : Les résultats de cette étude soulignent l'importance de s'attaquer aux niveaux de bruit excessifs dans le service des urgences afin de créer un environnement hospitalier sûr et thérapeutique pour les patients et le personnel. Les organismes de santé doivent mettre en œuvre des mesures proactives pour lutter contre les niveaux de bruit excessifs dans les services d'urgence.

Teaching cardiopulmonary resuscitation using virtual reality: A randomized study.
Alcázar Artero PM, Greif R, Cerón Madrigal JJ, Escribano D, Pérez Rubio MT, Alcázar Artero ME, López Guardiola P, Mendoza López M, Melendreras Ruiz R, Pardo Ríos M. | Australas Emerg Care. 2024 Mar;27(1):57-62
DOI: https://doi.org/10.1016/j.auec.2023.08.002
Keywords: Cardiopulmonary resuscitation; Clinical simulation; Innovation; Nurse; Salivary alpha-amylase; Serious gaming; Virtual reality.

RESEARCH PAPER

Introduction : The main functions of healthcare professionals include training and health education. In this sense, we must be able to incorporate new technologies and serious game to the teaching cardiopulmonary resuscitation.

Méthode : A multicenter, comparative and cross-sectional study was carried out to assess the learning of resuscitation of a group that was trained with the use of serious gaming with virtual reality, as compared to a control group trained with conventional classroom teaching.

Résultats : the mean quality obtained in chest compressions for The virtual reality group was 86.1 % (SD 9.3), and 74.8 % (SD 9.5) for the control group [mean difference 11.3 % (95 % CI 6.6-16.0), p < 0.001]. Salivary Alpha-Amylase was 218.882 (SD 177.621) IU/L for the virtual reality group and 155.190 (SD 116.746) IU/L for the control group [mean difference 63.691 (95 % CI 122.998-4.385), p = 0.037].

Conclusion : Using virtual reality and serious games can improve the quality parameters of chest compressions as compared to traditional training.

Conclusion (proposition de traduction) : L'utilisation de la réalité virtuelle et des jeux sérieux peut améliorer les paramètres de qualité des compressions thoraciques par rapport à la formation traditionnelle.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study.
Vahedian-Azimi A, Hassan IF, Rahimi-Bashar F, Elmelliti H, Salesi M, Alqahwachi H, Albazoon F, Akbar A, Shehata AL, Ibrahim AS, Ait Hssain A. | BMC Emerg Med. 2024 Mar 5;24(1):36
DOI: https://doi.org/10.1186/s12873-023-00905-8  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Extracorporeal circulation; Extracorporeal membrane oxygenation out-of-hospital cardiac arrest; In-hospital cardiac arrest; Prognosis.

Article

Introduction : The impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO).

Méthode : The impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO).

Résultats : The results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218-2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183-0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106-0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332-3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest.

Conclusion : Based on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.

Conclusion (proposition de traduction) : Sur la base de nos résultats, il a été déterminé que le temps de no-flow est un facteur prédictif plus efficace que le temps de low-flow pour évaluer les résultats cliniques des patients ayant subi un arrêt cardiaque extra-hospitalier ou un arrêt cardiaque intra-hospitalier et ayant bénéficié d'une ECMO. Cette compréhension de leurs capacités prédictives distinctes permet aux professionnels de la santé d'identifier plus précisément les patients à haut risque et d'adapter leurs interventions en conséquence.

Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials.
Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. | Br J Anaesth. 2024 Mar;132(3):491-506
DOI: https://doi.org/10.1016/j.bja.2023.11.050  | Télécharger l'article au format  
Keywords: analgesia; critical care; emergency; network meta-analysis; procedural sedation; systematic review.

Critical Care

Introduction : We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications.

Méthode : We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates.

Résultats : We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty).

Conclusion : When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

Conclusion (proposition de traduction) : En ce qui concerne la sédation et l'analgésie procédurales dans les services d'urgence et les unités de soins intensifs, le temps de récupération de la sédation est plus court avec le propofol qu'avec le midazolam-opioïdes, la satisfaction du patient est meilleure avec la kétamine-propofol et les effets indésirables respiratoires sont moins fréquents avec la kétamine.

The hidden expense of stethoscope hygiene versus the real costs of failure.
Peacock WF | Clin Exp Emerg Med. 2024 Mar;11(1):6-8
DOI: https://doi.org/10.15441/ceem.23.161  | Télécharger l'article au format  
Keywords: Aucun

Commentary

Editorial : It is well established that the stethoscope is covered in pathogens. Thus, it is recommended that to decrease the population of pathogens that reside on a stethoscope diaphragm, it should be cleaned with at least 60 seconds of alcohol scrubbing before each patient contact [1]. Unfortunately, compliance with these recommendations has never been demonstrated. In fact, the converse is well documented, with recommendation compliant stethoscope hygiene rates rarely exceeding double digits. This is because, if performed appropriately before each patient contact, it requires a significant amount of time that could otherwise be dedicated to patient care.

Conclusion : Given the extensive morbidity that occurs with failure to clean the stethoscope, and the fiscal value proposition resulting from the prevention of stethoscope related hospital associated infections, we suggest that improvements in stethoscope hygiene should be supported at the national and regulatory level. This should include the implementation of standardized institutional protocols, as well as support via national subsidies and public funds to insure the implementation and compliance in the use of touch free stethoscope barriers.

Conclusion (proposition de traduction) : Compte tenu de l'importante morbidité liée à l'absence de nettoyage du stéthoscope et de la valeur fiscale résultant de la prévention des infections nosocomiales liées au stéthoscope, nous suggérons que l'amélioration de l'hygiène du stéthoscope soit soutenue au niveau national et réglementaire. Cela devrait inclure la mise en œuvre de protocoles institutionnels standardisés, ainsi qu'un soutien par le biais de subventions nationales et de fonds publics pour assurer la mise en œuvre et le respect de l'utilisation de dispositifs de protection des stéthoscopes sans contact.

Point-of-care ultrasound for airway management in the emergency and critical care setting.
Gottlieb M, O'Brien JR, Ferrigno N, Sundaram T. | Clin Exp Emerg Med. 2024 Mar;11(1):22-32
DOI: https://doi.org/10.15441/ceem.23.094  | Télécharger l'article au format  
Keywords: Intubation; Airway management; Ultrasound; Ultrasonography

Review article

Editorial : Airway management is a common procedure within emergency and critical care medicine. Traditional techniques for predicting and managing a difficult airway each have important limitations. As the field has evolved, point-of-care ultrasound has been increasingly utilized for this application. Several measures can be used to sonographically predict a difficult airway, including skin to epiglottis, hyomental distance, and tongue thickness. Ultrasound can also be used to confirm endotracheal tube intubation and assess endotracheal tube depth. Ultrasound is superior to the landmark-based approach for locating the cricothyroid membrane, particularly in patients with difficult anatomy. Finally, we provide an algorithm for using ultrasound to manage the crashing patient on mechanical ventilation. After reading this article, readers will have an enhanced understanding of the role of ultrasound in airway management.

Conclusion : Airway management is a common procedure within emergency and critical care medicine. Traditional techniques for predicting and managing a difficult airway each have important limitations. As the field has evolved, POCUS has been increasingly utilized for this application. Ultrasound can be utilized to predict difficult airways, confirm ETT location and depth, locate the CTM, and facilitate the assessment and management of the crashing patient on mechanical ventilation.

Conclusion (proposition de traduction) : La gestion des voies aériennes est une procédure courante en médecine d'urgence et en soins intensifs. Les techniques traditionnelles de détection et de gestion des voies aériennes difficiles présentent chacune d'importantes limitations. Avec l'évolution du sujet, l'échographie au point d'intervention a été de plus en plus utilisée dans cette application. L'échographie peut être utilisée pour prédire les voies aériennes difficiles, confirmer l'emplacement et la profondeur du tube endotrachéal, localiser la membrane cricothyroïdienne et faciliter l'évaluation et la prise en charge du patient en état de choc sous ventilation mécanique.

Tranexamic acid for angiotensin-converting enzyme inhibitor–induced angioedema.
Pathak GN, Truong TM, Chakraborty A, Rao B, Monteleone C. | Clin Exp Emerg Med. 2024 Mar;11(1):94-99
DOI: https://doi.org/10.15441/ceem.23.051  | Télécharger l'article au format  
Keywords: Angiotensin-converting enzyme inhibitors; Angiotensin-converting enzyme inhibitor–induced angioedema; Bradykinin-mediated angioedema; Drug-induced angioedema; Tranexamic acid.

Brief review

Editorial : Approximately 0.7% of patients taking angiotensin-converting enzyme inhibitors (ACEIs) develop ACEI-induced angioedema (ACEI-IA). With no approved treatments for ACEI-IA, the risk of complications is concerning. Tranexamic acid (TXA) has the potential to prevent intubations and resolve ACEI-IA by inhibiting the downstream production of bradykinin. In this review, we aim to evaluate the safety and efficacy of TXA use in ACEI-IA. We queried the PubMed database for studies involving TXA for ACEI-IA from January 2003 to January 2023. Seven studies met the study inclusion criteria. Our results demonstrate that TXA may improve angioedema symptoms and prevent intubation. In addition, its availability, low cost, and safety profile support its use for improving the symptoms and complications of ACEI-IA in an emergency setting.

Conclusion : Future randomized controlled trials of TXA use in ACEI-IA are needed to further support its efficacy and safety in this indication. There have been no direct comparator studies for ACEI-IA between different agents, and future studies will allow a better comparison of efficacy and adverse effects to optimize agent selection. Potential drawbacks to the use of TXA include the possibility of thrombotic events, adverse gastrointestinal effects, and a lack of large-scale studies that evaluate its use.
ACEI-IA remains a key unmet medical need, accounting for approximately 30% to 40% of angioedema emergency department visits. As the ACEI class of medications is ubiquitously used for hypertension, heart failure, diabetes, and kidney disease, patients should be advised on the signs and symptoms of angioedema. Additionally, the gaining popularity of combination medications, the “polypill”, may further increase total ACEI exposure. Prompt treatment of ACEI-IA is needed to prevent intubation and improve clinical outcomes.
In this literature review, we highlight the valuable role of TXA in reducing intubation rates and improving angioedema symptoms in ACEI-IA. Notably, there were no deaths reported, and four patients requiring intubation in the evaluated studies were all intubated before TXA administration. TXA use may be advantageous due to availability, lower cost, and low prevalence of adverse effects compared to other off-label medications currently used for ACEI-IA.

Conclusion (proposition de traduction) : De futurs essais contrôlés randomisés sur l'utilisation de l'acide tranexamique dans l'angio-œdème induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine sont nécessaires pour mieux étayer l'efficacité et la sécurité de l'acide tranexamique dans cette indication. Il n'y a pas eu d'études comparatives directes entre différents agents pour l'angio-œdème induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine, et les études futures permettront une meilleure comparaison de l'efficacité et des effets indésirables afin d'optimiser le choix de l'agent. Les inconvénients potentiels de l'acide tranexamique comprennent la possibilité d'événements thrombotiques, les effets gastro-intestinaux indésirables et le manque d'études à grande échelle qui évaluent son utilisation.
L'angio-œdème induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine reste un besoin médical clé non satisfait, représentant environ 30 à 40 % des visites aux urgences pour angio-œdème. La classe des inhibiteurs de l'enzyme de conversion de l'angiotensine étant omniprésente dans le traitement de l'hypertension, de l'insuffisance cardiaque, du diabète et des maladies rénales, les patients doivent être informés des signes et des symptômes de l'œdème de Quincke. En outre, la popularité croissante des médicaments combinés, la « polypill », peut encore augmenter l'exposition totale aux inhibiteurs de l'enzyme de conversion de l'angiotensine. Un traitement rapide de l'œdème de Quincke induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine est nécessaire pour éviter l'intubation et améliorer les résultats cliniques.
Dans cette revue de la littérature, nous soulignons le rôle précieux de l'acide tranexamique dans la réduction des taux d'intubation et l'amélioration des symptômes de l'angio-œdème induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine. Il est à noter qu'aucun décès n'a été signalé et que les quatre patients nécessitant une intubation dans les études évaluées ont tous été intubés avant l'administration d'acide tranexamique. L'utilisation de l'acide tranexamique peut être intéressante en raison de sa disponibilité, de son faible coût et de la faible prévalence des effets indésirables par rapport à d'autres médicaments non homologués actuellement utilisés pour traiter l'œdème de Quincke induit par les inhibiteurs de l'enzyme de conversion de l'angiotensine.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition.
Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. | Crit Care. 2023 Mar 1;27(1):80
DOI: https://doi.org/10.1186/s13054-023-04327-7  | Télécharger l'article au format  
Keywords: Diagnostics; Emergency medicine; Haemostasis; Major bleeding; Management; Practice guideline; Trauma; Traumatic coagulopathy.

Guidelines

Introduction : Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

Méthode : The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

Résultats : This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

Conclusion : A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Conclusion (proposition de traduction) : Une approche multidisciplinaire et le respect de lignes directrices fondées sur des données probantes sont les piliers des meilleures pratiques dans la prise en charge des patients traumatisés graves. L'optimisation et la normalisation des soins de traumatologie en fonction des données disponibles dans toute l'Europe et au-delà permettront d'améliorer encore les résultats.

Consensus statement on the interhospital transfer of patients with acute aortic syndrome: TRAVERSING Delphi study.
Staniszewska A, Gaba K, Patterson B, Wilson S, Bell R, Bicknell C, Brooks M, Callaway M, Goode S, Grier S, Hobson A, Mouton R, Neequaye S, Owens G, Rajakaruna C, Redfern E, Tsang G, Hinchliffe R. | Emerg Med J. 2024 Feb 20;41(3):153-161
DOI: https://doi.org/10.1136/emermed-2023-213362  | Télécharger l'article au format  
Keywords: critical care transport; emergency ambulance systems; emergency care systems; pre-hospital care; vascular.

Original research

Introduction : Standardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim of the Transfer of Thoracic Aortic Vascular Emergencies to Regional Specialist INstitutes Group study was to establish an interdisciplinary consensus on the interhospital transfer of patients with AAS to specialist high-volume aortic centres.

Méthode : Consensus on the key aspects of interhospital transfer of patients with AAS was established using the Delphi method, in line with Conducting and Reporting of Delphi Studies guidelines. A national patient charity for aortic dissection was involved in the design of the Delphi study. Vascular and cardiothoracic surgeons, emergency physicians, interventional radiologists, cardiologists, intensivists and anaesthetists in the United Kingdom were invited to participate via their respective professional societies.

Résultats : Three consecutive rounds of an electronic Delphi survey were completed by 212, 101 and 58 respondents, respectively. Using predefined consensus criteria, 60 out of 117 (51%) statements from the survey were included in the consensus statement. The study concluded that patients can be taken directly to a specialist aortic centre if they have typical symptoms of AAS on the background of known aortic disease or previous aortic intervention. Accepted patients should be transferred in a category 2 ambulance (response time <18 min), ideally accompanied by transfer-trained personnel or Adult Critical Care Transfer Services. A clear plan should be agreed in case of a cardiac arrest occurring during the transfer. Patients should reach the aortic centre within 4 hours of the initial referral from their local hospital.

Conclusion : This consensus statement is the first set of national interdisciplinary recommendations on the interhospital transfer of patients with AAS. Its implementation is likely to contribute to safer and more standardised emergency referral pathways to regional high-volume specialist aortic units.

Conclusion (proposition de traduction) : Cette déclaration de consensus est le premier ensemble de recommandations interdisciplinaires nationales sur le transfert interhospitalier des patients présentant un syndrome aortique aigu. Sa mise en œuvre devrait contribuer à rendre plus sûres et plus standardisées les filières d'orientation des urgences vers les unités régionales spécialisées dans le syndrome aortique à haut volume.

Four-factor prothrombin complex concentrate versus andexanet alfa for the reversal of traumatic brain injuries.
Sadek E, Curtiss W, Andrews J, Hecht J. | Emerg Med J. 2024 Feb 20;41(3):162-167
DOI: https://doi.org/10.1136/emermed-2023-213229
Keywords: accidental falls; craniocerebral trauma; critical care

Original research

Introduction : Andexanet alfa was approved in 2018 for reversal of direct oral anticoagulants but due to issues of cost and access, four-factor prothrombin complex concentrate (4F-PCC) continues to be used for this indication. The objective of this study is to evaluate outcomes of reversal with these agents in patients with isolated traumatic brain injuries (TBI).

Méthode : This is a retrospective review of 35 trauma centres from 2014 to 2021. Patients were included with an Abbreviated Injury Scale (AIS)>2 for head and having received andexanet alfa or 4F-PCC within 24 hours of admission. Patients were excluded if P2Y12 inhibitor use or AIS>2 outside of head. Primary outcome includes rate of mortality/hospice at hospital discharge. Secondary outcomes include a composite of serious hospital complications. A subgroup analysis of severe TBI patients (AIS head 4 or 5) was completed. Multivariable logistic regression was used to account for differences in comorbidities and TBI severity.

Résultats : 4F-PCC was given to 265 patients with another 59 receiving andexanet alfa. Patients in the andexanet alfa group were more likely to have an AIS head score of 5 (47.5% vs 26.1%; p<0.005). After adjusting for severity of TBI and comorbidities with regard to tomortality/hospice, there were 15 (25.4%) patients in the andexanet alfa group and 49 (18.5%) in the 4F-PCC group (OR 1.34; 95% CI 0.67 to 2.71). This remained consistent when looking at severe patients with TBI with 12 (28.6%) andexanet alfa patients and 37 (28.7%) 4F-PCC patients (OR 0.93 (95% CI 0.40 to 2.16)). Severe hospital complications were also similar between groups with 5 (8.5%) andexanet alfa patients as compared with 21 (7.9%) 4F-PCC patients (OR 1.01; 95% CI 0.36 to 2.88).

Conclusion : There was no firm conclusion on the treatment effect in mortality/hospice or serious complications among isolated TBI patients reversed with 4F-PCC as compared with andexanet alfa.

Conclusion (proposition de traduction) : Il n'y a pas eu de conclusion définitive sur la réduction de la mortalité, de l'hospitalisation ou des complications graves chez les patients présentant des lésions cérébrales traumatiques isolées traitées par le 4F-PCC par rapport à l'andexanet alfa.

Efficacy of Intravenous Paracetamol, Dexketoprofen, and Ibuprofen in Treating Headache Induced by Acute Migraine Attack.
Şerife Ö, Atakan Y, Alten O, Aykut K, Mehmet U, Yeşim KÇ, Ezgi D, Murat S, Mert Ö, İbrahim T. | Eurasian J Emerg Med.. 2024 Mar;23(1):49-56
DOI: https://doi.org/10.4274/eajem.galenos.2024.84666.
Keywords: Dexketoprofen, emergency department, ibuprofen, migraine, acetaminophen

Original Article

Introduction : Migraine is the most prevalent cause of admission to the emergency department (ED) with pain complaints. This study seeks to provide a comparative evaluation of the efficacy of intravenous paracetamol, dexketoprofen, and ibuprofen in treating headache induced by acute migraine attack.

Méthode : Two hundred and seven volunteers with headache due to migraine attack were randomized into three groups. Group I was administered with intravenous paracetamol, Group II with intravenous dexketoprofen trometamol, and Group III with intravenous ibuprofen. A 100-mm visual analogue scale (VAS) score was used as an assessment scale to monitor dynamic changes in headaches during the 1-h observation of migraineurs.

Résultats : In Group I, the mean baseline VAS score was 79.65±13.87 and 11.83±14.37 at 60 min. In Group II, the mean baseline VAS score was 77.14±11.31 and 7.79±14.37 at 60 min. In Group III, the mean VAS score decreased from baseline 76.89±11.92 to 6.67±10.13 after 60 min. Considering the ΔVAS scores 30-min scores differed significantly between Group I and Group III (p=0.009).

Conclusion : IV paracetamol, dexketoprofen, and ibuprofen treatments did not differ significantly in acute migraine therapy. IV ibuprofen may be a first-line choice in EDs because of its immediate analgesic effect.

Conclusion (proposition de traduction) : Les traitements par le paracétamol, le dexkétoprofène et l'ibuprofène administrés par voie intraveineuse n'ont pas présenté de différences significatives dans le traitement de la migraine aiguë. L'ibuprofène IV peut être un choix de première intention dans les urgences en raison de son effet analgésique immédiat.

Commentaire : Gaskell H, Derry S, Wiffen PJ, Moore RA. Kétoprofène et dexkétoprofène oral en dose unique pour la douleur postopératoire aiguë chez l'adulte. Cochrane Database Syst Rev. 2017 May 25;5(5):CD007355  .

Breaking the Cycle: How Physical Therapy Modalities Impact Emergency Department Visits in Patients with Chronic Low Back Pain.
Ezgi AT, Ahmet Ç, Tuğba SM. | Eurasian J Emerg Med. 2024 Mar;23(1):70-74
DOI: https://doi.org/10.4274/eajem.galenos.2024.57983
Keywords: Emergency department, Low back pain, Physical therapy

Original Article

Introduction : Low back pain is a common health problem worldwide and ranks among the top ten reasons for emergency department visits, although the majority of cases do not require immediate care. This study aims to compare emergency department visits for low back pain during a 6-month follow-up period between patients receiving a home-based exercise program and those receiving additional physical therapy modalities, exploring a previously uninvestigated aspect.

Méthode : This study was retrospective and included 419 patients with chronic low back pain treated at the Department of Physical Medicine and Rehabilitation from July 2021 to January 2023. Patients were divided into two groups: those who received a home-based exercise program and those who received physical therapy modalities in addition to exercise programs. Using appropriate statistical methods, the two groups were analyzed for their emergency department visits and potential influencing factors during a 6-month follow-up period. p<0.05 was accepted as statistically significant.

Résultats : Patients receiving physiotherapy had significantly fewer emergency department visits during the 6-month follow-up period (p=0.001). No association was observed between emergency department visits and demographics.

Conclusion : The study demonstrated that integrating physical therapy modalities into the management of chronic low back pain resulted in fewer emergency department visits.

Conclusion (proposition de traduction) : L'étude a démontré que l'intégration des techniques de kinésithérapie dans la prise en charge de la lombalgie chronique permettait de réduire le nombre de visites aux urgences.

Simple acute postero-lateral elbow dislocation: A historical perspective.
Jauffrit D, Heraudet P, Tibbo M, Erbland A, Carlier Y, Mansat P, Laumonerie P. | Injury. 2024 Mar;55(3):111353
DOI: https://doi.org/10.1016/j.injury.2024.111353
Keywords: Biomechanics; dislocation; history; posterolateral instability.

REVIEW ARTICLE

Introduction : The aims of this study were to summarize (1) the historical knowledge of the posterolateral elbow dislocation (PLED) pattern and the biomechanical, radiographic, and clinical data that engendered its evolution; and (2) to help clinicians better understand the management of PLED.

Méthode : A literature search was performed using Ovid, Scopus and Cochrane Library, and the Medical Subject Headings vocabulary. Results are discussed as a chronologic review of the relevant literature between 1920-2022.

Résultats : In 1966 Osborn and Cotterill were the first to describe posterolateral rotatory instability (PLRI) causing the PLED. Several theories on PLED were then published by others surgeons as our understanding of elbow biomechanics continued to improve. Multiple treatment protocols have been designed based on the aforementioned theories. Conservative and surgical treatment for PLED provides excellent functional outcomes. However, high rates of persistent pain stiffness and instability have been reported long-term, and no single approach to treatment has been widely accepted.

Conclusion : Despite a growing body of biomechanical evidence, there is no consensus surgical indication for the treatment of PLED. Both conservative and surgical management result in satisfactory functional outcomes after PLED. However, elevated rates of residual pain, and instability have also been described and may limit heavy labor and sports participation. The next challenge for elbow surgeons will be to identify those patients who would benefit from surgical stabilization following PLED.

Conclusion (proposition de traduction) : Malgré un nombre croissant de preuves biomécaniques, il n'existe pas d'indication chirurgicale consensuelle pour le traitement de la luxation postéro-latérale du coude. Les traitements conservateurs et chirurgicaux donnent des résultats fonctionnels satisfaisants après une luxation postéro-latérale du coude. Cependant, des taux élevés de douleur résiduelle et d'instabilité ont également été décrits et peuvent limiter les tâches intensives et la pratique du sport. Le prochain défi pour les chirurgiens du coude sera d'identifier les patients qui bénéficieraient d'une stabilisation chirurgicale après une luxation postéro-latérale du coude.

Clinical value of S100B in detecting intracranial injury in elderly patients with mild traumatic brain injury.
Santing JAL, Hopman JH, Verheul RJ, van der Naalt J, van den Brand CL, Jellema K. | Injury. 2024 Mar;55(3):111313
DOI: https://doi.org/10.1016/j.injury.2024.111313
Keywords: Elderly; Intracranial hemorrhage; Mild traumatic brain injury; Minor head injury; S100B.

REVIEW

Introduction : The biomarker S100B is a sensitive biomarker to detect traumatic intracranial injury in patients mild traumatic brain injury (mTBI). Higher blood values of S100B, resulting in lower specificity and decreased head computed tomography (CT) reduction has been regarded as one of shortcomings in patients over 65 years of age. The purpose of this study was to assess the accuracy of plasma S100B to detect intracranial injury in elderly patients with mTBI.

Méthode : A posthoc analysis was performed of a larger prospective cohort study. Previous recorded patient variables and plasma values of S100B from patients with mTBI who presented to the Emergency Department (ED) within 6 h of injury, underwent a head CT and had a blood sample drawn as part of their routine clinical care, were partitioned at 65 years of age. Sensitivity, specificity, negative predictive value, and positive predictive value of plasma S100B for predicting traumatic intracranial lesions on head CT, with a cut-off set at 0.105 μg/L, were calculated. Results were compared with data from an additional systematic review on the accuracy of S100B to detect intracranial injury in elderly patients with mTBI.

Résultats : Data of 240 patients (48.4 %) of 65 years or older were analyzed. Sensitivity and NPV of S100B were 89 % and 86 % respectively, which is lower than among younger patients (both 97 %). The specificity decreased stepwise with older age: 22 %, 18 %, and 5 % for the age groups 65-74, 75-84, and ≥ 85 years old, respectively. The meta-analysis comprised 4 studies and the current study with data from 2166 patients. Pooled data estimated the sensitivity of s100B as 97.4 % (95 % CI 83.3-100 %) and specificity as 17.3 % (95 % CI 9.5-29.3 %) to detect intracranial injury in elderly patients with mTBI.

Conclusion : The biomarker S100B at the routine threshold has a limited clinical value in the management of elderly mTBI patients mainly due to a poor specificity leading to only a small decrease in head CTs. Alternate cut-off values and combining several plasma biomarkers with clinical variables may be useful strategies to increase the accuracy of S100B in (subgroups of) elderly mTBI patients.

Conclusion (proposition de traduction) : Le biomarqueur S100B au seuil de sécurité habituel a une valeur clinique limitée dans la détection des traumatismes crâniens légers chez les personnes âgées, principalement en raison d'une faible spécificité qui n'entraîne qu'une faible diminution du nombre de tomodensitométries crâniennes. D'autres valeurs seuils et la combinaison de plusieurs biomarqueurs plasmatiques avec des variables cliniques peuvent être des stratégies utiles pour augmenter la précision de la S100B dans les (sous-groupes de) patients âgés victimes d'un traumatisme craniocérébral léger.

Ultrasound-guided peripheral intravenous canulation by emergency nurses: A systematic review and meta-analysis.
Álvarez-Morales L, Gómez-Urquiza JL, Suleiman-Martos N, Membrive-Jiménez MJ, González-Díaz A, García Pérez R, Liñán-Gonzalez A. | Int Emerg Nurs. 2024 Mar;73:101422
DOI: https://doi.org/10.1016/j.ienj.2024.101422  | Télécharger l'article au format  
Keywords: mergency department; Emergency nurse; Peripheral intravenous cannulation; Peripheral intravenous catheter; Ultrasound; Ultrasound guidance.

Review

Introduction : Peripheral intravenous cannulation is a common procedure in the emergency department. Nevertheless, failure rates during the first attempt are as high as 40% in adults and 65% in children. Evidence suggests that physician performed ultrasound-guided peripheral intravenous cannulation (USG-PIVC) is an effective alternative to the traditional method; however, there is insufficient data on the efficacy of the technique performed by nurses.

Méthode : To examine the efficacy of the USG-PIVC technique performed by emergency department nurses.
Methods: A literature review with meta-analysis was performed. The databases used were PubMed, Scopus and CINAHL. The search was conducted in March 2023. Two meta-analysis one of clinical trials about the effectiveness and one about the succession rate were performed.

Résultats : 20 studies were selected and analysed. The studies showed that USGPIVC performed by emergency nurses increased the probability of both the overall success and a successful first attempt compared to the standard technique. In addition, patients showed high satisfaction and lower complication rates. However, the procedure had no significant effect on the time or number of attempts required. A lower probability of success was obtained as regards peripheral intravenous cannulation when the standard technique was used, OR = 0.42 (95 %CI 0.25-0.70p < 0,05).

Conclusion : Ultrasound-guided peripheral intravenous cannulation performed by emergency nurses is a safe and effective technique.

Conclusion (proposition de traduction) : La pose d'une voie veineuse périphérique guidée par ultrasons réalisée par des infirmières d'urgence est une technique sûre et efficace.

Patient-controlled analgesia morphine for the management of acute pain in the emergency department: a systematic review and meta-analysis.
Oon MB, Nik Ab Rahman NH, Mohd Noor N, Yazid MB. | Int J Emerg Med. 2024 Mar 7;17(1):37
DOI: https://doi.org/10.1186/s12245-024-00615-3  | Télécharger l'article au format  
Keywords: Acute pain; Emergency department; IV morphine; PCA morphine.

Review

Introduction : The ideal pain control approach is typically viewed as titration of analgesia for pain reduction and periodic pain evaluation. However, this method takes time and is not always possible in the crowded Emergency Department. Therefore, an alternative way to improve pain care in the Emergency Department is needed to avoid this unpleasant sensation in the patients. The best solution to tackle this situation is using Patient Controlled Analgesia (PCA), in the form of a PCA pump.

Méthode : This systematic review and meta-analysis was designated to evaluate the efficacy of PCA morphine in treating acute pain at Emergency Department.
Methods: We searched databases Cochrane Central Register of Controlled Trials (CENTRAL), Medline, and Google Scholar up to February 2022 and identified randomized controlled trials with English language only that compare PCA morphine to IV morphine in treating patients presenting with acute pain at Emergency Department.

Résultats : Eight trials were included in our review, comprising 1490 participants. We compared PCA morphine vs. IV morphine. There were no differences in the pain score between PCA and IV morphine (standard mean difference [SMD] = -0.20, p = 0.25). Further subgroup analyses (origin of the pain, time of assessment and the durations) showed no difference except for the dosages as the PCA morphine reduced the pain compared to IV morphine in low and high dosages but only two studies were involved. However, the analysis showed PCA morphine increased patient satisfaction and reduced the number of patients who required additional analgesia compared to IV morphine (MD 0.12, P < 0.001), (MD 0.47, P < 0.001) respectively. Data obtained in this review pertaining to adverse effects such as nausea, vomiting, pruritus, and drowsiness is limited since not all the trials reported the events.

Conclusion : PCA morphine do appear to have a beneficial effect on the outcome of patient satisfaction and the number of patients who required additional analgesia. However, further studies targeting a larger sample size is required to increase the certainty of the evidence.

Conclusion (proposition de traduction) : La morphine par PCA semble avoir un effet bénéfique sur la satisfaction des patients et sur le nombre de patients ayant besoin d'une analgésie supplémentaire. Toutefois, d'autres études ciblant un échantillon plus important sont nécessaires pour accroître la certitude des preuves.

The PIRATE mnemonic: providing a structured approach in the care for intoxicated patients at the emergency department.
Kraaijvanger N, Raven W, van Dijken T, Gresnigt F. | Int J Emerg Med. 2024 Mar 1;17(1):30
DOI: https://doi.org/10.1186/s12245-024-00606-4  | Télécharger l'article au format  
Keywords: Acute toxicology; Emergency department; Intoxications; Mnemonic.

Educational Advances in Emergency Medicine

Introduction : Expertise in toxicology is essential for acute care providers, as intoxicated patients frequently present to Emergency Departments. These patients can be challenging for care providers because they often present with uncertain substance exposure and unknown dose and timing of these exposures.

Méthode : The Dutch Society of Emergency Physicians has developed an mnemonic to support treating physicians in a structured approach for the management of (undifferentiated) intoxicated patients.
Results: The PIRATE mnemonic was developed, which includes the following aspects and sequence of care for the intoxicated patient: primary survey, investigation & identification, risk assessment, ADME (comprising pharmacokinetic therapeutic targets: absorption, distribution, metabolism, elimination), therapy and evaluation.

Résultats : The PIRATE mnemonic was developed, which includes the following aspects and sequence of care for the intoxicated patient: primary survey, investigation & identification, risk assessment, ADME (comprising pharmacokinetic therapeutic targets: absorption, distribution, metabolism, elimination), therapy and evaluation.

Conclusion : The toxicology section of the Dutch Society of Emergency Physicians developed the PIRATE mnemonic to provide a structured approach in the management of patients presenting with acute intoxications to Emergency Departments. It summarizes the essential steps and priorities required in the care of intoxicated patients. Further, it provides a common strategy for all specialties involved in the care of the acutely intoxicated patient, contributing to developing greater competence in poisoning management.

Conclusion (proposition de traduction) : La section toxicologie de la Société néerlandaise des médecins urgentistes a mis au point le moyen mnémotechnique PIRATE afin de fournir une approche structurée de la prise en charge des patients présentant une intoxication aiguë dans les services d'urgence. Il résume les étapes essentielles et les priorités requises dans la prise en charge des patients intoxiqués. En outre, il fournit une stratégie commune à toutes les spécialités impliquées dans la prise en charge des patients souffrant d'une intoxication aiguë, contribuant ainsi à développer une plus grande compétence dans la gestion des intoxications.

Commentaire : 
PIRATE
•Primary survey
  ABCDE assessment & stabilisation
•Investigation & Identification
  Investigation: ECG, lab, tox screen (which agent, levels)
  Identification: clinical features, history
•Risk assessment
  Agent type (immediate/slow release), dose, time of ingestion, clinical features, patient features (age, comorbidity)
•ADME
  Absorption ↓:e.g. gastric lavage, activated charcoal
  Distribution ↓: eg. Fab-fragments for Digoxine
  Metabolism ∆: eg. N-AC for Paracetamol
  Elimination ↓:e.g. hemodialysis
•Therapy
  Resuscitation, antidote, specific therapy
•Evaluation
  Monitoring, observation, disposition,
  Screen for child abuse , psychiatric evaluation

The PIRATE mnemonic is not intended to replace advice from the Poison Information Center. For advice on a specific case or intoxication, call your national poison center.

Pharmacologic Management of Pediatric Burns.
Warren JD, Hughes KM. | J Burn Care Res. 2024 Mar 4;45(2):277-291
DOI: https://doi.org/10.1093/jbcr/irad177
Keywords: burn; critical care; emergency department; intensive care units pediatric; pediatrics.

SUMMARY ARTICLE

Editorial : Many pediatric patients with burn injuries may be initially treated in a hospital where pediatric specialized care, including resources and trained personnel may be limited. This includes resuscitation in adult emergency departments and inpatient care in mixed adult-pediatric burn units. The intent of this review is to provide a compilation of topics for the adult trained pharmacist or another healthcare practitioner on the management of pediatric patients with burn injuries. This article focuses on several key areas of pharmacologic burn management in the pediatric patient that may differ from the adult patient, including pain and sedation, fluid resuscitation, nutrition support, antimicrobial selection, anticoagulation, and inhalation injury. It is important that all clinicians have resources to help optimize the management of burn injuries in the pediatric population as, in addition to burn injury itself, pediatric patients have different pharmacokinetics and pharmacodynamics affecting which medications are used and how they are dosed. This article highlights several key differences between pediatric and adult patients, providing an additional resource to assist adult-trained pharmacists or other healthcare practitioners with making clinical decisions in the pediatric burn population.

Conclusion : There are several key differences between pediatric and adult patients when providing care for burn injuries. Pediatric patients have differing pharmacokinetics and pharmacodynamics with larger volumes of distribution for water-soluble medications and more rapid renal clearance. In addition, appropriate assess- ment tools need to be used based on normal developmental milestones. Lastly, some medications used in the adult popula- tion may require closer monitoring in the pediatric population such as propofol and the risk for PRIS. This is an additional pediatric resource to assist the adult trained pharmacists with making clinical decisions in the pediatric burn population.

Conclusion (proposition de traduction) : Il existe plusieurs différences essentielles entre les patients pédiatriques et les patients adultes lorsqu'il s'agit de soigner une brûlure. Les patients pédiatriques ont une pharmacocinétique et une pharmacodynamie différentes, avec des volumes de distribution plus importants pour les médicaments hydrosolubles et une clairance rénale plus rapide. En outre, des outils d'évaluation appropriés doivent être utilisés en fonction des étapes normales du développement. Enfin, certains médicaments utilisés dans la population adulte peuvent nécessiter une surveillance plus étroite dans la population pédiatrique, comme le propofol et le risque de PRIS. Il s'agit d'une référence pédiatrique supplémentaire pour aider les pharmaciens formés à l'âge adulte à prendre des décisions cliniques dans la population pédiatrique des brûlés.

Knowledge, Attitudes, and Practices Regarding Electrical Burns.
AlQhtani AZ, Al-Swedan NH, Alkhunani TA, Basalem AA, Alotaibi AM, Alsaygh KW, AlSahabi AM, Alabdulkarim AO. | J Burn Care Res. 2024 Mar 4;45(2):478-486
DOI: https://doi.org/10.1093/jbcr/irad182
Keywords: Saudi Arabia; attitudes; electrical burn; knowledge; practices.

ORIGINAL ARTICLE

Editorial : Burn prevention programs can effectively reduce morbidity and mortality rates. In this article, we present the findings of our investigation of the knowledge, attitudes, and practices of the Saudi Arabian population regarding electrical burns. Our study was a cross-sectional online survey that used a five-part questionnaire to assess the participant's demographic information, knowledge of electrical burns, attitudes toward electrical injuries, and practices related to electrical burns and their prevention. Overall, 2314 individuals responded to the survey (males: 41.2%; females: 58.8%). A total of 839 participants (36%) had a personal or family history of electrical burns. Approximately ≥90% of the responses to questions on electrical burn-related knowledge were correct; relatively less responses to questions on the extent of tissue damage from electrical burns and arcs were correct (74% and 29%, respectively). Only 54% of the respondents knew that applying first aid to the burn-affected areas at home could lead to a better outcome; 27% and 19% did not know the correct answer and thought that this would not lead to a better outcome, respectively. The most common source of information was school or college (38.9%), followed by social media (20.8%) and internet websites (16.3%). Enhancing community awareness and practices related to electrical burns is a cost-effective and straightforward strategy to prevent the morbidity and mortality associated with electrical injuries.

Conclusion : In conclusion, such results represent the fact that 27% and 19% did not know the correct answer and thought that this would not lead to a better outcome for applying first aid to the burn-affected areas at home; One-fourth of the respondents simultaneously plugged more than one appliance into a single outlet and one-third of the respondents reported using an in- door electric conductor in an outdoor yard make it essential for healthcare agencies to take the findings of this study seri- ously and address any shortcomings. Community incentives should be initiated with a focus on educating people about the importance of awareness and best practices for dealing with electrical burns. This education can be integrated into school and university curricula. In addition, community health campaigns should be launched at various locations, such as shopping centers and public gatherings, to demon- strate proper practices related to electrical burn injuries and raise awareness among different audiences. Future planning and implementation of interventions fo- cused on improving community awareness and practices regarding electrical burns. We hope that our findings will con- tribute to the existing body of knowledge on electrical burns and encourage further research in this area.

Conclusion (proposition de traduction) : En conclusion, ces résultats montrent que 27 % et 19 % des personnes interrogées ne connaissaient pas la bonne réponse et pensaient que cela ne conduirait pas à un meilleur résultat pour l'application des premiers soins aux zones touchées par les brûlures à la maison ; un quart des personnes interrogées ont branché simultanément plus d'un appareil sur une seule prise et un tiers des personnes interrogées ont déclaré avoir utilisé un conducteur électrique à l'intérieur de la maison dans une cour extérieure. Des mesures d'incitation communautaires devraient être mises en place afin d'éduquer les gens sur l'importance de la sensibilisation et sur les meilleures pratiques à adopter en cas de brûlures électriques. Cette éducation peut être intégrée dans les programmes scolaires et universitaires. En outre, des campagnes de santé communautaire devraient être lancées dans différents lieux, tels que les centres commerciaux et les rassemblements publics, afin de démontrer les bonnes pratiques liées aux brûlures électriques et de sensibiliser les différents publics. La planification et la mise en œuvre futures des interventions se concentrent sur l'amélioration de la sensibilisation de la communauté et des pratiques concernant les brûlures électriques. Nous espérons que nos résultats contribueront à enrichir les connaissances actuelles sur les brûlures électriques et encourageront la poursuite des recherches dans ce domaine.

Implementation of Tenecteplase for Acute Ischemic Stroke Treatment.
Brown CS, Manuel FC, Mattson AE, Schmitt CJ, Hellickson JD, Clark SL, Wieruszewski ED. | J Emerg Nurs. 2024 Mar;50(2):171-177
DOI: https://doi.org/10.1016/j.jen.2023.11.004
Keywords: Aucun

CLINICAL

Introduction : Acute ischemic stroke is a neurologic emergency, requiring rapid recognition and treatment with intravenous thrombolysis. Since the publication of the 2019 American Heart Association/American Stroke Association Guidelines that recommend tenecteplase as an alternative agent, several centers across the United States are transitioning from alteplase to tenecteplase as the agent of choice for thrombolysis in acute ischemic stroke.

Méthode : Our health system transitioned to tenecteplase for the treatment of acute ischemic stroke in 2021 due to increasing evidence for efficacy and potential for improved door-to-needle time. Herein we describe our experience and provide guidance for other institutions to implement this change.

Conclusion : Emergency nurses are vital to the care of acute ischemic stroke patients. There are several pharmacologic and logistical differences between alteplase and tenecteplase for this indication. This paper outlines these key differences.

Conclusion (proposition de traduction) : Les infirmières des urgences jouent un rôle essentiel dans la prise en charge des patients victimes d'un accident vasculaire cérébral ischémique aigu. Il existe plusieurs différences pharmacologiques et logistiques entre l'alteplase et le tenecteplase pour cette indication. Ce document présente ces différences clés.

Difficult Intravascular Access in Pediatric Emergency Department: The Ultrasound-Assisted Strategy (DIAPEDUS Study).
D'Alessandro M, Ricci M, Bellini T, Chianucci B, Calevo MG, Piccotti E, Moscatelli A. | J Intensive Care Med. 2024 Mar;39(3):217-221
DOI: https://doi.org/10.1177/08850666231199050  | Télécharger l'article au format  
Keywords: emergency department; pediatrics; peripheral venous access; ultrasound.

Original Research

Introduction : Vein line positioning represents one of the first diagnostic and therapeutic steps in Pediatric Emergency Department (PED); however, the outcome of this maneuver is frequently not as expected, especially for difficult-to-access (DIVA) patients. The standard technique (visual-palpatory) has a low success rate; hence ultrasound (US) assistance has been suggested for DIVA patients, although controversial results have been obtained.

Méthode : Our study compared the success rate of an intravascular (IV) access procedure at the first attempt, with and without ultrasound assistance, in pediatric DIVA patients. Secondary objectives were the global success rate, the mean procedural time, the IV device's life span, and the complications rate.

Résultats : We conducted an observational, prospective, monocentric, no-profit cohort study enrolling 110 patients presenting to our ED, aged 0-21 years. All the patients were considered difficult-to-access patients according to the DIVA score (≥4) or history of previous difficult intravascular access. They were randomized into two homogeneous groups: 50 patients with the standard and 60 with the US-assisted technique. We obtained a significantly higher success rate at first attempt with the US-guided technique (90% vs 18%, p ≤ .00001). Moreover, the overall success rate was higher in the US group (95% vs 46%, p < .00001). The mean procedural time resulted significantly less in the US group (2.7 ± 2.2 min vs 10 ± 6.4 min, p < .0001), as well as the overall number of attempts to obtain a stable IV line (1.09 ± 0.34 attempts vs 2.38 ± 1.09 attempts, p < .0001). We experienced some post-procedural complications without differences in the two groups, although none were severe.

Conclusion : Our study showed that bedside ultrasound assisting implantation of peripheral venous access in pediatric DIVA patients improves first-time success rate, overall success rate, procedural time, and patient comfort, reducing the number of attempts to obtain a stable IV line.

Conclusion (proposition de traduction) : Notre étude a montré que l'échographie au chevet du patient pour guider la pose d'un abord veineux périphérique chez les enfants présentant des difficultés de pose améliore le taux de réussite de la première tentative, le taux de réussite global, la durée de la procédure et le confort du patient, tout en réduisant le nombre de tentatives pour obtenir une voie d'abord veineuse stable.

Hemorrhagic Shock in Isolated and Non-Isolated Pelvic Fractures: A Registries-Based Study.
Gottfried A, Gendler S, Chayen D, Radomislensky I, Mitchnik IY; Israel Trauma Group; Epshtein E, Tsur AM, Almog O, Talmy T. | Prehosp Emerg Care. 2024 Mar 18:1-9
DOI: https://doi.org/10.1080/10903127.2024.2322014  | Télécharger l'article au format  
Keywords: Aucun

Article

Introduction : Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures.

Méthode : Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min.

Résultats : Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures.

Conclusion : In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.

Conclusion (proposition de traduction) : Chez les jeunes patients souffrant de fractures du bassin, les blessures associées graves sont fréquentes, mais les fractures pelviennes isolées se présentent rarement avec un état de choc sévère à l'arrivée. Les protocoles de prise en charge préhospitaliers des fractures du bassin devraient donner la priorité à une évacuation rapide et à des mesures de réanimation visant à traiter les lésions associées.

Shock Index as a Predictor of Mortality and Hospital Admission in Prehospital Gastrointestinal Bleeding: A Retrospective Cohort Study.
Lowe J, Lowe Z, Ely R. | Prehosp Emerg Care. 2024 Mar 18:1-8
DOI: https://doi.org/10.1080/10903127.2024.2331739
Keywords: Aucun

Article

Introduction : To evaluate the Shock Index (SI) as a predictive tool for triage of gastrointestinal bleeding (GI) in the prehospital setting, assessing its correlation with mortality, admission rates, and hospital length of stay.

Méthode : In this retrospective cohort study, we analyzed data from the ESO Data Collaborative encompassing EMS records from the year 2022, focusing on 1525 patients with a primary GI bleeding diagnosis. The primary measure was the SI, calculated at initial contact and highest recorded prior to ED arrival. Statistical analysis included t-tests, linear regression, and ROC curves, performed using SPSS v29.

Résultats : A significantly higher mean SI was observed in patients who died (mean SI 0.997) compared to survivors (mean SI 0.795), p < 0.001. Admission rates also correlated with higher SI values, p < 0.001. However, SI was not predictive of the hospital length of stay. ROC analysis for mortality prediction yielded an AUC of 0.656 for the initial SI and 0.739 for the highest SI. The standard SI cutoff of 0.9 predicted mortality with a sensitivity of 74.14% and specificity of 55.35% for the highest SI.

Conclusion : The SI is a valuable predictive tool for mortality among prehospital patients with GI bleeding. Its application may improve the triage process, potentially influencing transport decisions and initial hospital care. Despite its predictive capability for mortality, the SI should be supplemented with other clinical assessments to make comprehensive prehospital care decisions. Further research into SI as part of a comprehensive assessment which includes end-title CO2, mentation, and heaviness of bleeding.

Conclusion (proposition de traduction) : Le Shock Index est un outil de prévision précieux de la mortalité chez les patients en phase préhospitalière présentant une hémorragie gastro-intestinale. Son application peut améliorer le processus de triage, influençant potentiellement les décisions de transport et les soins hospitaliers initiaux. Malgré sa capacité à prédire la mortalité, le Shock Index doit être complété par d'autres évaluations cliniques afin de prendre des décisions globales en matière de soins préhospitaliers. Des recherches supplémentaires sur le Shock Index dans le cadre d'une évaluation complète comprenant la capnie, la perception mentale et l'abondance du saignement.

Factors associated with the use of pharmacologic agents to facilitate out-of-hospital endotracheal intubation.
Wang HE, Kupas DF, Paris PM, Yealy DM. | Prehosp Emerg Care. 2004 Jan-Mar;8(1):1-9
DOI: https://doi.org/10.1080/312703002740  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : To identify a set of clinical factors most strongly associated with the use of drug-facilitated intubation (DFI) in the out-of-hospital setting.

Méthode : The authors used data from a prospective, multicentered endotracheal intubation (ETI) observational cohort trial, including patients from 45 emergency medical services in Pennsylvania. Providers reported clinical, physiologic, and anatomic factors associated with each ETI effort. The authors included only data from the 23 services using DFI. They identified all non-arrest (presence of a pulse) adult patients. They included both successful and failed ETIs. They defined DFI cases as patients who received a sedative or neuromuscular-blocking agent to facilitate ETI. The authors also classified patients who underwent nasotracheal intubation as DFI. They defined control subjects as patients undergoing conventional oral ETI. They performed multivariate logistic regression to identify the clinical, physiologic, and anatomic factors characteristic of DFI. They examined alternate forms of the final prediction model.

Résultats : The authors analyzed data from 208 nonarrest patients, including 92 DFIs and 116 control subjects. Of 34 factors potentially related to DFI, 17 were excluded on univariate analysis (likelihood ratio p>0.25). Multivariate logistic regression revealed the following as positively associated with DFI: presence of clenched jaw/trismus (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.10-4.95; p=0.026); increased verbal Glasgow Coma Scale score (OR, 1.71; 95% CI, 1.29-2.26; p<0.001); use of cervical spine precautions (OR, 2.30; 95% CI, 1.15-4.62; p=0.018). Anterior vocal cords (OR, 0.27; 95% CI, 0.10-0.71; p=0.004) and laryngospasm (OR, 0.14; 95% CI, 0.02-1.17; p=0.025) were negatively associated with DFI. The model showed good fit (Hosmer-Lemeshow p=0.75) and discrimination (area under the curve=0.76).

Conclusion : The authors identified a set of predictors strongly associated with DFI. These data offer insight into the current use of DFI and support the development of consensus-based guidelines for this procedure.

Conclusion (proposition de traduction) : Les auteurs ont identifié un ensemble de facteurs prédictifs fortement associés à l'intubation facilitée par des médicaments (utilisation d'hypnotiques ou de curares pour faciliter l'intubation endotrachéale). Ces données donnent un aperçu de l'utilisation actuelle de l'intubation facilitée par des médicaments et soutiennent le développement de lignes directrices consensuelles pour cette procédure.

Retrospective Comparison of Upper and Lower Extremity Intraosseous Access During Out-of-Hospital Cardiac Arrest Resuscitation.
Smida T, Crowe R, Jarvis J, Ratcliff T, Goebel M. | Prehosp Emerg Care. 2024 Mar 26:1-8
DOI: https://doi.org/10.1080/10903127.2024.2321285
Keywords: Aucun

Online ahead of print

Introduction : Intraosseous (IO) access is frequently utilized during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients. Due to proximity to the heart and differential flow rates, the anatomical site of IO access may impact patient outcomes. Using a large dataset, we aimed to compare the outcomes of OHCA patients who received upper or lower extremity IO access during resuscitation.

Méthode : The ESO Data Collaborative public use research datasets were used for this retrospective study. All adult (≥18 years of age) OHCA patients with successful IO access in an upper or lower extremity were evaluated for inclusion. Patients were excluded if they had intravenous (IV) access prior to IO access, or if they had a Do Not Resuscitate order documented. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to discharge and survival to discharge to home. Mixed-effects multivariable logistic regression models adjusted for age, sex, etiology, witnessed status, pre-first responder cardiopulmonary resuscitation (CPR), initial electrocardiogram (ECG) rhythm, location [private/residential, public, or assisted living/institutional], and response time in addition to the primary airway management strategy (endotracheal intubation, supraglottic device, surgical airway, no advanced airway) were used to compare the outcomes of patients with upper extremity IO access to the outcomes of patients with lower extremity IO access.

Résultats : After application of exclusion criteria, 155,884 patients who received IO access during resuscitation remained (76% lower extremity, 24% upper extremity). Upper extremity IO access was associated with greater adjusted odds of ROSC (1.11 [1.08, 1.15]), and this finding was consistent across multiple patient subgroups. Secondary analyses suggested that upper extremity access was associated with increased survival to discharge (1.18 [1.00, 1.39]) and survival to discharge to home (1.23 [1.02, 1.48]) in comparison to lower extremity IO access.

Conclusion : In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.

Conclusion (proposition de traduction) : Dans ce grand ensemble de données préhospitalières, la pose d'un cathéter intra-osseux au niveau des membres supérieurs a été associée à une légère augmentation des chances de retour à une circulation spontanée par rapport à la pose d'un cathéter intra-osseux au niveau des membres inférieurs. Ces données confirment la nécessité d'une étude prospective sur le site idéal de la voie d'accès intra-osseuse lors de la réanimation d'un arrêt cardiaque en dehors de l'hôpital.

Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: The race against time.
Gaisendrees C, Schlachtenberger G, Müller L, Jaeger D, Djordjevic I, Krasivskyi I, Elederia A, Walter S, Vollmer M, Weber C, Luehr M, Wahlers T. | Resusc Plus. 2024 Mar 21;18:100613
DOI: https://doi.org/10.1016/j.resplu.2024.100613  | Télécharger l'article au format  
Keywords: Cardiogenic shock; ECPR; IHCA; Mechanical circulatory support; OHCA ECMO.

Clinical paper

Introduction : Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. Cardiac arrests can be categorized depending on location: in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Despite this distinction, studies comparing the two are scarce, especially in comparing outcomes after ECPR. This study compared patient characteristics, cardiac arrest characteristics, and outcomes.

Méthode : Between 2016 and 2022, patients who underwent ECPR for cardiac arrest at our institution were retrospectively analyzed, depending on the arrest location: IHCA and OHCA. We compared periprocedural characteristics and used multinomial regression analysis to indicate parameters contributing to a favorable outcome.

Résultats : A total of n = 157 patients (100%) were analyzed (OHCA = 91; IHCA = 66). Upon admission, OHCA patients were younger (53.2 ± 12.4 vs. 59.2 ± 12.6 years) and predominantly male (91.1% vs. 66.7%, p=<0.001). The low-flow time was significantly shorter in IHCA patients (41.1 ± 27.4 mins) compared to OHCA (63.6 ± 25.1 mins). Despite this significant difference, in-hospital mortality was not significantly different in both groups (IHCA = 72.7% vs. OHCA = 76.9%, p = 0.31). Both groups' survival-to-discharge factors were CPR duration, low flow time, and lactate values upon ECMO initiation.

Conclusion : Survival-to-discharge for ECPR in IHCA and OHCA was around 25%, and there was no statistically significant difference between the two cohorts. Factors predicting survival were lower lactate levels before cannulation and lower low-flow time. As such, OHCA patients seem to tolerate longer low-flow times and thus metabolic impairments compared to IHCA patients and may be considered for ECMO cannulation on a broader time span than IHCA.

Conclusion (proposition de traduction) : Le taux de survie à la sortie de l'hôpital pour la réanimation cardio-pulmonaire extracorporelle en cas d'arrêt cardiaque hospitalier et extrahospitalier est d'environ 25 %, et il n'y a pas de différence statistiquement significative entre les deux cohortes. Les facteurs prédictifs de survie étaient des niveaux de lactate inférieurs avant la canulation et un temps de bas débit inférieur. Ainsi, les patients ayant présenté un arrêt cardiaque en dehors de l'hôpital semblent tolérer des temps de bas débit plus longs et donc des déficiences métaboliques par rapport aux patients ayant subi un arrêt cardiaque à l'hôpital et peuvent être considérés pour une canulation ECMO sur une période plus longue que les patients ayant subi un arrêt cardiaque à l'hôpital.

Association between obesity and neurological outcomes among out-of-hospital cardiac arrest patients: The SOS-KANTO 2017 study.
Aoki M, Aso S, Suzuki M, Tagami T, Sawada Y, Yasunaga H, Kitamura N, Oshima K; behalf of the SOS-KANTO 2017 Study Group. | Resusc Plus. 2023 Nov 23;17:100513
DOI: https://doi.org/10.1016/j.resplu.2023.100513  | Télécharger l'article au format  
Keywords: Body mass index; Obesity; Out-of-hospital cardiac arrest; Outcome.

Research article

Introduction : To assess the association between body mass index (BMI) and neurological outcomes among patients with out-of-hospital cardiac arrest (OHCA).

Méthode : This prospective, multicenter, observational study conducted between 2019 and 2021 included adults with OHCA who were hospitalized after return of spontaneous circulation. Based on the BMI, the patients were categorized as underweight (BMI < 18.5 kg/m₂), normal weight (BMI 18.5-24.9 kg/m₂), overweight (BMI 25.0-29.9 kg/m₂), or obese (BMI ≥ 30 kg/m₂). The normal weight group served as the reference. Favorable neurological outcomes were defined as a Cerebral Performance Category score of ≤ 2 at 30 days. Multivariate logistic regression analyses were performed to adjust for patient characteristics, OHCA circumstances, and time variables.

Résultats : Of the 9,909 patients with OHCA who presented during the study period, 637 were eligible, of whom 10.8% (69/637), 48.9% (312/637), 27.6% (176/637), and 12.5% (80/637) were underweight, normal weight, overweight, and obese, respectively. These groups had favorable neurological outcome in 23.2%, 29.2%, 20.5%, and 16.2% of patients, respectively. Obese and overweight patients had a significantly lower rate of favorable neurologic outcomes (adjusted odds ratio [OR] = 0.35; 95% confidence interval [CI] = 0.16-0.77; adjusted OR = 0.53; 95% CI = 0.31-0.90, respectively) than those with a normal weight.

Conclusion : Obese and overweight patients with OHCA have reduced rates of favorable neurological outcomes, suggesting that clinicians should pay attention to the BMI of patients.

Conclusion (proposition de traduction) : Les patients obèses ou en surpoids victimes d'un arrêt cardiaque extrahospitalier présentent des taux réduits de résultats neurologiques favorables, ce qui suggère que les cliniciens devraient prêter attention à l'IMC des patients.

Factors associated with favourable neurological outcomes following cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A retrospective multi-centre cohort study.
Tominaga N, Takiguchi T, Seki T, Hamaguchi T, Nakata J, Yamamoto T, Tagami T, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Yokobori S; SAVE-J II study group Investigation Supervision. | Resusc Plus. 2024 Feb 8;17:100574
DOI: https://doi.org/10.1016/j.resplu.2024.100574  | Télécharger l'article au format  
Keywords: Body movement; Extracorporeal cardiopulmonary resuscitation; Gasping; Neurological outcome; Out-of-hospital cardiac arrest; Pupillary reflex.

Research article

Introduction : To investigate the factors associated with favourable neurological outcomes in adult patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA).

Méthode : This retrospective observational study used secondary analysis of the SAVE-J II multicentre registry data from 36 institutions in Japan. Between 2013 and 2018, 2157 patients with OHCA who underwent ECPR were enrolled in SAVE-J II. A total of 1823 patients met the study inclusion criteria. Adult patients (aged ≥ 18 years) with OHCA, who underwent ECPR before admission to the intensive care unit, were included in our secondary analysis. The primary outcome was a favourable neurological outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 or 2. We used a multivariate logistic regression model to examine the association between factors measured at the incident scene or upon hospital arrival and favourable neurological outcomes.

Résultats : Multivariable analysis revealed that shockable rhythm at the scene [odds ratio (OR); 2.11; 95% confidence interval (CI), 1.16-3.95] and upon hospital arrival (OR 2.59; 95% CI 1.60-4.30), bystander CPR (OR 1.63; 95% CI 1.03-1.88), body movement during resuscitation (OR 7.10; 95% CI 1.79-32.90), gasping (OR 4.33; 95% CI 2.57-7.28), pupillary reflex on arrival (OR 2.93; 95% CI 1.73-4.95), and male sex (OR 0.43; 95% CI 0.24-0.75) significantly correlated with neurological outcomes.

Conclusion : Shockable rhythm, bystander CPR, body movement during resuscitation, gasping, pupillary reflex, and sex were associated with favourable neurological outcomes in patients with OHCA treated with ECPR.

Conclusion (proposition de traduction) : Le rythme choquable, la réanimation par un tiers, les mouvements du corps pendant la réanimation, le halètement, le réflexe pupillaire et le sexe ont été associés à des résultats neurologiques favorables chez les patients ayant subi un arrêt cardiaque extrahospitalier et ayant bénéficié d'une réanimation cardiopulmonaire.

Association among blood pressure, end-tidal carbon dioxide, peripheral oxygen saturation and mortality in prehospital post-resuscitation care.
Heikkilä E, Setälä P, Jousi M, Nurmi J. | Resusc Plus. 2024 Feb 13;17:100577
DOI: https://doi.org/10.1016/j.resplu.2024.100577  | Télécharger l'article au format  
Keywords: Critical care; Emergency medical service; Helicopter emergency medical service; Postresuscitation; Prehospital care.

Research article

Introduction : Post-resuscitation care is described as the fourth link in a chain of survival in resuscitation guidelines. However, data on prehospital post-resuscitation care is scarce. We aimed to examine the association among systolic blood pressure (SBP), peripheral oxygen saturation (SpO₂) and end-tidal carbon dioxide (EtCO₂) after prehospital stabilisation and outcome among patients resuscitated from out-of-hospital cardiac arrest (OHCA).

Méthode : In this retrospective study, we evaluated association of the last measured prehospital SBP, SpO₂ and EtCO₂ before patient handover with 30-day and one-year mortality in 2,611 patients receiving prehospital post-resuscitation care by helicopter emergency medical services in Finland. Statistical analyses were completed through locally estimated scatterplot smoothing (LOESS) and multivariable logistic regression. The regression analyses were adjusted by sex, age, initial rhythm, bystander CPR, and time interval from collapse to the return of spontaneous circulation (ROSC).

Résultats : Mortality related to SBP and EtCO₂ values were U-shaped and lowest at 135 mmHg and 4.7 kPa, respectively, whereas higher SpO₂ shifted towards lower mortality. In adjusted analyses, increased 30-day mortality and one year mortality was observed in patients with SBP < 100 mmHg (OR 1.9 [95% CI 1.4-2.4]) and SBP < 100 (OR 1.8 [1.2-2.6]) or EtCO₂ < 4.0&,nbsp;kPa (OR 1.4 [1.1-1.5]), respectively. SpO₂ was not significantly associated with either 30-day or one year mortality.

Conclusion : After prehospital post-resuscitation stabilization, SBP < 100 mmHg and EtCO₂ < 4.0 kPa were observed to be independently associated with higher mortality. The optimal targets for prehospital post-resuscitation care need to be established in the prospective studies.

Conclusion (proposition de traduction) : Après stabilisation préhospitalière en post-réanimation, on a observé que la PAS < 100 mmHg et l'EtCO₂ < 4,0 kPa (30 mmHg) étaient associées de manière indépendante à une mortalité plus élevée. Les objectifs optimaux pour les soins préhospitaliers post-réanimation doivent être établis dans le cadre d'études prospectives.

Therapeutic efficacy of tranexamic acid on traumatic brain injury: a systematic review and meta-analysis.
Song JX, Wu JX, Zhong H, Chen W, Zheng JC. | Scand J Trauma Resusc Emerg Med. 2024 Mar 7;32(1):18
DOI: https://doi.org/10.1186/s13049-024-01188-z  | Télécharger l'article au format  
Keywords: Meta-analysis; Therapeutic efficacy; Tranexamic acid; Traumatic brain injury.

Original researc

Introduction : Tranexamic acid (TXA) demonstrates therapeutic efficacy in the management of traumatic brain injury (TBI). The objective of this systematic review and meta-analysis was to evaluate the safety and effectiveness of TXA in patients with TBI.

Méthode : The databases, namely PubMed, Embase, Web of Science, and Cochrane Library databases, were systematically searched to retrieve randomized controlled trials (RCTs) investigating the efficacy of TXA for TBI from January 2000 to November 2023.

Résultats : The present meta-analysis incorporates ten RCTs. Compared to the placebo group, administration of TXA in patients with TBI resulted in a significant reduction in mortality (P = 0.05), hemorrhage growth (P = 0.03), and volume of hemorrhage growth (P = 0.003). However, no significant impact was observed on neurosurgery outcomes (P = 0.25), seizure occurrence (P = 0.78), or pulmonary embolism incidence (P = 0.52).

Conclusion : The administration of TXA is significantly associated with reduced mortality and hemorrhage growth in patients suffering from TBI, while the need of neurosurgery, seizures, and incidence of pulmonary embolism remains comparable to that observed with placebo.

Conclusion (proposition de traduction) : L'administration d'acide tranexamique est significativement associée à une réduction de la mortalité et de la croissance des hémorragies chez les patients souffrant de lésions cérébrales traumatiques, tandis que la nécessité d'une neurochirurgie, les crises d'épilepsie et l'incidence de l'embolie pulmonaire restent comparables à celles observées avec le placebo.

The association between blood glucose levels on arrival at the hospital and patient outcomes after out-o.
Taira T, Inoue A, Kuroda Y, Oosuki G, Suga M, Nishimura T, Ijuin S, Ishihara S. | Am J Emerg Med. 2024 Mar;77:46-52
DOI: https://doi.org/10.1016/j.ajem.2023.12.004
Keywords: Cardiac arrest; Mortality; Neurological outcome; Prognostic factor; Stress hyperglycemia; Survival.

Research article

Introduction : This study aimed to investigate the association between blood glucose levels on arrival at the hospital and 1-month survival and favorable neurological outcomes in patients with OHCA using a large Japanese dataset.

Méthode : This study was a secondary analysis of data from the JAAM-OHCA Registry. Adult (≥18 years) patients with witnessed OHCA transported to emergency departments and registered in the database from June 2014 to December 2019 were included in the study. The primary and secondary endpoints were 1-month survival and 1-month favorable neurological outcomes (Glasgow-Pittsburgh Cerebral Performance Category score 1 or 2), respectively. Patients were categorized into the following four groups based on blood glucose levels on arrival at the hospital: <80 mg/dL, 80-179 mg/dL, 180-299 mg/dL, and ≥300 mg/dL.

Résultats : This study included 11,387 patients. Survival rates were 1.3%, 3.1%, 7.0%, and 5.7% in the <80 mg/dL, 80-179 mg/dL, 180-299 mg/dL, and ≥ 300 mg/dL blood glucose groups, respectively. The rates of favorable neurological outcomes in each group were 0.4%, 1.5%, 3.3%, and 2.5%, respectively. Multivariable analysis showed that 180-299 mg/dL glucose was significantly associated with 1-month survival and favorable neurological outcomes compared with 80-179 mg/dL glucose (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.34-2.31; p < 0.001 and OR, 1.52; 95 % Cl, 1.02-2.25; p = 0.035, respectively). In this study, blood glucose levels with the best outcomes likely ranged from 200 to 250 mg/dL based on the cubic spline regression model.

Conclusion : Blood glucose level of 180-299 mg/dL on arrival at the hospital was significantly associated with 1-month survival and favorable neurological outcomes compared to blood glucose level of 80-179 mg/dL in patients with OHCA.

Conclusion (proposition de traduction) : Une glycémie comprise entre 180 et 299 mg/dl à l'arrivée à l'hôpital était significativement associée à la survie à un mois et à des résultats neurologiques favorables par rapport à une glycémie comprise entre 80 et 179 mg/dl chez les patients victimes d'un arrêt cardiaque extrahospitalier.

Risk of arrhythmia in post-resuscitative shock after out-of-hospital cardiac arrest with epinephrine versus norepinephrine.
Normand S, Matthews C, Brown CS, Mattson AE, Mara KC, Bellolio F, Wieruszewski ED. | Am J Emerg Med. 2024 Mar;77:72-76
DOI: https://doi.org/10.1016/j.ajem.2023.12.003
Keywords: Cardiogenic shock; Critical care; Epinephrine; Norepinephrine; Out-of-hospital cardiac arrest; Vasopressors.

Research article

Introduction : To determine the rates of clinically significant tachyarrhythmias and mortality in the management of post-resuscitative shock after return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA) who receive a continuous epinephrine versus norepinephrine infusion.

Méthode : Retrospective cohort study.
Setting: A large multi-site health system with hospitals across the United States.
Patients: Adult patients admitted for OHCA with post-resuscitative shock managed with either epinephrine or norepinephrine infusions within 6 h of ROSC.
Interventions: None.

Résultats : Between May 5^th, 2018, to January 31^st, 2022, there were 221 patients admitted for OHCA who received post-resuscitative epinephrine or norepinephrine infusions. There was no difference in the rate of tachyarrhythmias between epinephrine and norepinephrine infusion in univariate (47.1% vs 41.7%, OR 1.24, 95% CI 0.71-2.20) or multivariable analysis (OR 1.34, 95% CI 0.68-2.62). Patients treated with epinephrine were more likely to die during hospitalization than those treated with norepinephrine (90.0% vs 54.3%, OR 6.21, 95% CI 2.37-16.25, p < 0.001). Epinephrine treated patients were more likely to have re-arrest during hospital admission (55.7% vs 14.6%, OR 5.77, 95% CI 2.74-12.18, p < 0.001).

Conclusion : There was no statistically significant difference in clinically significant cardiac tachyarrhythmias in post-OHCA patients treated with epinephrine versus norepinephrine infusions after ROSC. Re-arrest rates and in-hospital mortality were higher in patients who received epinephrine infusions in the first 6 h post-ROSC. Results of this study add to the literature suggesting norepinephrine may be the vasopressor of choice in post-OHCA patients with post-resuscitative shock after ROSC.

Conclusion (proposition de traduction) : Il n'y a pas eu de différence statistiquement significative en ce qui concerne les tachyarythmies cardiaques cliniquement significatives chez les patients ayant présenté un arrêt cardiaque extrahospitalier et traités par des perfusions d'adrénaline ou de noradrénaline après le retour de la circulation spontanée. Les taux de réarrêt et de mortalité à l'hôpital étaient plus élevés chez les patients ayant reçu des perfusions d'épinéphrine dans les 6 premières heures suivant le retour de la circulation spontanée. Les résultats de cette étude s'ajoutent à la littérature suggérant que la norépinéphrine pourrait être le vasopresseur de choix chez les patients ayant subi un arrêt cardiaque extrahospitalier et présentant un choc post-réanimation après le retour de la circulation spontanée.

Safety and efficacy of fixed versus variable-dose prothrombin complex concentrate for emergent reversal of vitamin K antagonists: A systematic review and meta-analysis.
Condeni MS, Weant KA, Neyens RR, Eriksson EA, Miano TA. | Am J Emerg Med. 2024 Mar;77:91-105
DOI: https://doi.org/10.1016/j.ajem.2023.11.066
Keywords: Anti-coagulation reversal; Four-factor prothrombin complex concentrate; International normalized ratio; Intracranial hemorrhage; Thrombosis; Vitamin k antagonists.

Research article

Introduction : Four-factor prothrombin complex concentrate (4F-PCC) is standard of care for emergent vitamin K antagonist (VKA) reversal but optimal dosing is uncertain. This meta-analysis estimated the proportion of patients treated with fixed dose (FD) 4F-PCC who achieved adequate reversal and compared safety and efficacy of FD versus weight-based dose (WB) strategies.

Méthode : This review was conducted according to PRISMA guidelines. Medline and Scopus were searched and included studies evaluating FD regimens and comparing FD and WB for emergent VKA reversal. Data was pooled using random effects. Subgroup analyses examined heterogeneity. Risk of bias was assessed with Newcastle-Ottawa Scale and RoB2 score.

Résultats : Twenty-three studies (n = 2055) were included with twelve (n = 1143) comparing FD versus WB. The proportion of patients achieving goal INR with FD varied depending on the INR target, being significantly higher for INR <2 (90.9%, 95% Confidence Interval (CI) 87.2, 94.06) compared to INR <1.6 (70.97%, 95%CI 65.33, 76.31). Compared to WB, FD was less likely to achieve a goal INR <1.6 (Risk Difference (RD) -13%, 95% CI -21, -4) but achieved similar reversal for a goal INR <2.0, (RD -1%, 95%CI -7, 4). There was no difference in hospital mortality (RD 4%, 95%CI -2, 9) or thrombosis (RD 0.0%, 95%CI -3, 3).

Conclusion : FD VKA reversal was associated with significantly lower attainment of goal INR compared to WB with lower INR targets. This did not translate to differences in hospital mortality, but these results should be interpreted cautiously in light of the observational nature of the included studies.

Conclusion (proposition de traduction) : La réversion des anti-vitamine K à dose fixe a été associée à une atteinte significativement plus faible de l'INR cible par rapport à la dose basée sur le poids avec des objectifs d'INR plus faibles. Cela ne s'est pas traduit par des différences dans la mortalité hospitalière, mais ces résultats doivent être interprétés avec prudence à la lumière de la nature observationnelle des études incluses.

Isotonic balanced fluid versus 0.9% saline in patients with moderate to severe traumatic brain injury: A double-blinded randomised controlled trial.
Poh K, Bustam A, Hasan MS, Mohd Yunos N, Cham CY, Lim FJ, Ahmad Zahedi AZ, Zambri A, Noor Azhar M. | Am J Emerg Med. 2024 Mar;77:106-114
DOI: https://doi.org/10.1016/j.ajem.2023.11.064
Keywords: 0.9% saline; Fluid therapy; GOS-E; Glasgow Outcome Scale-Extended; Isotonic balanced fluid; Randomised controlled trial; Sterofundin; Traumatic brain injury.

Research article

Introduction : Traumatic brain injury (TBI) is a global health concern with significant economic impact. Optimal fluid therapy aims to restore intravascular volume, maintain cerebral perfusion pressure and blood flow, thus preventing secondary brain injury. While 0.9% saline (NS) is commonly used, concerns about acid-base and electrolyte imbalance and development of acute kidney injury (AKI) lead to consideration of balanced fluids as an alternative.

Méthode : his study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS.
Design, settings and participants: A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019.
Intervention or exposure: Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type.
Outcomes measure and analysis: The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated.

Résultats : A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months.

Conclusion : In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.

Conclusion (proposition de traduction) : Chez les patients souffrant de lésions cérébrales traumatiques modérées à graves, l'utilisation de Sterofundin n'a pas été associée à une réduction de la mortalité à l'hôpital, au développement d'une lésion rénale aiguë ou à une amélioration de l'échelle de résultats de Glasgow étendue à 6 mois, par rapport à une solution saline à 0,9 %.

Utility of end-tidal carbon dioxide to guide resuscitation termination in prolonged out-of-hospital cardiac arrest.
Hambelton C, Wu L, Smith J, Thompson K, Neth MR, Daya MR, Jui J, Lupton JR. | Am J Emerg Med. 2024 Mar;77:77-80
DOI: https://doi.org/10.1016/j.ajem.2023.11.030
Keywords: Cardiac arrest; End-tidal carbon dioxide; Resuscitation; Termination of resuscitation.

Short communication

Introduction : To evaluate if the change in end-tidal carbon dioxide (ETCO₂) over time has improved discriminatory value for determining resuscitation futility compared to a single ETCO₂ value in prolonged, refractory non-shockable out-of-hospital cardiac arrest (OHCA).

Méthode : This is a retrospective analysis of adult refractory non-shockable, non-traumatic OHCA patients in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry) from 2018 to 2021. We defined refractory non-shockable OHCA cases as patients with lack of a shockable rhythm at any time or return of spontaneous circulation at any time prior to 30-min of on-scene resuscitation. We abstracted ETCO₂ values first recorded after advanced airway placement and nearest to the 30-min mark of on-scene resuscitation (30 min-ETCO₂) from EMS charts. The primary outcome was survival to hospital discharge. We compared 30 min-ETCO₂ cutoffs of 10 mmHg and 20 mmHg to the trend (increasing or not) from initial to 30 min-ETCO₂ (delta-ETCO₂) using sensitivity, specificity, and area under the receiver operating curves (AUROC).

Résultats : Of 3837 adult OHCA, 2850 were initially non-shockable, and there were 617 (16.1%) cases of refractory non-shockable OHCA at 30-min. We excluded 320 cases without at least two ETCO₂ recordings in the EMS chart, leaving 297 cases that met inclusion criteria. Of these, 176 (59.3%) were transported and 2 (0.7%) survived to discharge. Using absolute 30 min-ETCO₂ cutoffs, both survivors were in the >10 mmHg group (sensitivity 100.0%, specificity 12.5%), whereas only one survivor was identified in the >20 mmHg group (sensitivity 50.0%, specificity 32.5%). Using delta-ETCO₂, both survivors were in the increasing ETCO₂ group (sensitivity 100.0%, specificity 60.7%). In comparing the two tests that did not misclassify survivors, the AUROC [95% CI] was higher when using delta-ETCO₂ (0.803 [0.775-0.831]) compared to an absolute cutoff of 10 mmHg (0.563 [0.544-0.582]).

Conclusion : Nearly one-sixth of EMS-treated adult OHCA patients had refractory non-shockable arrests after at least 30 min of ongoing resuscitation. In this group, the ETCO₂ trend following advanced airway placement may be more accurate in guiding termination of resuscitation than an absolute ETCO₂ cutoff of 10 or 20 mmHg.

Conclusion (proposition de traduction) : Près d'un sixième des adultes victimes d'un arrêt cardiaque extrahospitalier traités par les services médicaux d'urgence ont présenté un arrêt réfractaire non choquable après au moins 30 minutes de réanimation. Dans ce groupe, la tendance de l'ETCO₂ après le contrôle des voies respiratoires spécialisée (sonde endotrachéale ou dispositif supraglottique) peut être plus précise pour guider l'arrêt de la réanimation qu'un seuil absolu d'ETCO₂ de 10 ou 20 mmHg.

Cumulative epinephrine dose during cardiac arrest and neurologic outcome after extracorporeal cardiopulmonary resuscitation.
Garcia SI, Seelhammer TG, Saddoughi SA, Finch AS, Park JG, Wieruszewski PM. | Am J Emerg Med. 2024 Mar 15;80:61-66
DOI: https://doi.org/10.1016/j.ajem.2024.03.013  | Télécharger l'article au format  
Keywords: Cardiac arrest; Epinephrine; Extracorporeal cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; Favorable neurologic outcome.

Article

Introduction : Epinephrine is recommended without an apparent ceiling dosage during cardiac arrest. However, excessive alpha- and beta-adrenergic stimulation may contribute to unnecessarily high aortic afterload, promote post-arrest myocardial dysfunction, and result in cerebral microvascular insufficiency in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR).

Méthode : This was a retrospective cohort study of adults (≥ 18 years) who received ECPR at large academic ECMO center from 2018 to 2022. Patients were grouped based on the amount of epinephrine given during cardiac arrest into low (≤ 3 mg) and high (> 3 mg) groups. The primary endpoint was neurologic outcome at hospital discharge, defined by cerebral performance category (CPC). Multivariable logistic regression was used to assess the relationship between cumulative epinephrine dosage during arrest and neurologic outcome.

Résultats : Among 51 included ECPR cases, the median age of patients was 60 years, and 55% were male. The mean cumulative epinephrine dose administered during arrest was 6.2 mg but ranged from 0 to 24 mg. There were 18 patients in the low-dose (≤ 3 mg) and 25 patients in the high-dose (> 3 mg) epinephrine groups. Favorable neurologic outcome at discharge was significantly greater in the low-dose (55%) compared to the high-dose (24%) group (p = 0.025). After adjusting for age, those who received higher doses of epinephrine during the arrest were more likely to have unfavorable neurologic outcomes at hospital discharge (odds ratio 4.6, 95% CI 1.3, 18.0, p = 0.017).

Conclusion : After adjusting for age, cumulative epinephrine doses above 3 mg during cardiac arrest may be associated with unfavorable neurologic outcomes after ECPR and require further investigation.

Conclusion (proposition de traduction) : Après ajustement pour l'âge, les doses cumulées d'adrénaline supérieures à 3 mg pendant un arrêt cardiaque peuvent être associées à des résultats neurologiques défavorables après l'ECPR et nécessitent une étude plus approfondie

Commentaire : Article qui nous incite à privilégier les faibles doses d’adrénaline (3 mg) chez les patients qui pourraient bénéficier d’une réanimation cardio-pulmonaire extracorporelle (ECMO).

Decoding pain through facial expressions: a study of patients with migraine.
Chen WT, Hsiao FJ, Coppola G, Wang SJ. | J Headache Pain. 2024 Mar 11;25(1):33
DOI: https://doi.org/10.1186/s10194-024-01742-1  | Télécharger l'article au format  
Keywords: Chronic migraine (CM); Episodic migraine (EM); Facial Action Coding System (FACS); Facial expression; Pain.

RESEARCH

Introduction : The present study used the Facial Action Coding System (FACS) to analyse changes in facial activities in individuals with migraine during resting conditions to determine the potential of facial expressions to convey information about pain during headache episodes.

Méthode : Facial activity was recorded in calm and resting conditions by using a camera for both healthy controls (HC) and patients with episodic migraine (EM) and chronic migraine (CM). The FACS was employed to analyse the collected facial images, and intensity scores for each of the 20 action units (AUs) representing expressions were generated. The groups and headache pain conditions were then examined for each AU.

Résultats : The study involved 304 participants, that is, 46 HCs, 174 patients with EM, and 84 patients with CM. Elevated headache pain levels were associated with increased lid tightener activity and reduced mouth stretch. In the CM group, moderate to severe headache attacks exhibited decreased activation in the mouth stretch, alongside increased activation in the lid tightener, nose wrinkle, and cheek raiser, compared to mild headache attacks (all corrected p < 0.05). Notably, lid tightener activation was positively correlated with the Numeric Rating Scale (NRS) level of headache (p = 0.012). Moreover, the lip corner depressor was identified to be indicative of emotional depression severity (p < 0.001).

Conclusion : Facial expressions, particularly lid tightener actions, served as inherent indicators of headache intensity in individuals with migraine, even during resting conditions. This indicates that the proposed approach holds promise for providing a subjective evaluation of headaches, offering the benefits of real-time assessment and convenience for patients with migraine.

Conclusion (proposition de traduction) : Les expressions faciales, en particulier les actions de resserrement des paupières, ont servi d'indicateurs inhérents de l'intensité des maux de tête chez les personnes migraineuses, même dans des conditions de repos. Cela indique que l'approche proposée est prometteuse pour fournir une évaluation subjective des maux de tête, offrant les avantages d'une évaluation en temps réel et de la commodité pour les patients migraineux.

Effect of a cervical collar on optic nerve sheath diameter in trauma patients.
Yazici MM, Yavaşi Ö. | World J Emerg Med. 2024;15(2):126-130
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2024.023  | Télécharger l'article au format  
Keywords: Computed tomography; Emergency medicine; Optic nerve sheath diameter; Trauma.

Original Article

Introduction : As advocated in advanced trauma life support and prehospital trauma life support protocols, cervical immobilization is applied until cervical spine injury is excluded. This study aimed to show the difference in optic nerve sheath diameter (ONSD) between patients with and without a cervical collar using computed tomography (CT).

Méthode : This was a single-center, retrospective study examining trauma patients who presented to the emergency department between January 1, 2021, and December 31, 2021. The ONSD on brain CT of the trauma patients was measured and analyzed to determine whether there was a difference between the ONSD with and without the cervical collar.

Résultats : The study population consisted of 169 patients. On CT imaging of patients with (n=66) and without (n=103) cervical collars, the mean ONSD in the axial plane were 5.43 ± 0.50 mm and 5.04 ± 0.46 mm respectively for the right eye and 5.50 ± 0.52 mm and 5.11 ± 0.46 mm respectively for the left eye. The results revealed an association between the presence of a cervical collar and the mean ONSD, which was statistically significant (P<0.001) for both the right and left eyes.

Conclusion : A cervical collar may be associated with increased ONSD. The effect of this increase in the ONSD on clinical outcomes needs to be investigated, and the actual need for cervical collar in the emergency department should be evaluated on a case-by-case basis.

Conclusion (proposition de traduction) : Le port d'un collier cervical peut être associé à une augmentation du diamètre de la gaine du nerf optique. L'effet de cette augmentation du diamètre de la gaine du nerf optique sur les résultats cliniques doit être étudié, et la nécessité réelle d'un collier cervical dans le service des urgences doit être évaluée au cas par cas.

Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis.
Ko YC, Tsai TY, Wu CK, Lin KW, Hsieh MJ, Lu TP, Matsuyama T, Chiang WC, Ma MH. | World J Emerg Surg. 2024 Mar 19;19(1):10
DOI: https://doi.org/10.1186/s13017-024-00536-9  | Télécharger l'article au format  
Keywords: Emergency medical service; Pre-hospital; Tourniquet; Vascular extremity trauma.

Review

Introduction : Tourniquets (TQ) have been increasingly adopted in pre-hospital settings recently. This study examined the effectiveness and safety of applying TQ in the pre-hospital settings for civilian patients with traumatic vascular injuries to the extremities.

Méthode : We systematically searched the Ovid Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from their inception to June 2023. We compared pre-hospital TQ (PH-TQ) use to no PH-TQ, defined as a TQ applied after hospital arrival or no TQ use at all, for civilian vascular extremity trauma patients. The primary outcome was overall mortality rate, and the secondary outcomes were blood product use and hospital stay. We analyzed TQ-related complications as safety outcomes. We tried to include randomized controlled trials (RCTs) and non-randomized studies (including non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and case-control studies), if available. Pooled odds ratios (ORs) were calculated and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

Résultats : Seven studies involving 4,095 patients were included. In the primary outcome, pre-hospital TQ (PH-TQ) use significantly decrease mortality rate in patients with extremity trauma (odds ratio [OR], 0.48, 95% confidence interval [CI] 0.27-0.86, I₂ = 47%). Moreover, the use of PH-TQ showed the decreasing trend of utilization of blood products, such as packed red blood cells (mean difference [MD]: -2.1 [unit], 95% CI: -5.0 to 0.8, I₂ = 99%) or fresh frozen plasma (MD: -1.0 [unit], 95% CI: -4.0 to 2.0, I2 = 98%); however, both are not statistically significant. No significant differences were observed in the lengths of hospital and intensive care unit stays. For the safety outcomes, PH-TQ use did not significantly increase risk of amputation (OR: 0.85, 95% CI: 0.43 to 1.68, I₂ = 60%) or compartment syndrome (OR: 0.94, 95% CI: 0.37 to 2.35, I₂ = 0%). The certainty of the evidence was very low across all outcomes.

Conclusion : The current data suggest that, in the pre-hospital settings, PH-TQ use for civilian patients with vascular traumatic injury of the extremities decreased mortality and tended to decrease blood transfusions. This did not increase the risk of amputation or compartment syndrome significantly.

Conclusion (proposition de traduction) : Les données actuelles suggèrent que, dans le cadre préhospitalier, l'utilisation de garrot pour les patients civils présentant des lésions traumatiques vasculaires des extrémités réduit la mortalité et tend à diminuer les transfusions sanguines. Le risque d'amputation ou de syndrome des loges n'a pas été augmenté de manière significative.