Blood biomarkers for the differentiation between central and peripheral vertigo in the emergency department: a systematic review and meta-analysis.
Klokman VW, Koningstein FN, Dors JWW, Sanders MS, Koning SW, de Kleijn DPV, Jie KE. | Acad Emerg Med.  2024 Apr;31(4):371-385
DOI: https://doi.org/10.1111/acem.14864  | Télécharger l'article au format  
Keywords: biomarker; dizziness; meta‐analysis; stroke; systematic review; vertigo.

SYSTEMATIC REVIEW

Introduction : In patients with acute vestibular syndrome (AVS), differentiating between stroke and nonstroke causes is challenging in the emergency department (ED). Correct diagnosis of vertigo etiology is essential for early optimum treatment and disposition.

Méthode : The aim of this systematic review and meta-analysis was to summarize the published evidence on the potential of blood biomarkers in the diagnosis and differentiation of peripheral from central causes of AVS.
Methods: A literature search was conducted for studies published until January 1, 2023, in PubMed, Ovid Medline, and EMBASE databases analyzing biomarkers for the differentiation between central and peripheral AVS. The Quality Assessment of Diagnostic Accuracy Studies questionnaire 2 was used for quality assessment. Pooled standardized mean difference and 95% confidence intervals were calculated if a biomarker was reported in two or more studies. Heterogeneity among included studies was investigated using the I² metric.

Résultats : A total of 17 studies with 859 central and 4844 peripheral causes of acute dizziness or vertigo, and analysis of 61 biomarkers were included. The general laboratory markers creatinine, blood urea nitrogen, albumin, C-reactive protein, glucose, HbA1c, leukocyte counts, and neutrophil counts and the brain-derived biomarkers copeptin, S100 calcium-binding protein β (S100β), and neuron-specific enolase (NSE) significantly differentiated central from peripheral causes of AVS.

Conclusion : This systematic review and meta-analysis highlights the potential of generalized inflammatory markers and brain-specific blood protein markers of NSE and S100β as diagnostic biomarkers for central from peripheral differentiation in AVS. These results, as a complement to clinical characteristics, provide guidance for future large-scale diagnostic research, in this challenging ED patient population.

Conclusion (proposition de traduction) : Cette revue systématique et cette méta-analyse mettent en évidence le potentiel des marqueurs inflammatoires généralisés et des marqueurs des protéines sanguines spécifiques au cerveau que sont la NSE et la S100β en tant que biomarqueurs diagnostiques permettant de différencier les vertiges centraux des vertiges périphériques dans les services d'urgence. Ces résultats, en complément des caractéristiques cliniques, fournissent des orientations pour de futures recherches diagnostiques à grande échelle, dans cette population difficile de patients des services d'urgence.

Peripheral nervous system and neuromuscular disorders in the emergency department: A review.
Sivadasan A, Cortel-LeBlanc MA, Cortel-LeBlanc A, Katzberg H. | Acad Emerg Med.  2024 Apr;31(4):386-397
DOI: https://doi.org/10.1111/acem.14861  | Télécharger l'article au format  
Keywords: Guillain–Barré syndrome; myasthenia; neuromuscular; respiratory failure.

SPECIAL CONTRIBUTION

Introduction : Acute presentations and emergencies in neuromuscular disorders (NMDs) often challenge clinical acumen. The objective of this review is to refine the reader's approach to history taking, clinical localization and early diagnosis, as well as emergency management of neuromuscular emergencies.

Méthode : An extensive literature search was performed to identify relevant studies. We prioritized meta-analysis, systematic reviews, and position statements where possible to inform any recommendations.

Discussion : The spectrum of clinical presentations and etiologies ranges from neurotoxic envenomation or infection to autoimmune disease such as Guillain-Barré Syndrome (GBS) and myasthenia gravis (MG). Delayed diagnosis is not uncommon when presentations occur "de novo," respiratory failure is dominant or isolated, or in the case of atypical scenarios such as GBS variants, severe autonomic dysfunction, or rhabdomyolysis. Diseases of the central nervous system, systemic and musculoskeletal disorders can mimic presentations in neuromuscular disorders.

Conclusion : Fortunately, early diagnosis and management can improve prognosis. This article provides a comprehensive review of acute presentations in neuromuscular disorders relevant for the emergency physician.

Conclusion (proposition de traduction) : Les maladies du système nerveux central, les troubles systémiques et musculo-squelettiques peuvent imiter les présentations des troubles neuromusculaires. Heureusement, un diagnostic et une prise en charge précoces peuvent améliorer le pronostic. Cet article fournit une revue complète des présentations aiguës des maladies neuromusculaires pertinentes pour le médecin urgentiste.

Early versus late advanced airway management for adult patients with out-of-hospital cardiac arrest: A time-dependent propensity score-matched analysis.
Amagasa S, Iwamoto S, Kashiura M, Yasuda H, Kishihara Y, Uematsu S, Moriya T. | Acad Emerg Med.  2024 Apr 8
DOI: https://doi.org/10.1111/acem.14907  | Télécharger l'article au format  
Keywords: airway management; cardiopulmonary resuscitation; heart arrest; intubation.

Original article

Introduction : The objective was to investigate whether early advanced airway management during the entire resuscitation period is associated with favorable neurological outcomes and survival in patients with out-of-hospital cardiac arrest (OHCA).

Méthode : We performed a retrospective cohort study of patients with OHCA aged ≥18 years enrolled in OHCA registry in Japan who received advanced airway management during cardiac arrest between June 2014 and December 2020. To address resuscitation time bias, we performed risk set matching analyses in which patients who did and did not receive advanced airway management were matched at the same time point (min) using the time-dependent propensity score; further, we compared early (≤10 min) and late (>10 min) advanced airway management. The primary and secondary outcome measures were favorable neurological outcomes using Cerebral Performance Category scores and survival at 1 month after cardiac arrest.

Résultats : Of the 41,101 eligible patients, 21,446 patients received early advanced airway management. Thus, risk set matching was performed with a total of 42,866 patients. In the main analysis, early advanced airway management was significantly associated with favorable neurological outcomes (risk ratio [RR] 0.997, 95% confidence interval [CI] 0.995-0.999) and survival (RR 0.990, 95% CI 0.986-0.994) at 1 month after cardiac arrest. In the sensitivity analysis with early advanced airway management defined as ≤5 min and ≤20 min, the results were comparable.

Conclusion : Although early advanced airway management was statistically significant for improved neurological outcomes and survival at 1 month after cardiac arrest, the RR was very close to 1, indicating that the timing of advanced airway management has minimal impact on clinical outcomes, and decisions should be made based on the individual needs of the patient.

Conclusion (proposition de traduction) : Bien qu'une prise en charge précoce des voies aériennes ait été statistiquement significative pour l'amélioration des résultats neurologiques et de la survie un mois après l'arrêt cardiaque, le RR était très proche de 1, ce qui indique que le moment de la prise en charge des voies aériennes a un impact minimal sur les résultats cliniques et que les décisions doivent être prises en fonction des besoins individuels du patient.

Commentaire : Vaste étude rétrospective portant sur des patients victimes d'un arrêt cardiaque extrahospitalier qui mets en évidence un lien très faible, et probablement cliniquement insignifiant, entre l'évolution neurologique favorable et la survie chez les patients ayant bénéficié d'une prise en charge précoce des voies aériennes par rapport à une prise en charge tardive.

Pre-oxygenation using high-flow nasal oxygen versus tight facemask in trauma patients undergoing emergency anaesthesia.
Sjöblom A, Hedberg M, Gille A, Guerra A, Aanesen V, Forsberg IM, Fagerlund MJ. | Acta Anaesthesiol Scand.  2024 Apr;68(4):447-456
DOI: https://doi.org/10.1111/aas.14368  | Télécharger l'article au format  
Keywords: airway management; emergency anaesthesia; high-flow nasal oxygen; pre-oxygenation; rapid sequence induction; respiratory physiology; trauma.

RESEARCH ARTICLE

Introduction : Patients suffering from major traumatic injuries frequently require emergency anaesthesia. Due to often compromised physiology and the time-sensitive management, trauma patients may be more prone to desaturate during induction of anaesthesia. We hypothesised that pre-oxygenation using high-flow nasal oxygen would decrease the risk of desaturation during induction of anaesthesia in trauma patients and the study therefore aimed to compare the frequency of desaturation when pre-oxygenation was performed with high-flow nasal oxygen or a traditional facemask.

Méthode : This exploratory, prospective, before-and-after study was conducted at the Karolinska University Hospital, Sweden. Adult (≥18 years of age) patients suffering major traumatic injuries needing emergency anaesthesia were included around the clock. Patients were pre-oxygenated using a tight-fitting facemask during the first nine months of enrollment. High-flow nasal oxygen was then introduced as a method for pre-oxygenation of trauma patients. The primary outcome was the proportion of patients desaturating <93% during induction of anaesthesia, assessed from the start of pre-oxygenation until one minute after intubation. Secondary outcomes included perceived difficulty of pre-oxygenation among anaesthetists (assessed on a scale between 1 and 10) and safety outcomes, such as incidence of regurgitations and intracranial gas (assessed radiologically).

Résultats : Data from 96 patients were analysed. Facemask pre-oxygenation was performed in 66 patients, while 30 patients were pre-oxygenated with high-flow nasal oxygen. The most frequent trauma mechanisms were stabbing injuries (n = 34 (35%)) and fall injuries (n = 21 (22%)). There were no differences in patient characteristics between the groups. Eight (12%) versus three (10%) patients desaturated <93% in the facemask and high-flow nasal oxygen group respectively, OR 0.81 (95% CI 0.20-3.28), p = .76. Anaesthetists assessed pre-oxygenation using high-flow nasal oxygen as easier compared to facemask pre-oxygenation. No patient in any group showed signs of regurgitation. Among patients with facial or skull fractures requiring anaesthesia before radiology was performed, intracranial gas was seen in four (40%) patients pre-oxygenated with a facemask and in no patient pre-oxygenated with HFNO (p = .23).

Conclusion : In this prospective study investigating trauma patients undergoing emergency anaesthesia, we could not see any difference in the number of patients desaturating when pre-oxygenation was performed with high-flow nasal oxygen compared to a tight-fitting facemask. Pre-oxygenation using high-flow nasal oxygen was assessed as easier compared to facemask pre-oxygenation.

Conclusion (proposition de traduction) : Dans cette étude prospective portant sur des patients traumatisés bénéficiant d'une anesthésie d'urgence, nous n'avons pas pu constater de différence dans le nombre de patients ayant présenté une désaturation lorsque la préoxygénation était effectuée à l'aide d'oxygène nasal à haut débit par rapport à un masque facial étanche. La préoxygénation à l'aide d'oxygène nasal à haut débit a été jugée plus facile que la préoxygénation au masque facial.

Transthoracic impedance variability to assess quality of chest compression in out-of-hospital cardiac arrest.
Magliocca A, Castagna V, Fornari C, Zimei G, Merigo G, Penna A, Carlson J, Fumagalli F, Stirparo G, Migliari M, Coppo A, Sechi GM, Grasselli G, Hardig BM, Ristagno G. | Acta Anaesthesiol Scand.  2024 Apr;68(4):556-566
DOI: https://onlinelibrary.wiley.com/doi/10.1111/aas.14374
Keywords: cardiopulmonary resuscitation; chest compression fraction; outcome; transthoracic impedance; variability.

Research article

Introduction : Chest compression is a lifesaving intervention in out-of-hospital cardiac arrest (OHCA), but the optimal metrics to assess its quality have yet to be identified. The objective of this study was to investigate whether a new parameter, that is, the variability of the chest compression-generated transthoracic impedance (TTI), namely Imp_CC , which measures the consistency of the chest compression maneuver, relates to resuscitation outcome.

Méthode : This multicenter observational, retrospective study included OHCAs with shockable rhythm. Imp_CC variability was evaluated with the power spectral density analysis of the TTI. Multivariate regression model was used to examine the impact of Imp_CC variability on defibrillation success. Secondary outcome measures were return of spontaneous circulation and survival.

Résultats : Among 835 treated OHCAs, 680 met inclusion criteria and 565 matched long-term outcomes. Imp_CC was significantly higher in patients with unsuccessful defibrillation compared to those with successful defibrillation (p = .0002). Lower Imp_CC variability was associated with successful defibrillation with an odds ratio (OR) of 0.993 (95% confidence interval [95% CI], 0.989-0.998, p = .003), while the standard chest compression fraction (CCF) was not associated (OR 1.008 [95 % CI, 0.992-1.026, p = .33]). Neither Imp_CC nor CCF was associated with long-term outcomes.

Conclusion : In this population, consistency of chest compression maneuver, measured by variability in TTI, was an independent predictor of defibrillation outcome. Imp_CC may be a useful novel metrics for improving quality of care in OHCA.

Conclusion (proposition de traduction) : Dans cette population, la régularité des compressions thoraciques, mesurée par la variabilité de l'impédance transthoracique, était un facteur prédictif indépendant de réussite de la défibrillation. L'impédance transthoracique générée par la compression thoracique peut être une nouvelle mesure utile pour améliorer la qualité des soins lors d'un arrêt cardiaque extrahospitalier.

Emergency resuscitative thoracotomy in severe trauma: Analysis of the nation-wide registry data in Japan.
Okano H, Terayama T, Okamoto H, Yamazaki T. | Acute Med Surg.  2024 Apr 24;11(1):e958
DOI: https://doi.org/10.1002/ams2.958  | Télécharger l'article au format  
Keywords: Japan; cardiac arrest; database; resuscitation; thoracotomy.

ORIGINAL ARTICLE

Introduction : Emergency resuscitative thoracotomy is a potentially lifesaving procedure for patients with cardiac pulmonary arrest and profound circulatory failure resulting from a severe injury. However, survival rate post-emergency resuscitative thoracotomy shows considerable variation, with many studies constrained by limited sample sizes and ambiguous criteria for inclusion. Herein, we assessed the outcomes of emergency r

Méthode : Data of patients aged ≥18 years between 2004 and 2019 were analyzed. The primary outcome measure was survival at discharge. Descriptive statistics were used to compare the survivor and nonsurvivor groups. A multivariable logistic regression analysis was conducted to identify predictors of survival in patien

Résultats : Among patients who underwent emergency resuscitative thoracotomy, 684/5062 (13.5%) survived. Age <65 years (adjusted odds ratio, 1.351; 95% confidence interval, 1.130-1.615; p < 0.001), absence of cardiac pulmonary arrest on emergency department arrival (adjusted odds ratio, 1.694; 95% confidence interval, 1.280-2.243; p < 0.01), Injury Severity Score <16 (adjusted odds ratio, 2.195; 95% confidence interval, 1.611-2.992; p < 0.01), and penetrating injury (adjusted odds ratio, 1.834; 95% confidence interval, 1.384-2.431; p < 0.01) were identified as factors associated with survival at discharge.

Conclusion : The survival rate for emergency resuscitative thoracotomy in Japan stands at approximately 13.5%. Factors contributing to survival include younger age, absence of cardiopulmonary arrest at emergency department arrival, lack of severe trauma, and sustaining penetrating injuries.

Conclusion (proposition de traduction) : Le taux de survie à la thoracotomie de sauvetage d'urgence au Japon est d'environ 13,5 %. Les facteurs contribuant à la survie sont le jeune âge, l'absence d'arrêt cardio-respiratoire à l'arrivée au service des urgences, l'absence de traumatisme grave et de lésions pénétrantes.

Association between eGFR and neurological outcomes among patients with out-of-hospital cardiac arrest: A nationwide prospective study in Japan.
Kandori K, Okada A, Nakajima S, Matsuyama T, Kitamura T, Narumiya H, Iizuka R, Hitosugi M, Okada Y. | Acute Med Surg.  2024 Apr 17;11(1):e952
DOI: https://doi.org/10.1002/ams2.952  | Télécharger l'article au format  
Keywords: cardiac rhythm; comorbidity; estimated glomerular filtration rate; out‐of‐hospital cardiac arrest; renal dysfunction.

ORIGINAL ARTICLE

Introduction : We aimed to investigate the association between estimated glomerular filtration rate and prognosis in out-of-hospital cardiac arrest patients and explore the heterogeneity of the association.

Méthode : Patients experiencing out-of-hospital cardiac arrest due to medical causes and registered in the JAAM-OHCA Registry between June 2014 and December 2019 were stratified into shockable rhythm, pulseless electrical activity, and asystole groups according to the cardiac rhythm at the scene. The primary outcome was a 1-month favorable neurological status. Adjusted odds ratios with 95% confidence intervals were calculated to investigate the association between estimated glomerular filtration rate and outcomes using a logistic model.

Résultats : Of the 19,443 patients included, 2769 had initial shockable rhythm at the scene, 5339 had pulseless electrical activity, and 11,335 had asystole. As the estimated glomerular filtration rate decreased, the adjusted odds ratio for a 1-month favorable neurological status decreased among those with initial shockable rhythm (estimated glomerular filtration rate, adjusted odds ratio [95% CI]: 45-59 mL/min/1.73 m², 0.61 [0.47-0.79]; 30-44 mL/min/1.73 m², 0.45 [0.32-0.62]; 15-29 mL/min/1.73 m², 0.35 [0.20-0.63]; and <15 mL/min/1.73 m², 0.14 [0.07-0.27]). Estimated glomerular filtration rate was associated with neurological outcomes in patients aged <65 years with initial shockable rhythm but not in those aged >65 years or patients with initial pulseless electrical activity or asystole.

Conclusion : The estimated glomerular filtration rate is associated with neurological prognosis in out-of-hospital cardiac arrest patients with initial shockable rhythm at the scene but not in those with initial non-shockable rhythm.

Conclusion (proposition de traduction) : Le débit de filtration glomérulaire estimé est associé au pronostic neurologique chez les patients ayant présenté un arrêt cardiaque extrahospitalier avec un rythme initial choquable sur le lieu de l'accident, mais pas chez ceux dont le rythme initial n'était pas choquable.

Ketamine Efficacy for Management of Status Epilepticus: Considerations for Prehospital Clinicians.
Williams NC, Morgan LA, Friedman J, Siegler J. | Air Med J.  2024 Mar-Apr;43(2):84-89
DOI: https://doi.org/10.1016/j.amj.2023.09.011
Keywords: Aucun

Literature Review

Editorial : Current first-line therapies for seizure management recommend benzodiazepines, which target gamma-aminobutyric acid type A channels to stop the seizure activity. However, seizures may be refractory to traditional first-line therapies, transitioning into status epilepticus and becoming resistant to gamma-aminobutyric acid type A augmenting drugs. Although there are other antiseizure medications available for clinicians to use in the intensive care unit, these options can be less readily available outside of the intensive care unit and entirely absent in the prehospital setting. Instead, patients frequently receive multiple doses of first-line agents with increased risk of hemodynamic or airway collapse. Ketamine is readily available in the prehospital setting and emergency department, has well-established antiseizure effects with a favorable safety profile, and is a drug often used for several other indications. This article aimed to explore the utilization of ketamine for seizure management in the prehospital setting, reviewing seizure pathophysiology, established treatment mechanisms of action and pharmacokinetics, and potential benefits of early ketamine use in status epilepticus.

Conclusion : Although there is a lack of prospective studies and randomized controlled trials specific to ketamine’s use in SE, particularly early in the treatment course, there is an abundance of data that demonstrate a favorable safety profile, high sensitivity, and high specificity for the management of RSE. The data are currently insufficient to create formal recommendations for standardized practice and primarily hold only level 3 quality. With respect to resource-limited environments, ketamine has merit because of its antiseizure profile but not necessarily more benefit than other more established agents such as valproic acid, levetiracetam, and phenytoin/fosphenytoin. Still, the safety profile of ketamine creates an argument for the consideration of earlier use, particularly if other options are unavailable. Prehospital clinicians have a fundamental understanding of the medication and frequently use it for a variety of conditions, allowing for a natural expansion into SE treatment without causing a training burden. Ultimately, although there is increasing evidence to consider ketamine in the early treatment of SE, higher-quality evidence is needed before routine recommendations can be made.

Conclusion (proposition de traduction) : Malgré le manque d'études prospectives et d'essais contrôlés randomisés portant spécifiquement sur l'utilisation de la kétamine dans l'état de mal épileptique, en particulier au début du traitement, de nombreuses données démontrent un profil de sécurité favorable, une sensibilité et une spécificité élevées pour la prise en charge de l'état de mal épileptique réfractaire et de l'état de mal épileptique. Les données sont actuellement insuffisantes pour créer des recommandations formelles pour une pratique standardisée et ne sont principalement que de niveau 3 de qualité. En ce qui concerne les environnements à ressources limitées, la kétamine est intéressante en raison de son profil anticonvulsivant, mais ne présente pas nécessairement plus d'avantages que d'autres agents mieux établis tels que l'acide valproïque, le lévétiracétam et la phénytoïne/fosphénytoïne. Néanmoins, le profil de sécurité de la kétamine plaide en faveur d'une utilisation plus précoce, en particulier si d'autres options ne sont pas disponibles. Les urgentistes ont une connaissance approfondie du médicament et l'utilisent fréquemment pour diverses pathologies, ce qui permet d'étendre naturellement le traitement de l'état de mal épileptique sans alourdir la formation. En fin de compte, bien qu'il y ait de plus en plus de preuves pour envisager la kétamine dans le traitement précoce de l'état de mal épileptique, des preuves de meilleure qualité sont nécessaires avant que des recommandations de routine puissent être émises.

Pediatric Intubations in a Semiurban Helicopter Emergency Medicine Service: A Retrospective Review.
Morton S, Keane S, O'Meara M. | Air Med J.  2024 Mar-Apr;43(2):106-110
DOI: https://doi.org/10.1016/j.amj.2023.10.007
Keywords: Aucun

Original Research Pediatric

Introduction : Although a small proportion of helicopter emergency medical service (HEMS) missions are for pediatric patients, it is recognized that children do present unique challenges. This case series aims to evaluate the intubation first-pass success rate in HEMS pediatric patients for both medical and trauma patients in a UK semiurban environment.

Méthode : A retrospective review of the computerized records system was performed from January 1, 2015, to July 31, 2022, at 1 UK HEMS. Anonymous data relating to advanced airway interventions in patients < 16 years of age were extracted. Primary analysis related to the first-pass success rate was performed; secondary analysis relating to the initial Glasgow Coma Scale (GCS) of the pediatric patients requiring prehospital anesthesia (rapid sequence induction with drugs) and first-pass success rates by clinician group was also performed.

Résultats : Of the pediatric patients, 15.8% required intubation. The overall first-pass success rate for intubation (including in cardiac arrest) was 83.5%; for prehospital anesthesia (drugs administered), it was 98.4%. First-pass success rates were lowest for those under 2 years of age (45.2% without drugs and 87.5% with drugs). There was no difference between physician background in the first-pass success rate. The median GCS for pediatric prehospital anesthesia was 7 versus 5 for adults (P = .012). No children with an initial GCS of 15 had prehospital anesthesia.

Conclusion : The overall intubation first-pass success rates for pediatric patients is high at 83.5% and higher still for prehospital anesthesia (98.4%). However, it remains a rare intervention for clinicians, and children under 2 years of age require special consideration.

Conclusion (proposition de traduction) : Le taux de réussite global de l'intubation au premier essai chez les patients pédiatriques est élevé (83,5 %) et encore plus élevé pour l'anesthésie préhospitalière (98,4 %). Cependant, cette intervention reste rare pour les cliniciens et les enfants de moins de 2 ans doivent faire l'objet d'une attention particulière.

Factors Associated With Desaturation in Prehospital Rapid Sequence Intubation in a Helicopter Emergency Medical Service.
Hayes-Bradley C, Miller M, Kua BH, Ragavan D, Gospel A, Partyka C, Bliss JM, Ferguson IMC. | Air Med J.  2024 Mar-Apr;43(2):157-162
DOI: https://doi.org/10.1016/j.amj.2023.11.013  | Télécharger l'article au format  
Keywords: Aucun

Original Research

Introduction : Desaturation during prehospital rapid sequence intubation (RSI) is common and is associated with patient morbidity. Past studies have identified oxygen saturations at induction, the grade of laryngoscopy, and multiple attempts to intubate as being associated with desaturation. This study aimed to investigate whether there are other factors, identifiable before RSI, associated with desaturation.

Méthode : This was a study of a physician-paramedic critical care team operating as Aeromedical Operations, NSW Ambulance. Prehospital RSIs (using paralysis) were studied retrospectively via patient case notes, monitor data, and an airway database. The review occurred between April 1, 2016, and December 31, 2018. Desaturation was defined as monitor recordings of saturations ≤ 92%. Logistic regression was performed for factors likely to be associated with desaturation.

Résultats : Desaturation occurred in 67 of 350 (19.1%) RSIs. Factors significantly associated with desaturation included male sex, a chest injury, increased weight, and lower saturations pre-RSI.

Conclusion : Increased weight, chest injuries, and lower oxygen saturations are associated with desaturation at RSI. The variable male sex may be a surrogate for other as-yet unidentified factors.

Conclusion (proposition de traduction) : Un poids plus élevé, des lésions thoraciques et des saturations en oxygène plus basses sont associés à la désaturation lors de l'intubation en séquence rapide. La composante masculine peut être un indicateur d'autres facteurs qui n'ont pas encore été identifiés.

Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury.
Mansvelder FJ, Bossers SM, Loer SA, Bloemers FW, Van Lieshout EMM, Den Hartog D, Hoogerwerf N, van der Naalt J, Absalom AR, Peerdeman SM, Bulte CSE, Schwarte LA, Schober P; BRAIN-PROTECT collaborators. | Anesthesiology.  2024 Apr 1;140(4):742-751
DOI: https://doi.org/10.1097/aln.0000000000004894  | Télécharger l'article au format  
Keywords: Aucun

Critical Care Medicine

Introduction : Severe traumatic brain injury is a leading cause of morbidity and mortality among young people around the world. Prehospital care focuses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. This study therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine and the 30-day mortality in patients with severe traumatic brain injury who received prehospital airway management in the Netherlands.

Méthode : This study is a retrospective analysis of the prospectively collected observational data of the Brain Injury: Prehospital Registry of Outcomes, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) cohort study. Patients with suspected severe traumatic brain injury who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and inverse probability of treatment weighting analysis.

Résultats : In total, 1,457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (32.9% mortality for etomidate versus 33.8% mortality for S(+)-ketamine; P = 0.716; odds ratio, 1.04; 95% CI, 0.83 to 1.32; P = 0.711), as well as after adjustment for potential confounders (odds ratio, 1.08; 95% CI, 0.67 to 1.73; P = 0.765; and risk difference 0.017; 95% CI, -0.051 to 0.084; P = 0.686). Likewise, in planned subgroup analyses for patients with confirmed traumatic brain injury and patients with isolated traumatic brain injury, no significant differences were found. Consistent results were found after multiple imputations of missing data.

Conclusion : The analysis found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with traumatic brain injury and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence the patient mortality rate in this population.

Conclusion (proposition de traduction) : L'analyse n'a pas mis en évidence de lien entre l'utilisation de l'étomidate ou de la S(+)-kétamine comme agent anesthésique pour l'intubation chez les patients souffrant de lésions cérébrales traumatiques et la mortalité après 30 jours en milieu préhospitalier, ce qui suggère que le choix de l'agent d'induction peut ne pas influencer le taux de mortalité des patients dans cette population.

Adenosine Should Be First-Line Treatment for Supraventricular Tachycardia.
McDowell M, Lyons N. | Ann Emerg Med.  2024 Apr;83(4):395-397
DOI: https://doi.org/10.1016/j.annemergmed.2023.10.017
Keywords: Aucun

Controverses cliniques

Editorial : Les inhibiteurs calciques et l'adénosine constituent tous deux des moyens efficaces pour traiter la tachycardie supraventriculaire paroxystique. Dans cette édition de « Clinical Controversies », des intervenants présentent des argumentaires opposés sur les questions que les cliniciens doivent prendre en compte lors du choix d'un agent de première intention pour leurs patients.

Conclusion : In conclusion, adenosine is efficacious in narrow QRS- complex tachycardias as both a diagnostic aid when the underlying rhythm is uncertain and as definitive treatment for established SVT in nearly all patient populations. Not only is adenosine recommended over calcium channel blockers for adults in the American Heart Association and European Society of Cardiology guidelines, the data for use in special populations exceed that of calcium channel blockers.1,2 The ultra-short-acting duration and ease of administration shown in the recent literature make adenosine an optimal therapy for SVT. Emergency medicine clinicians should continue to utilize adenosine as the first-line agent over calcium channel blockers for SVT.

Conclusion (proposition de traduction) : En conclusion, l'adénosine est efficace dans les tachycardies à QRS fins, à la fois comme aide au diagnostic lorsque le rythme sous-jacent est incertain et comme traitement définitif de la TSV établie dans presque toutes les populations de patients. Non seulement l'adénosine est recommandée par rapport aux inhibiteurs calciques chez les adultes dans les lignes directrices de l'American Heart Association et de la Société européenne de cardiologie, mais les données relatives à son utilisation dans des populations particulières dépassent celles des inhibiteurs calciques. La durée d'action ultra-courte et la facilité d'administration démontrées dans la littérature récente font de l'adénosine un traitement optimal de la TSV. Les médecins urgentistes devraient continuer à utiliser l'adénosine comme agent de première intention par rapport aux inhibiteurs calciques pour le traitement de la TSV.

Commentaire : On pourrait conclure que dans la TSV chez les enfants, les patients atteints de malformations cardiaques congénitales et les femmes enceintes ont pourrait préférer l’adénosine et chez tous les autres patients hémodynamiquement stables, les inhibiteurs calciques (diltiazem) comme agents de première intention par rapport à l'adénosine.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review.
Moore L, Ben Abdeljelil A, Tardif PA, Zemek R, Reed N, Yeates KO, Emery CA, Gagnon IJ, Yanchar N, Bérubé M, Dawson J, Berthelot S, Stang A, Beno S, Beaulieu E, Turgeon AF, Labrosse M, Lauzier F, Pike I, Macpherson A, Freire GC. | Ann Emerg Med.  2024 Apr;83(4):327-339
DOI: https://doi.org/10.1016/j.annemergmed.2023.11.012
Keywords: Aucun

Pediatric

Introduction : Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations.

Méthode : We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.

Résultats : We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses.

Conclusion : We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Conclusion (proposition de traduction) : Nous avons identifié 34 recommandations fondées sur des données probantes de qualité moyenne à élevée, dont la mise en œuvre peut être envisagée dans des contextes cliniques. Notre revue met en évidence des domaines importants pour la recherche future. Cette revue souligne également l'importance de fournir des stratégies pour faciliter la mise en œuvre des recommandations des lignes directrices de pratique clinique pour les lésions cérébrales légères pédiatriques.

Commentaire : 

Calcium channel blockers should be first-line treatment for hemodynamically stable supraventricular tachycardia.
Rech MA, Gottlieb M. | Ann Emerg Med.  2024 Apr;83(4):394-395
DOI: https://doi.org/10.1016/j.annemergmed.2023.09.003
Keywords: Aucun

Controverses cliniques

Editorial : Les inhibiteurs calciques et l'adénosine constituent tous deux des moyens efficaces pour traiter la tachycardie supraventriculaire paroxystique. Dans cette édition de « Clinical Controversies », des intervenants présentent des argumentaires opposés sur les questions que les cliniciens doivent prendre en compte lors du choix d'un agent de première intention pour leurs patients.

Conclusion : In conclusion, calcium channel blockers are efficacious treatment options recommended by current guidelines for paroxysmal supraventricular tachycardia that spare the distressing adverse effects and clinically relevant drug interactions associated with adenosine. Emergency clinicians should consider calcium channel blockers as first-line agents over adenosine in hemodynamically stable patients with paroxysmal supraventricular tachycardia.

Conclusion (proposition de traduction) : En conclusion, les inhibiteurs calciques sont une option thérapeutique efficace recommandée par les lignes directrices actuelles dans la tachycardie supraventriculaire paroxystique qui évitent les effets indésirables pénibles et les interactions médicamenteuses cliniquement pertinentes associées à l'adénosine. Les urgentistes devraient considérer les inhibiteurs calciques comme des agents de première intention par rapport à l'adénosine chez les patients hémodynamiquement stables souffrant de tachycardie supraventriculaire paroxystique.

Commentaire : On pourrait conclure que dans la TSV chez les enfants, les patients atteints de malformations cardiaques congénitales et les femmes enceintes ont pourrait préférer l’adénosine et chez tous les autres patients hémodynamiquement stables, les inhibiteurs calciques (diltiazem) comme agents de première intention par rapport à l'adénosine.

Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model.
Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. | Ann Emerg Med.  2024 Apr;83(4):351-359
DOI: https://doi.org/10.1016/j.annemergmed.2023.08.018
Keywords: Aucun

Pediatric

Introduction : Button battery ingestion can cause alkaline esophageal injury. There is interest in first-aid household products to neutralize the injury. The objective was to investigate which household products are effective at reducing button battery injury.

Méthode : Two cadaveric porcine experiments were performed. Experiment 1 utilized esophageal mucosal segments. A button battery (3VCR2032) was placed onto the mucosa, and substances (saline control, honey, jam, orange juice, yogurt, milk, and cola) were applied every 10 minutes for 6 applications. Tissue pH was measured every 10 minutes, and macroscopic ulceration size was assessed at 120 minutes. Experiment 2 used an intact esophageal model with a battery inserted into the lumen and jam, honey, and saline irrigation as per experiment 1. Tissue pH, macroscopic and histopathology changes were evaluated at 60, 90 and 120 minutes.

Résultats : In experiment 1, only honey and jam had a lower mean tissue pH at 120 minutes (8.0 [standard deviation [SD] 0.9, n=12] and 7.1 [SD 1.7, n=12], respectively) compared to saline solution 11.9 (SD 0.6, n=6, P<.0001). Both honey (0.24 cm², SD 0.17) and jam (0.37 cm², SD 0.40) had smaller mean areas of ulceration compared to saline solution (3.90 cm², SD 1.03, P<.0001). In experiment 2, honey and jam had significantly lower mean tissue pH at all timepoints compared to saline solution. Histologic changes were evident at 60 minutes in the saline group, whereas honey and jam exhibited no or minimal changes until 120 minutes.

Conclusion : Honey and jam were able to neutralize injury caused by a button battery resulting in a smaller area of ulceration. Jam should be further explored as a possible first-aid option as an alternative to honey in suspected button battery ingestion prior to definitive management.

Conclusion (proposition de traduction) : Le miel et la confiture ont permis de neutraliser les lésions causées par une pile bouton, ce qui a entraîné une réduction de la zone d'ulcération. La confiture devrait être étudiée plus avant en tant qu'option de premier secours possible, en remplacement du miel, en cas de suspicion d'ingestion d'une pile bouton, avant la prise en charge définitive.

The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization.
Jouffroy R, Djossou F, Neviere R, Jaber S, Vivien B, Heming N, Gueye P. | Ann Intensive Care.  2024 Apr 16;14(1):58
DOI: https://doi.org/10.1186/s13613-024-01282-6  | Télécharger l'article au format  
Keywords: Early therapy; Healthcare trajectory; Network; Shock; sepsis.

Review

Editorial : This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.

Conclusion : Early access to the “chain of survival and rehabilitation for sepsis” ensures the early initiation of life saving treatments followed by the orientation of the patient to the adequate facility for advanced care. Earlier warning will be ensured by raising awareness of the condition among general practitioners, nurses, paramedics, prehospital caregivers and the general public. Earlier advanced care, based mainly on early antibiotic therapy and hemodynamic optimization, is possible independently of the pre- hospital emergency medical service organization even for primary health care when no ambulance can be dispatch to the scene. Triaging and admission to the adequate facility are essential for adequate source control. Advanced in hospital care helps overcome organ failure while waiting for the cause of sepsis to be treated. Rehabilitation is essential for survivors to recover an acceptable quality of life.
The ongoing public health challenge appears to be the development of coordinated actions, starting at the prehospital setting right through to rehabilitation, to be delivered as quickly as possible, thereby enhancing successful recovery for patients suffering from sepsis.

Conclusion (proposition de traduction) : L'accès précoce à la "chaîne de survie et de réadaptation pour la septicémie" garantit l'initiation rapide des traitements vitaux, suivie de l'orientation du patient vers l'établissement adéquat pour des soins avancés. La sensibilisation des médecins généralistes, des infirmières, du personnel paramédical, du personnel soignant préhospitalier et du grand public à cette pathologie permettra de donner l'alerte plus tôt. Des soins avancés plus précoces, basés principalement sur une antibiothérapie précoce et une optimisation hémodynamique, sont possibles indépendamment de l'organisation du service médical d'urgence pré-hospitalier, même pour les soins de santé primaires lorsqu'aucune ambulance ne peut être dépêchée sur les lieux. Le triage et l'admission dans l'établissement adéquat sont essentiels pour un contrôle adéquat de la source. Les soins hospitaliers avancés permettent de surmonter la défaillance des organes en attendant que la cause de la septicémie soit traitée. La rééducation est essentielle pour que les survivants retrouvent une qualité de vie acceptable.
Le défi actuel en matière de santé publique semble être le développement d'actions coordonnées, depuis le milieu préhospitalier jusqu'à la réadaptation, à mettre en œuvre le plus rapidement possible, afin d'améliorer le rétablissement des patients souffrant de septicémie.

Predicting the need for urgent endoscopic intervention in lower gastrointestinal bleeding: a retrospective review.
Ridha B, Hey N, Ritchie L, Toews R, Turcotte Z, Jamison B. | BMC Emerg Med.  2024 Apr 23;24(1):71
DOI: https://doi.org/10.1186/s12873-024-00990-3  | Télécharger l'article au format  
Keywords: Emergency department; Endoscopy; LGIB; Lower gastrointestinal bleeding.

RESEARCH

Introduction : Lower gastrointestinal bleeding (LGIB) is a common reason for emergency department visits and subsequent hospitalizations. Recent data suggests that low-risk patients may be safely evaluated as an outpatient. Recommendations for healthcare systems to identify low-risk patients who can be safely discharged with timely outpatient follow-up have yet to be established. The primary objective of this study was to determine the role of patient predictors for the patients with LGIB to receive urgent endoscopic intervention.

Méthode : A retrospective chart review was performed on 142 patients. Data was collected on patient demographics, clinical features, comorbidities, medications, hemodynamic parameters, laboratory values, and diagnostic imaging. Logistic regression analysis, independent samples t-testing, Mann Whitney U testing for non-parametric data, and univariate analysis of categorical variables by Chi square test was performed to determine relationships within the data.

Résultats : A retrospective chart review was performed on 142 patients. Data was collected on patient demographics, clinical features, comorbidities, medications, hemodynamic parameters, laboratory values, and diagnostic imaging. Logistic regression analysis, independent samples t-testing, Mann Whitney U testing for non-parametric data, and univariate analysis of categorical variables by Chi square test was performed to determine relationships within the data.

Conclusion : A hemoglobin drop of > 20 g/L was the only patient parameter that predicted the need for urgent endoscopic intervention in the emergency department.

Conclusion (proposition de traduction) : Une chute de l'hémoglobine de > 2 g/dL était le seul paramètre patient qui permettait de prédire la nécessité d'une intervention endoscopique urgente au service des urgences.

Cutoff of the reverse shock index multiplied by the Glasgow coma scale for predicting in-hospital mortality in adult patients with trauma: a retrospective cohort study.
Park JS, Choi SJ, Kim MJ, Choi SY, Kim HY, Park YS, Chung SP, Lee JH. | BMC Emerg Med.  2024 Apr 8;24(1):55
DOI: https://doi.org/10.1186/s12873-024-00978-z  | Télécharger l'article au format  
Keywords: Mortality; Reverse shock index multiplied by the Glasgow coma scale; Trauma; Triage.

RESEARCH

Introduction : Early identification of patients at risk of potential death and timely transfer to appropriate healthcare facilities are critical for reducing the number of preventable trauma deaths. This study aimed to establish a cutoff value to predict in-hospital mortality using the reverse shock index multiplied by the Glasgow Coma Scale (rSIG).

Méthode : This multicenter retrospective cohort study used data from 23 emergency departments in South Korea between January 2011 and December 2020. The outcome variable was the in-hospital mortality. The relationship between rSIG and in-hospital mortality was plotted using the shape-restricted regression spline method. To set a cutoff for rSIG, we found the point on the curve where mortality started to increase and the point where the slope of the mortality curve changed the most. We also calculated the cutoff value for rSIG using Youden's index.

Résultats : A total of 318,506 adult patients with trauma were included. The shape-restricted regression spline curve showed that in-hospital mortality began to increase when the rSIG value was less than 18.86, and the slope of the graph increased the most at 12.57. The cutoff of 16.5, calculated using Youden's index, was closest to the target under-triage and over-triage rates, as suggested by the American College of Surgeons, when applied to patients with an rSIG of 20 or less. In addition, in patients with traumatic brain injury, when the rSIG value was over 25, in-hospital mortality tended to increase as the rSIG value increased.

Conclusion : We propose an rSIG cutoff value of 16.5 as a predictor of in-hospital mortality in adult patients with trauma. However, in patients with traumatic brain injury, a high rSIG is also associated with in-hospital mortality. Appropriate cutoffs should be established for this group in the future.

Conclusion (proposition de traduction) : Nous proposons une valeur seuil de 16,5 pour l'indice de choc inverse (rSIG) comme facteur prédictif de la mortalité hospitalière chez les patients adultes victimes d'un traumatisme. Cependant, chez les patients souffrant de lésions cérébrales traumatiques, un indice de choc inverse multiplié par l'échelle de coma de Glasgow (rSIG) élevé est également associé à une mortalité à l'hôpital. Des seuils appropriés devront être établis pour ce groupe à l'avenir.

Chronic nicotine exposure elicits pain hypersensitivity through activation of dopaminergic projections to anterior cingulate cortex.
Chen D, Shen L, Zhang YZ, Kan BF, Lou QQ, Long DD, Huang JY, Zhang Z, Hu SS, Wang D. | Br J Anaesth.  2024 Apr;132(4):735-745
DOI: https://doi.org/10.1016/j.bja.2023.12.034
Keywords: allodynia; anterior cingulate cortex; chronic nicotine exposure; dopamine receptor; dopaminergic pathway; nociceptive hypersensitivity.

PAIN

Introduction : Cigarette smoking is commonly reported among chronic pain patients in the clinic. Although chronic nicotine exposure is directly linked to nociceptive hypersensitivity in rodents, underlying neurobiological mechanisms remain unknown.

Méthode : Multi-tetrode recordings in freely moving mice were used to test the activity of dopaminergic projections from the ventral tegmental area (VTA) to pyramidal neurones in the anterior cingulate cortex (ACC) in chronic nicotine-treated mice. The VTA→ACC dopaminergic pathway was inhibited by optogenetic manipulation to detect chronic nicotine-induced allodynia (pain attributable to a stimulus that does not normally provoke pain) assessed by von Frey monofilaments (force units in g).

Résultats : Allodynia developed concurrently with chronic (28-day) nicotine exposure in mice (0.36 g [0.0141] vs 0.05 g [0.0018], P<0.0001). Chronic nicotine activated dopaminergic projections from the VTA to pyramidal neurones in the ACC, and optogenetic inhibition of VTA dopaminergic terminals in the ACC alleviated chronic nicotine-induced allodynia in mice (0.06 g [0.0064] vs 0.28 g [0.0428], P<0.0001). Moreover, optogenetic inhibition of Drd2 dopamine receptor signalling in the ACC attenuated nicotine-induced allodynia (0.07 g [0.0082] vs 0.27 g [0.0211], P<0.0001).

Conclusion : These findings implicate a role of Drd2-mediated dopaminergic VTA→ACC pathway signalling in chronic nicotine-elicited allodynia.

Conclusion (proposition de traduction) : Ces résultats montrent que la signalisation dopaminergique médiée par les récepteurs D2 de l'aire tegmentale ventrale vers les neurones pyramidaux du cortex cingulaire antérieur joue un rôle dans l'allodynie chronique induite par la nicotine.

Association of ketamine use during procedural sedation with oxygen desaturation and healthcare utilisation: a multicentre retrospective hospital registry study.
Salloum E, Lotte Seibold E, Azimaraghi O, Rudolph MI, Beier J, Schaefer MS, Sauer WJ, Tam C, Fassbender P, Kiyatkin M, Eikermann M, Wongtangman K. | Br J Anaesth.  2024 Apr;132(4):779-788
DOI: https://doi.org/10.1016/j.bja.2023.11.016
Keywords: hypoxaemia; ketamine; monitored anaesthesia care (MAC); nursing home discharge; oxygen desaturation; procedural sedation.

QUALITY AND PATIENT SAFETY

Introduction : We investigated the effects of ketamine on desaturation and the risk of nursing home discharge in patients undergoing procedural sedation by anaesthetists.

Méthode : We included adult patients who underwent procedures under monitored anaesthetic care between 2005 and 2021 at two academic healthcare networks in the USA. The primary outcome was intraprocedural oxygen desaturation, defined as oxygen saturation <90% for ≥2 consecutive minutes. The co-primary outcome was a nursing home discharge.

Résultats : Among 234,170 included patients undergoing procedural sedation, intraprocedural desaturation occurred in 5.6% of patients who received ketamine vs 5.2% of patients who did not receive ketamine (adjusted odds ratio [ORadj] 1.22, 95% confidence interval [CI] 1.15-1.29, P<0.001; adjusted absolute risk difference [ARD_adj] 1%, 95% CI 0.7-1.3%, P<0.001). The effect was magnified by age > 65 yr, smoking, or preprocedural ICU admission (P-for-interaction < 0.001, OR_adj 1.35, 95% CI 1.25-1.45, P < 0.001; ARD_adj 2%, 95% CI 1.56-2.49%, P < 0.001), procedural risk factors (upper endoscopy of longer than 2 h; P-for-interaction < 0.001, OR_adj 2.91, 95% CI 1.85-4.58, P < 0.001; ARD_adj 16.2%, 95% CI 9.8-22.5%, P < 0.001), and high ketamine dose (P-for-trend < 0.001, OR_adj 1.61, 95% CI, 1.43-1.81 for ketamine > 0.5 mg kg-1). Concomitant opioid administration mitigated the risk (P-for-interaction < 0.001). Ketamine was associated with higher odds of nursing home discharge (OR_adj 1.11, 95% CI 1.02-1.21, P = 0.012; ARD_adj 0.25%, 95% CI 0.05-0.46%, P = 0.014).

Conclusion : Ketamine use for procedural sedation was associated with an increased risk of oxygen desaturation and discharge to a nursing home. The effect was dose-dependent and magnified in subgroups of vulnerable patients.

Conclusion (proposition de traduction) : L'utilisation de la kétamine pour la sédation procédurale a été associée à un risque accru de désaturation en oxygène et de sortie en institution. L'effet était dépendant de la dose et amplifié dans les sous-groupes de patients vulnérables.

Analgesia for rib fractures: a narrative review.
van Zyl T, Ho AM, Klar G, Haley C, Ho AK, Vasily S, Mizubuti GB. | Can J Anaesth.  2024 Apr;71(4):535-547
DOI: https://doi.org/10.1007/s12630-024-02725-1
Keywords: analgesia; regional analgesia; review; rib fracture; risk stratification; trauma.

Review Article/Brief Review

Introduction : Les fractures des côtes sont des blessures courantes et douloureuses souvent associées à une morbidité importante (p. ex., complications respiratoires) et à des taux de mortalité élevés, surtout chez les personnes âgées. La stratification des risques et la mise en œuvre rapide de voies analgésiques à l’aide d’une approche d’analgésie multimodale constituent un critère d’évaluation principal des soins visant à réduire la morbidité et la mortalité associées aux fractures des côtes. Ce compte rendu narratif a pour L'objectif est de décrire les données probantes les plus récentes et les parcours de soins actuellement disponibles, y compris les outils de stratification des risques et les blocs analgésiques pharmacologiques et régionaux fréquemment utilisés dans le cadre de l’approche analgésique multimodale largement recommandée.

Méthode : La littérature disponible a été recherchée à l’aide des bases de données PubMed et Embase pour chaque sujet abordé dans le présent compte rendu et examinée par des expert·es en contenu.

Résultats : Quatre outils de stratification des risques ont été identifiés, le score de l’Étude de la prise en charge des traumatismes contondants de la paroi thoracique (Study of the Management of Blunt Chest Wall Trauma) étant le plus prédictif. Les données probantes actuelles sur les techniques d’analgésie pharmacologiques (c.-à-d. acétaminophène, anti-inflammatoires non stéroïdiens, gabapentinoïdes, kétamine, lidocaïne et dexmédétomidine) et d’analgésie régionale (c.-à-d. analgésie péridurale thoracique, bloc paravertébral thoracique, bloc du plan des muscles érecteurs du rachis et bloc du plan du muscle grand dentelé) ont été examinées, de même que la physiopathologie de la ou des fractures des côtes et de leurs complications associées, y compris l’apparition de douleurs chroniques et d’incapacités.

Conclusion : Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Conclusion (proposition de traduction) : Les fractures des côtes continuent d’être un diagnostic grave, avec des taux élevés de mortalité, de développement de douleurs chroniques et d’invalidité. Il a été démontré qu’une approche multidisciplinaire de la prise en charge, combinée à une analgésie appropriée et à l’adhésion aux ensembles et protocoles de soins, réduit la morbidité et la mortalité. La plupart des parcours de soins de stratification des risques identifiés sont peu performants pour prédire la mortalité et les complications après une ou plusieurs fractures de côtes.

Postprocedural Anticoagulation After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction: A Multicenter, Randomized, Double-Blind Trial.
Yan Y, Guo J, Wang X, Wang G, Fan Z, Yin D, Wang Z, Zhang F, Tian C, Gong W, Liu J, Lu J, Li Y, Ma C, Vicaut E, Montalescot G, Nie S; RIGHT Investigators. | Circulation.  2024 Apr 16;149(16):1258-1267
DOI: https://doi.org/10.1161/circulationaha.123.067079  | Télécharger l'article au format  
Keywords: ST elevation myocardial infarction; anticoagulants; percutaneous coronary intervention.

ORIGINAL RESEARCH ARTICLE

Introduction : Postprocedural anticoagulation (PPA) is frequently administered after primary percutaneous coronary intervention in ST-segment-elevation myocardial infarction, although no conclusive data support this practice.

Méthode : The RIGHT trial (Comparison of Anticoagulation Prolongation vs no Anticoagulation in STEMI Patients After Primary PCI) was an investigator-initiated, multicenter, randomized, double-blind, placebo-controlled, superiority trial conducted at 53 centers in China. Patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention were randomly assigned by center to receive low-dose PPA or matching placebo for at least 48 hours. Before trial initiation, each center selected 1 of 3 PPA regimens (40 mg of enoxaparin once daily subcutaneously; 10 U·kg·h of unfractionated heparin intravenously, adjusted to maintain activated clotting time between 150 and 220 seconds; or 0.2 mg·kg·h of bivalirudin intravenously). The primary efficacy objective was to demonstrate superiority of PPA to reduce the primary efficacy end point of all-cause death, nonfatal myocardial infarction, nonfatal stroke, stent thrombosis (definite), or urgent revascularization (any vessel) within 30 days. The key secondary objective was to evaluate the effect of each specific anticoagulation regimen (enoxaparin, unfractionated heparin, or bivalirudin) on the primary efficacy end point. The primary safety end point was Bleeding Academic Research Consortium 3 to 5 bleeding at 30 days.

Résultats : Between January 10, 2019, and September 18, 2021, a total of 2989 patients were randomized. The primary efficacy end point occurred in 37 patients (2.5%) in both the PPA and placebo groups (hazard ratio, 1.00 [95% CI, 0.63 to 1.57]). The incidence of Bleeding Academic Research Consortium 3 to 5 bleeding did not differ between the PPA and placebo groups (8 [0.5%] vs 11 [0.7%] patients; hazard ratio, 0.74 [95% CI, 0.30 to 1.83]).

Conclusion : Routine PPA after primary percutaneous coronary intervention was safe but did not reduce 30-day ischemic events.

Conclusion (proposition de traduction) : L'anticoagulation post-procédurale systématique après une intervention coronarienne percutanée primaire est sûre mais ne réduit pas les événements ischémiques à 30 jours.

Diagnostic performance of a clinical ultrasound-based algorithm for acute heart failure in patients presenting to the emergency department with dyspnea.
L'Hermitte N, Markarian T, Grau-Mercier L, Coisy F, Muller L, Saadi L, Claret PG, Krebs H, Bobbia X. | Emergencias.  2024 Apr;36(2):109-115
DOI: https://doi.org/10.55633/s3me/011.2024  | Télécharger l'article au format  
Keywords: Acute heart failure; Deceleration time of early mitral flow; Echocardiography; Emergency department; Ultrasonography, lung

Original article

Introduction : To study the diagnostic performance of an ultrasound-based algorithm that includes the deceleration time (DT) of early mitral filling to establish a diagnosis of acute heart failure (AHF) in patients who come to an emergency department because of dyspnea.

Méthode : Prospective analysis in a convenience sample of patients who came to a hospital emergency department with acute dyspnea. The algorithm included ultrasound findings and 4 echocardiographic findings as follows: mitral annular plane systolic excursion, Doppler mitral flow velocity, tissue Doppler imaging measure of the lateral annulus, and the DT of early mitral filling. The definitive diagnosis was made by 2 physicians blinded to each other's diagnosis and the ultrasound findings.

Résultats : A total of 166 adult patients with a mean (SD) age of 76 (13) years were included; 79 (48%) were women. AHF was the definitive diagnosis in 62 patients (37%). Diagnostic agreement was good between the 2 physicians (κ = 0.71). The algorithm classified all the patients, and there were no undetermined diagnoses. Diagnostic performance indicators for the ultrasound-based algorithm integrating early DT findings were as follows: area under the receiver operating characteristic curve, 0.91 (95% CI, 0.86-0.96); sensitivity, 87% (95% CI, 76%-94%); specificity, 95% (95% CI, 89%-98%); positive likelihood ratio, 18.1 (95% CI, 7.7-42.8); and negative likelihood ratio, 0.14 (95% CI, 0.07-0.26).

Conclusion : The ultrasound-based algorithm integrating the DT of early mitral filling performs well for diagnosing AHF in emergency patients with dyspnea. The inclusion of early DT allows all patients to be diagnosed.

Conclusion (proposition de traduction) : L'algorithme échographique intégrant le temps de décélération du remplissage mitral précoce donne de bons résultats pour le diagnostic de l'insuffisance cardiaque aiguë chez les patients se présentant aux urgences avec une dyspnée. L'inclusion du temps de décélération précoce permet de diagnostiquer tous les patients.

Review article: Efficacy of prophylactic ondansetron versus placebo or control in reducing vomiting in children undergoing ketamine procedural sedation in the emergency department: A systematic review and meta-analysis.
Hudson JL, Wong J, Durkin M, Gangathimmaiah V, Furyk J. | Emerg Med Australas.  2024 Apr;36(2):178-186
DOI: https://doi.org/10.1111/1742-6723.14372
Keywords: conscious sedation; ketamine; ondansetron; paediatric; review; vomiting.

Review Article

Introduction : Ketamine is commonly used for procedural sedation anaesthesia in paediatric patients undergoing painful procedures in the ED. Ketamine's safety profile is excellent, but ketamine-associated vomiting (KAV) is common. Routine ondansetron prophylaxis could reduce KAV incidence. This literature review evaluated the efficacy of prophylactic ondansetron in reducing ketamine-associated vomiting incidence.

Méthode : A systematic literature review was performed on databases and trial registries on 14 January 2023 to identify randomised controlled trials. The primary outcome was reduction in ketamine-associated vomitingincidence, for any route of prophylactic ondansetron, in ED and up to 24 h post-discharge. ED length of stay, parental satisfaction and time to resumption of normal diet were secondary outcomes. Data analysis was performed using Revman 5.3. Meta-analysis was performed using random effects modelling. Risk of bias was assessed using the Cochrane Risk-of-Bias 2 tool. Evidence quality was assessed using Grading of Recommendation, Assessment Development and Evaluation methodology

Résultats : Five trials with 920 participants met the eligibility criteria. Prophylactic ondansetron resulted in a reduction in KAV incidence overall odds ratio of 0.51 (95% confidence interval: 0.36-0.73).

Conclusion : Intravenous and intramuscular prophylactic ondansetron showed benefit whereas the effect of oral administration was unclear. There was no difference between groups for secondary outcomes overall. The quality of evidence was deemed to be low overall because of high risk of bias and imprecision in outcome measures. This review found low to moderate certainty evidence that prophylactic ondansetron reduces ketamine-associated vomitingincidence. Methodologically rigorous research, with appropriately timed prophylactic ondansetron based on the route of administration, would further elucidate prophylactic oral ondansetron's efficacy.

Conclusion (proposition de traduction) : L'ondansétron prophylactique administré par voie intraveineuse et intramusculaire s'est révélé bénéfique, tandis que l'effet de l'administration orale n'était pas clair. Il n'y a pas eu de différence entre les groupes pour les résultats secondaires en général. La qualité des preuves a été jugée faible dans l'ensemble en raison du risque élevé de biais et de l'imprécision des mesures des résultats. Cette revue a trouvé des preuves de certitude faible à modérée que l'ondansétron prophylactique réduit l'incidence des vomissements associés à la kétamine. Des recherches méthodologiquement rigoureuses, avec un ondansétron prophylactique administré au bon moment en fonction de la voie d'administration, permettraient d'élucider davantage l'efficacité de l'ondansétron prophylactique par voie orale.

Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department.
Waheed S, Razzak JA, Khan N, Raheem A, Mian AI. | Emerg Med Int.  2024;2024:6600829
DOI: https://doi.org/10.1155/2024/6600829  | Télécharger l'article au format  
Keywords: Difficult airway; Emergency medicine; Endotracheal intubation; Physiological airway; Prediction.

Research Article

Introduction : Critically ill patients have increased risk of cardiovascular collapse following endotracheal intubation due to physiological instability. Tis study aims to validate the Difcult Airway Physiological Score (DAPS) in adults to predict the risk of serious outcomes in the emergency department of a tertiary care private hospital.

Méthode : Tis is a cohort study conducted in the emergency de- partment (ED) from 2021 to 2022. Difcult Airway Physiological Score (DAPS) was derived from a sample of 1021 patients through a retrospective study. Te variables in the score were age, gender, time of intubation, vitals and vomiting at presentation, pH <7.3, fever, physician’s anticipation for patient decline, and agitation. Te model performance was assessed prospectively on a separate dataset (n � 326) using train-test split method. Postintubation desaturation, hypotension, cardiac arrest, and mortality postintubation were the serious outcomes. ROC analysis, sensitivity, specifcity, PPV, and NPV were used to assess score validity.

Résultats : Our study includes 326 patients, of which 123 (37.7%) were males and 203 (62.2%) were females. Te sample was divided into high-risk (DAPS ≥10) group, n � 194 with mean age of 52 (SD � ±18) years, and low-risk (DAPS <10) group, n � 132 with mean age of 47.7 (SD � ±17.4) years. Te shock index ≥0.9 was in 128 (66%), while it was <0.9 in low-risk n � 111 (84%), p value <0.001. Similarly, pH <7.3 was seen in 70 (36.1%) in high-risk group compared to 4 (3%) in low-risk group, p value <0.001. Cardiac arrest was observed in 56 (17.2%) patients, of which 45 (23.2%) were in high-risk and 11 (8.3%) in low-risk groups (p < 0.001). Hypotension was the primary outcome in the high-risk group 100 (51.5%) versus 32 (24.2%) in low-risk group (p < 0.001). Te DAPS of 10 had an area under the curve of 0.865 (0.71–0.84). Te sensitivity of DAPS was 78.5%, specifcity 77.9%, and accuracy 78.2%.

Conclusion : Te score can accurately predict serious outcomes in critically ill adult patients with physiologically difcult airway demonstrating good sensitivity and specifcity.

Conclusion (proposition de traduction) : Le score DAPS peut prédire avec précision les résultats indésirables chez les patients adultes en état critique dont les voies respiratoires sont physiologiquement difficiles, avec une bonne sensibilité et une bonne spécificité.

A Single High-Sensitivity Cardiac Troponin T Strategy for Ruling Out Myocardial Infarction.
Gilje P, Mohammad MA, Roos A, Ekelund U, Björk J, Lindahl B, Holzmann M, Mokhtari A. | Emerg Med Int.  2024;2024:2241528
DOI: https://doi.org/10.1155/2024/2241528  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Introduction : Ruling out acute myocardial infarction (AMI) in the emergency department (ED) is challenging. Studies have shown that a high-sensitivity cardiac troponin T (hs-cTnT) <5 ng/L or <6 ng/L at presentation (0 h) can be used to rule out AMI. Te objective of this study was to identify whether an even higher hs-cTnT threshold can be used for a safe rule out of AMI in the ED.

Méthode : Te derivation cohort consisted of 24,973 ED patients with a primary complaint of chest pain. In this cohort, we identifed the highest concentration of 0 h hs-cTnT that corresponded to a negative predictive value (NPV) of ≥99.5% for the primary endpoint of AMI/all-cause death within 30 days and the secondary endpoint of all-cause death within one year. Te results were validated in two cohorts consisting of 132,021 and 1167 ED chest pain patients.

Résultats : Te 0 h hs-cTnT threshold corresponding to a NPV of ≥99.5% for the primary endpoint was <9 ng/L (NPV: 99.6% and 95% CI: 99.5–99.7). Tis cutof provided a sensitivity of 96.2% (95% CI: 95.2–97.1) and identifed 59.7% of the patients as low risk compared to 35.8% and 43.9% with a 0 h hs-cTnT <5 ng/L and <6 ng/L, respectively. Te results were similar in the validation cohorts and seemed to perform even better in patients where the 0 h hs-cTnT was measured >3 h after symptom onset and in those with a nonischemic ECG and nonhigh risk history.

Conclusion : A 0 h hs-cTnT cutof of <9 ng/L safely rules out AMI/death within 30 days in a majority of chest pain patients and is a more efective strategy than the currently recommended <5 ng/L and <6 ng/L cutofs.

Conclusion (proposition de traduction) : Un seuil de 0 h hs-cTnT de <9 ng/L permet d'exclure en toute sécurité un IAM/décès dans les 30 jours chez une majorité de patients souffrant de douleurs thoraciques et constitue une stratégie plus efficace que les seuils de <5 ng/L et <6 ng/L actuellement recommandés.

Scoring systems for prediction of malaria and dengue fever in non-endemic areas among travellers arriving from tropical and subtropical areas.
Satarvandi D, van der Werff SD, Nauclér P, Hildenwall H, Sondén K. | Emerg Med J.  2024 April 21;41(4):242-248
DOI: https://doi.org/10.1136/emermed-2023-213296  | Télécharger l'article au format  
Keywords: clinical management; management; pediatric emergency medicine; tropical medicine.

Original research

Introduction : Fever is a common symptom among travellers returning from tropical/subtropical areas to Europe, and promptly distinguishing severe illnesses from self-limiting febrile syndromes is important but can be challenging due to non-specific clinical presentation.

Méthode : A cross-sectional study enrolled adults and children who sought care during 2015-2020 at Karolinska University Hospital, Stockholm, Sweden with fever within 2 months after returning from travel to a tropical/subtropical area. Data on symptoms and laboratory parameters were prospectively and retrospectively collected. Two separate scoring systems for malaria and dengue were developed based on backward elimination regressions.

Résultats : In total, 2113 adults (18-94 years) and 202 children (1-17 years) were included, with 112 (4.8%) confirmed malaria by blood thick smear and 90 (3.9%) PCR/serology dengue-positive cases. Malaria was more likely in a patient who had visited sub-Saharan Africa and presented with combination of thrombocytopenia, anaemia and fever ≥39.5°C. Leucopenia, muscle pain and rash after travelling to Asia or South/Latin America indicated high probability of dengue. Two scoring systems with points between 0 and 7 for prediction of malaria or dengue were created based on the above predictors. Scores ≥3 indicated >80% sensitivity and specificity for malaria and >90% specificity for dengue in children and adults (area under the curve (AUC) for dengue: 0.92 in adults (95% CI 0.90 to 0.95) and 0.95 in children (95% CI 0.88 to 1.0); AUC for malaria: 0.93 in adults (95% CI 0.91 to 0.96) and 0.88 in children (95% CI 0.78 to 0.99)). Internal validation of optimism and overfitting was managed with bootstrap.

Conclusion : The presented scoring systems provide novel tools for structured assessment of patients with tropical fever in a non-endemic area and highlight clinical signs associated with a potential severe aetiology to direct the need for microbial investigation.

Conclusion (proposition de traduction) : Le système de score présenté fournit de nouveaux outils pour l'évaluation systématique des patients atteints de fièvre tropicale dans une zone non endémique et met en évidence les signes cliniques associés à une étiologie potentiellement grave afin de déterminer la nécessité d'une investigation microbienne.

Assessment of discordance between radiologists and emergency physicians of RADIOgraphs among discharged patients in an emergency department: the RADIO-ED study.
Bouillon-Minois JB, Lambert C, Dutheil F, Raconnat J, Benamor M, Dalle B, Laurent M, Adeyemi OJ, Lhoste-Trouilloud A, Schmidt J. | Emerg Radiol.  2024 Apr;31(2):125-131
DOI: https://doi.org/10.1007/s10140-024-02206-4
Keywords: Emergency department; Quality; Radiology; Safety; X-ray.

Original Article

Introduction : The possibility to perform standard X-rays is mandatory for all French Emergency Department (ED). Initial interpretation is under the prescriber emergency physician-who continually works under extreme conditions, but a radiologist needs to describe a report as soon as possible. We decided to assess the rate of discordance between emergency physicians and radiologists among discharged patients.

Méthode : We performed a monocentric study on an adult ED among discharged patients who had at least one X-ray during their consult. We used an automatic electronic system that classified interpretation as concordant or discordant. We review all discordant interpretation, which were classified as false negative, false positive, or more exam needed.

Résultats : For 1 year, 8988 patients had 12,666 X-rays. We found a total of 742 (5.9%) discordant X-rays, but only 277 (2.2%) discordance had a consequence (new consult or exam not initially scheduled). We found some factors associated with discordance such as male sex, or ankle, foot, knee, finger, wrist, ribs, and elbow locations.

Conclusion : On discharged patients, using a systematic second interpretation of X-ray by a radiologist, we found a total of 2.2% discordance that had an impact on the initial care.

Conclusion (proposition de traduction) : Chez les patients sortis de l'hôpital, en utilisant une seconde interprétation systématique des radiographies par un radiologue, nous avons trouvé un total de 2,2 % de discordances qui ont eu un impact sur les soins initiaux.

A meta-analysis on the diagnostic utility of ultrasound in pediatric distal forearm fractures.
Hassankhani A, Amoukhteh M, Jannatdoust P, Valizadeh P, Ghadimi DJ, Vasavada PS, Johnston JH, Gholamrezanezhad A. | Emerg Radiol.  2024 Apr;31(2):213-228
DOI: https://doi.org/10.1007/s10140-024-02208-2  | Télécharger l'article au format  
Keywords: Forearm; Pediatrics; Radius fractures; Ulna fractures; Ultrasonography.

Review Article

Introduction : Pediatric distal forearm fractures, comprising 30% of musculoskeletal injuries in children, are conventionally diagnosed using radiography. Ultrasound has emerged as a safer diagnostic tool, eliminating ionizing radiation, enabling bedside examinations with real-time imaging, and proving effective in non-hospital settings.

Méthode : The objective of this study is to evaluate the diagnostic efficacy of ultrasound for detecting distal forearm fractures in the pediatric population. A systematic review and meta-analysis were conducted through a comprehensive literature search in PubMed, Scopus, Web of Science, and Embase databases until October 1, 2023, following established guidelines. Eligible studies, reporting diagnostic accuracy measures of ultrasound in pediatric patients with distal forearm fractures, were included. Relevant data elements were extracted, and data analysis was performed.

Résultats : he analysis included 14 studies with 1377 patients, revealing pooled sensitivity and specificity of 94.5 (95% CI 92.7-95.9) and 93.5 (95% CI 89.6-96.0), respectively. Considering pre-test probabilities of 25%, 50%, and 75% for pediatric distal forearm fractures, positive post-test probabilities were 83%, 44%, and 98%, while negative post-test probabilities were 2%, 6%, and 15%, respectively. The bivariate model indicated significantly higher diagnostic accuracy in the subgroup with trained ultrasound performers vs. untrained performers (p = 0.03). Furthermore, diagnostic accuracy was significantly higher in the subgroup examining radius fractures vs. ulna fractures (p < 0.001), while no significant differences were observed between 4-view and 6-view ultrasound subgroups or between radiologist ultrasound interpreters and non-radiologist interpreters.

Conclusion : This study highlighted ultrasound's reliability in detecting pediatric distal forearm fractures, emphasizing the crucial role of expertise in precisely confirming fractures through ultrasound examinations.

Conclusion (proposition de traduction) : Cette étude a mis en évidence la fiabilité de l'échographie dans la détection des fractures distales de l'avant-bras en pédiatrie, soulignant le rôle crucial de l'expertise dans la confirmation précise des fractures par les examens échographiques.

Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study.
Fathi M, Mirjafari A, Yaghoobpoor S, Ghanikolahloo M, Sadeghi Z, Bahrami A, Myers L, Gholamrezanezhad A. | Emerg Radiol.  2024 Apr;31(2):251-268
DOI: https://doi.org/10.1007/s10140-024-02213-5  | Télécharger l'article au format  
Keywords: Head and neck injury; Mortality rate; Pan-scan; Whole-body CT scan.

Review Article

Introduction : Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT).

Méthode : Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg's tests were performed to rule out any publication bias.

Résultats : Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28-0.60; I² = 99.8%), 6% (95% CI, 0.02-0.09; I² = 97.2%), and 9% (95% CI, 0.05-0.13; I² = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28-0.51; I² = 99.8%), abdominal injuries in 23% (95% CI, 0.03-0.43; I² = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11-0.27; I² = 99.4%), extremity injuries 33% (95% CI, 0.23-0.43; I² = 99.2%), and pelvic injuries 11% (95% CI, 0.04-0.18; I² = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83-1.06; I² = 40.1%) was calculated while comparing WBCT and non-WBCT groups.

Conclusion : This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.

Conclusion (proposition de traduction) : Cette revue systématique et cette méta-analyse donnent un aperçu de la sécurité, de l'efficacité et de l'efficience possibles de la tomodensitométrie du corps entier comme outil de diagnostic pour les patients victimes de traumatismes graves, quel que soit leur état hémodynamique. Chez les patients souffrant de lésions graves dues à un traumatisme, qu'il y ait ou non des indicateurs d'instabilité hémodynamique, l'approche que nous recommandons est de réaliser, dans la mesure du possible, une tomodensitométrie du corps entier sans interrompre la réanimation hémostatique. Grâce à cette technologie, il est possible de décider de la stratégie chirurgicale optimale pour ces patients sans retarder leurs soins finaux ni augmenter considérablement leur dose de radiation.

Emergency airway management: an EUSEM statement with regard to the guidelines of the Society of Critical Care Medicine.
Hohenstein C, Merz S, Eppler F, Arslan V, Ayvaci BM, Ünlü L; European Society for Emergency Medicine. | Eur J Emerg Med.  2024 Apr 1;31(2):83-85
DOI: https://doi.org/10.1097/mej.0000000000001114  | Télécharger l'article au format  
Keywords: Aucun

Viewpoint

Editorial : Emergency airway management (EAM) is a complex task. Manual skills needed for EAM are learned through practice and need to be maintained with regular training.
Patients and their conditions are usually completely unknown, the administration of drugs for the procedure with all the potential side effects must be induced promptly, although conditions are not optimal.
Recently, the Society of Critical Care Medicine (SCCM) published practice guidelines for EAM of critically ill patients. In this viewpoint, we aim to briefly and critically examine the recommendations and identify further necessary action points. These are the key points that we also convey to emergency physicians and paramedics in the EAM Course of the European Society of Emergency Medicine (EUSEM).

Conclusion : Recently, several studies have led to an improved evidence base regarding EAM. We advocate that emergency physicians take responsibility for EAM and are the primary individuals to carry it out. EAM courses should include theoretical, practical and mental-cognitive content. We consider three things to be crucial: prevention of desaturation, prevention of hypotension, and a high firstpass success rate. We also consider mental and cognitive training as an essential part of education.

Conclusion (proposition de traduction) : Récemment, plusieurs études ont permis d'améliorer les données probantes concernant la prise en charge des voies aériennes en urgence. Nous préconisons que les médecins urgentistes prennent la décision de prendre en charge les voies aériennes d'urgence et qu'ils soient les premiers à le faire. Les cours sur la prise en charge des voies aériennes en urgence devraient inclure un contenu théorique, pratique et comportemental. Nous considérons que trois éléments sont cruciaux : la prévention de la désaturation, la prévention de l'hypotension et un taux élevé de réussite du premier essai. Nous considérons également que la formation théorique et comportementale est un élément essentiel de l'enseignement.

Dynamic monitoring tools for patients admitted to the emergency department with circulatory failure: narrative review with panel-based recommendations.
Douglas IS, Elwan MH, Najarro M, Romagnoli S. | Eur J Emerg Med.  2024 Apr 1;31(2):98-107
DOI: https://doi.org/10.1097/mej.0000000000001103
Keywords: Aucun

Review

Editorial : La remplissage vasculaire est couramment utilisé dans les services d'urgence (SU). Malgré le potentiel délétère de la sur- et de la sous-réanimation, les recommandations des sociétés professionnelles continuent à préconiser l'administration d'un volume fixe de liquide lors de la réanimation initiale. Prédire si un patient donné répondra à au remplissage vasculaire reste l'une des questions les plus importantes, mais aussi l'une des plus difficiles, auxquelles les urgentistes sont confrontés dans leur pratique clinique. Les paramètres de contrôle (c'est-à-dire la pression artérielle et la fréquence cardiaque) sont largement utilisés dans les soins habituels pour estimer les changements du volume d'éjection systolique. En raison de leur insuffisance dans l'estimation du volume d'éjection systolique, des techniques non invasives (par exemple, la bioréactance, l'échocardiographie, la technologie non invasive du brassard) ont été proposées comme méthode plus précise et plus facile à déployer pour évaluer le débit et la réponse à la précharge. Les systèmes de surveillance dynamique basés sur le test de précharge cardiaque et l'évaluation du volume systolique, en utilisant des méthodes non invasives et continues, fournissent une stratégie plus précise, faisable, efficace et raisonnablement exacte pour la prédiction de la réponse aux remplissage vasculaire que les mesures statiques. Dans cet article, nous avons cherché à analyser les différentes méthodes actuellement disponibles pour la surveillance dynamique de la réponse à la précharge.

Conclusion : Noninvasive monitoring has evolved in the past few years, seeing the appearance of promising new devices.
Different noninvasive methods are currently available for dynamic monitoring of preload responsiveness. According to the current evidence and the authors experience, non invasive methods that assess accurately real-time dynamic monitoring of SV and CO, may be considered as the method of choice for dynamic monitoring in the ED.

Conclusion (proposition de traduction) : La surveillance non invasive a évolué au cours des dernières années, avec l'apparition de nouveaux dispositifs prometteurs.
Différentes méthodes non invasives sont actuellement disponibles pour le monitorage dynamique de la réponse à la précharge. Selon les données actuelles et l'expérience des auteurs, les méthodes non invasives qui évaluent avec précision le monitorage dynamique en temps réel du volume systolique et du débit cardiaque peuvent être considérées comme la méthode de choix pour le monitorage dynamique aux urgences.

Management of syncope in the Emergency Department: a European prospective cohort study (SEED).
Reed MJ, Karuranga S, Kearns D, Alawiye S, Clarke B, Möckel M, Karamercan M, Janssens K, Riesgo LG, Torrecilla FM, Golea A, Fernández Cejas JA, Lupan-Muresan EM, Zaimi E, Nuernberger A, Rennét O, Skjaerbaek C, Polyzogopoulou E, Imecz J, Groff P, Camilleri R, Cimpoesu D, Jovic M, Miró Ò, Anderson R, Laribi S; SEED investigators. | Eur J Emerg Med.  2024 Apr 1;31(2):136-146
DOI: https://doi.org/10.1097/mej.0000000000001101
Keywords: Aucun

Original article

Introduction : In 2018, the European Society of Cardiology (ESC) produced syncope guidelines that for the first-time incorporated Emergency Department (ED) management. However, very little is known about the characteristics and management of this patient group across Europe.

Méthode : To examine the prevalence, clinical presentation, assessment, investigation (ECG and laboratory testing), management and ESC and Canadian Syncope Risk Score (CSRS) categories of adult European ED patients presenting with transient loss of consciousness (TLOC, undifferentiated or suspected syncope).
Design: Prospective, multicentre, observational cohort study.
Settings and participants: Adults (≥18 years) presenting to European EDs with TLOC, either undifferentiated or thought to be of syncopal origin.

Résultats : Between 00:01 Monday, September 12th to 23:59 Sunday 25 September 2022, 952 patients presenting to 41 EDs in 14 European countries were enrolled from 98 301 ED presentations (n = 40 sites). Mean age (SD) was 60.7 (21.7) years and 487 participants were male (51.2%). In total, 379 (39.8%) were admitted to hospital and 573 (60.2%) were discharged. 271 (28.5%) were admitted to an observation unit first with 143 (52.8%) of these being admitted from this. 717 (75.3%) participants were high-risk according to ESC guidelines (and not suitable for discharge from ED) and 235 (24.7%) were low risk. Admission rate increased with increasing ESC high-risk factors; 1 ESC high-risk factor; n = 259 (27.2%, admission rate=34.7%), 2; 189 (19.9%; 38.6%), 3; 106 (11.1%, 54.7%, 4; 62 (6.5%, 60.4%), 5; 48 (5.0%, 67.9%, 6+; 53 (5.6%, 67.9%). Furthermore, 660 (69.3%), 250 (26.3%), 34 (3.5%) and 8 (0.8%) participants had a low, medium, high, and very high CSRS respectively with respective admission rates of 31.4%, 56.0%, 76.5% and 75.0%. Admission rates (19.3-88.9%), use of an observation/decision unit (0-100%), and percentage high-risk (64.8-88.9%) varies widely between countries.

Conclusion : This European prospective cohort study reported a 1% prevalence of syncope in the ED. 4 in 10 patients are admitted to hospital although there is wide variation between country in syncope management. Three-quarters of patients have ESC high-risk characteristics with admission percentage rising with increasing ESC high-risk factors.

Conclusion (proposition de traduction) : Cette étude de cohorte prospective européenne fait état d'une prévalence de 1 % de syncopes aux urgences. 4 patients sur 10 sont admis à l'hôpital, bien que la prise en charge de la syncope varie considérablement d'un pays à l'autre. Les trois quarts des patients présentent des caractéristiques à haut risque de l'ESC, le pourcentage d'admission augmentant avec les facteurs à haut risque de l'ESC.

Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan.
Tsuboi M, Hibiya M, Kawaura H, Seki N, Hasegawa K, Hayashi T, Matsuo K, Furuya S, Nakajima Y, Hitomi S, Ogawa K, Suzuki H, Yamamoto D, Asami M, Sakamoto S, Kamiyama J, Okuda Y, Minami K, Teshigahara K, Gokita M, Yasaka K, Taguchi S, Kiyota K. | Eur J Trauma Emerg Surg.  2024 Apr;50(2):505-512
DOI: https://doi.org/10.1007/s00068-023-02383-w  | Télécharger l'article au format  
Keywords: Doctor car; Emergency medical service; Pre-hospital care; Survival outcome; Trauma.

Original Article

Introduction :  In Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a "doctor car". Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan.

Méthode : A nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations.

Résultats : This study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065-1.415]).

Conclusion : Using nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Conclusion (proposition de traduction) : S'appuyant sur des données nationales, cette nouvelle étude suggère que la présence de médecins de transports routiers améliorent le taux de survie à l'hôpital des patients souffrant de traumatismes graves au Japon. Par conséquent, les médecins de transports routiers pourraient être une option pour les stratégies de traumatologie.

A mortality indicator in acute pulmonary embolism: the inferior vena cava contrast reflux score feasibility.
Murat Yazici M, Altuntas G, HGündo ̆gdu H. | Front Emerg Med.  2024;8(2):e12
DOI: https://doi.org/10.18502/fem.v8i2.15460  | Télécharger l'article au format  
Keywords: Inferior Vena Cava Reflux Score; Mortality Indicator; Pulmonary Embolism

ORIGINAL ARTICLE

Introduction : Acute pulmonary embolism (APE) is frequently associated with high morbidity and mortality rates. Numerous studies have investigated the prognostic significance of cardiovascular computed tomography (CT)parameters. This study aimed to investigate potential CT scan predictors of 24-hour mortality in APE and toevaluate the value of the inferior vena cava (IVC) reflux score calculated on CT scan in predicting mortality.

Méthode : This study was a single-center, retrospective study. Approval from the local ethics committee (decision no. 2023/76) was obtained before patients’ data scanning. Patients who were admitted to the emergencydepartment (ED) of a tertiary education and research hospital in Turkey between January 1, 2019, and December31, 2021, who were diagnosed with APE at CT scan in the ED and whose treatment was started, and who did notmeet the exclusion criteria were included in the study. The relationship between CT scan findings and early andlate mortality was evaluated.

Résultats : The study population comprised 226 patients, meeting the inclusion and exclusion criteria. Of the 226 patients, a total of 39 (17.3%) patients died, 16 (7.1%) within the first 24 hours. In evaluating CT scan parameters, the inferior vena cava (IVC) reflux score showed a statistically significant difference between the groupswith and without mortality (24-hour P=0.001; 30-day P=0.001). Patients who died within the first 24-hour and 30-day after admission showed a reflux grade 3 into IVC more often than survivors (24-hour odds ratio (OR): 14.57, 95% confidence interval (CI): 3.64,58.1; P=0.001); 30-day (OR: 6.54, 95% CI: 2.51,16.98; P=0.001). However,other CT parameters were evaluated, and no statistical relationship was found between the groups with andwithout mortality.

Conclusion : The cardiovascular CT scan findings may not be suitable for use as predictors of mortality. However,the IVC reflux score may be a good indicator of both early and late mortality.

Conclusion (proposition de traduction) : Les résultats de la tomodensitométrie cardiovasculaire ne peuvent pas être utilisés comme prédicteurs de mortalité. Toutefois, le score de reflux de la VCI peut être un bon indicateur de la mortalité précoce et tardive.

The diagnostic value of T-wave to R–wave amplitude ratioon electrocardiogram in the diagnosis of hyperkalemia.
Çinpolat R, Kerem Çorbacio ̆glu ̧S, Emektar E, Çevik Y. | Front Emerg Med.  2024;8(2):e15
DOI: https://doi.org/10.18502/fem.v8i2.15463  | Télécharger l'article au format  
Keywords: ECG; Emergency Department; Hyperkalemia, T/R Rati

Original article

Introduction : The aim of this study is determining the diagnostic value of the T-wave to R–wave amplitude ratio(T/R ratio) in the electrocardiogram (ECG) at the time of admission in terms of the diagnosis of hyperkalemia inpatients who are at risk for hyperkalemia who apply to the emergency department (ED)

Méthode : This cross-sectional study was conducted with patients over 18 years of age who presented to the EDand have an estimated glomerular filtration rate (eGFR) below 60ml/min/1.73m2. The patients were dividedinto 2 groups according to the potassium value; hyperkalemia and normokalaemia groups. T/R ratios weremeasured on the ECG. All measurements were made in these precordial leads; V2, V3, and VThighest (is definedas precordial lead where the T wave is measured the highest).

Résultats : A total of 345 patients with low eGFR were included. Hyperkalemia was detected in 115 (33.3%) of thesepatients, while 230 patients (66.6%) were in the normokalaemia group. T wave amplitude and T/R ratio werefound to be statistically significantly increased in the hyperkalemia group in all leads (V2, V3, and VThighest).Area under the curve (AUC) values are 0.778 for T/R ratio and 0.717 for T wave amplitude

Conclusion : The presence of increased T/R ratio in the ECG of patients with known low eGFR may be morehelpful for the diagnosis of hyperkalemia than the classical hyperkalemia ECG findings.

Conclusion (proposition de traduction) : La présence d'une augmentation du rapport T/R à l'ECG des patients dont on sait que le DFGe est faible peut être plus utile pour le diagnostic d'hyperkaliémie que les résultats classiques de l'ECG de l'hyperkaliémie.

Does a prehospital applied pelvic binder improve patient survival?.
Reiter A, Strahl A, Kothe S, Pleizier M, Frosch KH, Mader K, Hättich A, Nüchtern J, Cramer C. | Injury.  2024 Apr;55(4):111392
DOI: https://doi.org/10.1016/j.injury.2024.111392  | Télécharger l'article au format  
Keywords: Notre étude a montré que la pose de ceintures pelviennes en préhospitaliers n'avaient pas d'impact significatif sur les pronostics des patients souffrant de fractures pelviennes instables, le score de gravité des blessures (ISS) étant le facteur prédictif de survie le plus important. L'évaluation de la gravité des blessures et la gestion de la perte de sang restent cruciales pour ces patients. Si les ceintures pelviennes n'ont pas d'impact significatif sur la survie, ils jouent néanmoins un rôle dans la stabilisation des fractures pelviennes et la gestion de la perte de sang.

General Trauma Section

Méthode : Pelvic fractures are serious and oftentimes require immediate medical attention. Pelvic binders have become a critical tool in the management of pelvic injuries, especially in the prehospital setting. Proper application of the pelvic binder is essential to achieve the desired result. This study evaluates the effectiveness of prehospitally applied pelvic binders in improving outcomes for patients with pelvic fractures.

Résultats : This retrospective cohort study analyzed 66 patients with unstable pelvic ring fracture classified as AO61B or 61C, who were treated at a Level I hospital in the emergency room between January 2014 and December 2018. The ideal position for a pelvic binder was determined, and patients were divided into three sub-groups based on whether they received a pelvic binder in the ideal position, outside the optimal range, or not at all. The primary outcome measure was the survival rate of the patients.

Discussion : 66 trauma patients with unstable pelvic fractures were enrolled, with a mean age of 53.8 years, who presented to our ER between 2014 and 2018. The mean ISS score was 21.9, with 60.3 % of patients having a moderate to severe injury (ISS > 16 points). Pelvic binder usage did not differ significantly between patients with an ISS < or ≥ 16 points. A total of 9 patients (13.6 %) died during hospitalization, with a mean survival time of 8.1 days. The survival rate did not differ significantly between patients with or without a pelvic binder, or between those with an ideally placed pelvic binder versus those with a binder outside the ideal range. The ISS score, heart rate, blood pressure at admission, and hemoglobin level were significantly different between the group of patients who died and those who survived, indicating their importance in predicting outcomes.

Conclusion (proposition de traduction) : Our study found that prehospital pelvic binders did not significantly impact patient outcomes for unstable pelvic fractures, with injury severity score (ISS) being the strongest predictor of survival. Assessing injury severity and managing blood loss remain crucial for these patients. While pelvic binders may not impact survival significantly, they still play a role in stabilizing pelvic fractures and managing blood loss.

Commentaire : Fracture stabilization; Pelvic binder; Prehospital care; Unstable pelvic fractures.

Hypotension during intensive care stay and mortality and morbidity: a systematic review and meta-analysis.
Schuurmans J, van Rossem BTB, Rellum SR, Tol JTM, Kurucz VC, van Mourik N, van der Ven WH, Veelo DP, Schenk J, Vlaar APJ. | Intensive Care Med.  2024 Apr;50(4):516-525
DOI: https://doi.org/10.1007/s00134-023-07304-4  | Télécharger l'article au format  
Keywords: Hypotension; Intensive care unit; Meta-analysis; Morbidity; Mortality.

Systematic Review

Introduction : The aim of this study is to provide a summary of the existing literature on the association between hypotension during intensive care unit (ICU) stay and mortality and morbidity, and to assess whether there is an exposure-severity relationship between hypotension exposure and patient outcomes.

Méthode : CENTRAL, Embase, and PubMed were searched up to October 2022 for articles that reported an association between hypotension during ICU stay and at least one of the 11 predefined outcomes. Two independent reviewers extracted the data and assessed the risk of bias. Results were gathered in a summary table and studies designed to investigate the hypotension-outcome relationship were included in the meta-analyses.

Résultats : A total of 122 studies (176,329 patients) were included, with the number of studies varying per outcome between 0 and 82. The majority of articles reported associations in favor of 'no hypotension' for the outcomes mortality and acute kidney injury (AKI), and the strength of the association was related to the severity of hypotension in the majority of studies. Using meta-analysis, a significant association was found between hypotension and mortality (odds ratio: 1.45; 95% confidence interval (CI) 1.12-1.88; based on 13 studies and 34,829 patients), but not for AKI.

Conclusion : Exposure to hypotension during ICU stay was associated with increased mortality and AKI in the majority of included studies, and associations for both outcomes increased with increasing hypotension severity. The meta-analysis reinforced the descriptive findings regarding mortality but did not yield similar support for AKI.

Conclusion (proposition de traduction) : Dans la plupart des études incluses, le fait d'être hypotendu pendant le séjour en USI était associé à une augmentation de la mortalité et des lésions rénales aiguës, et les associations pour les deux résultats augmentaient avec la gravité de l'hypotension. La méta-analyse a renforcé les résultats descriptifs concernant la mortalité, mais n'a pas apporté de preuves similaires pour les lésions rénales aiguës.

Commentaire : Les associations entre l'hypotension et les résultats pour les patients étaient particulièrement prononcées lorsque la pression artérielle moyenne (PAM) tombait en dessous de 60 mmHg et la pression artérielle systolique (PA systolique) en dessous de 90 mmHg pour la mortalité, et lorsque la pression artérielle moyenne (PAM) tombait en dessous de 55 mmHg pour l'insuffisance rénale aiguë.

Monitoring capillary refill time in septic shock.
Hernandez G, Carmona P, Ait-Oufella H. | Intensive Care Med.  2024 Apr;50(4):580-582
DOI: https://doi.org/10.1007/s00134-024-07361-3  | Télécharger l'article au format  
Keywords: Aucun

Editorial

Editorial : Capillary refill time (CRT) has been proposed as a marker of tissue hypoperfusion based on physiological and clinical–epidemiological data and is increasingly used as a monitor in shock states and other conditions [1,2,3,4]. Indeed, besides being costless and universally available, CRT is a dynamic parameter which changes rapidly in response to hemodynamic interventions, thus making it a suitable bedside tool to monitor and guide septic shock resuscitation [1]. Unfortunately, specific guidelines to standardize how to estimate CRT do not currently exist. This toolbox aims to provide a practical overview of the fundamentals of CRT assessment to facilitate and optimize its use at the bedside.

Conclusion : A growing body of evidence supports the role of CRT assessment as a relevant monitoring tool for septic shock and other critically ill patients. CRT exhibits a rapid response to hemodynamic interventions and thus may be useful to tailor fluid and vasoactive drug administration, and eventually to disclose the status of macro- to microcirculatory coupling. Its use as a resuscitation target in septic shock was supported by ANDROMEDA-SHOCK trial and is being further addressed by an ongoing major trial. However, training and standardization of the acquisition technique are mandatory to accurately measure CRT and use it to guide resuscitation.

Conclusion (proposition de traduction) : Le temps de remplissage capillaire a une réponse rapide aux traitements hémodynamiques et peut donc être utile pour adapter l'administration de liquides de remplissage et de médicaments vasoactifs, et éventuellement pour diagnostiquer l'état du couplage entre la macro- et la microcirculation. Son utilisation comme cible de réanimation en cas de choc septique a été validée par l'essai ANDROMEDA-SHOCK et fait l'objet d'une étude plus approfondie dans le cadre d'un essai majeur en cours. Cependant, la technique d'acquisition doit impérativement faire l'objet d'une formation et d'une normalisation afin de mesurer avec précision le temps de remplissage capillaire et de l'utiliser pour guider la réanimation.

Commentaire : 
Signal d'alerte
• Triage au service des urgences ou en milieu préhospitalier.
• Signal d'alerte pour l'activation de l'équipe d'intervention rapide.
• Surveillance de la perfusion dans la salle de réveil postopératoire ou dans les unités d'aval pour les patients à haut risque.

Variable prédictive
• Prédicteur du dysfonctionnement des organes, des résultats cliniques et de la mortalité dans plusieurs états critiques, y compris le choc septique et cardiogénique.
• Prédicteur de l'instabilité hémodynamique intralésionnelle ou de l'intolérance à l'élimination des liquides.

Outil de surveillance
• Cible pour la réanimation du choc septique.
• Surveillance de la réponse de la perfusion aux interventions hémodynamiques aiguës telles que l'administration de liquides de remplissage ou d'agents vasoactifs chez les patients en état de choc.
• Identification des patients dont le couplage macromicrocirculatoire est préservé.

Déterminants physiopathologiques
• État du volume sanguin.
• Débit cardiaque.
• Tonus sympathique.
• Dysfonctionnement endothélial.
• Dérèglements rhéologiques.

Pièges
• Peau foncée.
• Hypothermie.
• Maladie vasculaire périphérique.
• Nécessite une formation et une normalisation.
• Température et éclairage de la pièce.

Oxygenation and ventilation during prolonged experimental cardiopulmonary resuscitation with either continuous or 30:2 compression-to-ventilation ratios together with 10 cmH₂0 positive end-expiratory pressure.
Kopra J, Litonius E, Pekkarinen PT, Laitinen M, Heinonen JA, Fontanelli L, Skrifvars MB. | Intensive Care Med Exp.  2024 Apr 12;12(1):36
DOI: https://doi.org/10.1186/s40635-024-00620-z  | Télécharger l'article au format  
Keywords: Arterial oxygen pressure; Cardiac arrest; Cardiopulmonary resuscitation; Computed tomography; Electrical impedance tomography; Hypoxaemia; Mechanical chest compression; Ventilation.

Research Articles

Introduction : In refractory out-of-hospital cardiac arrest, the patient is commonly transported to hospital with mechanical continuous chest compressions (CCC). Limited data are available on the optimal ventilation strategy. Accordingly, we compared arterial oxygenation and haemodynamics during manual asynchronous continuous ventilation and compressions with a 30:2 compression-to-ventilation ratio together with the use of 10 cmH₂O positive end-expiratory pressure (PEEP).

Méthode : Intubated and anaesthetized landrace pigs with electrically induced ventricular fibrillation were left untreated for 5 min (n = 31, weight ca. 55 kg), after which they were randomized to either the CCC group or the 30:2 group with the the LUCAS® 2 piston device and bag-valve ventilation with 100% oxygen targeting a tidal volume of 8 ml/kg with a PEEP of 10 cmH₂O for 35 min. Arterial blood samples were analysed every 5 min, vital signs, near-infrared spectroscopy and electrical impedance tomography (EIT) were measured continuously, and post-mortem CT scans of the lungs were obtained.

Résultats : The arterial blood values (median + interquartile range) at the 30-min time point were as follows: PaO2: 180 (86-302) mmHg for the 30:2 group; 70 (49-358) mmHg for the CCC group; PaCO2: 41 (29-53) mmHg for the 30:2 group; 44 (21-67) mmHg for the CCC group; and lactate: 12.8 (10.4-15.5) mmol/l for the 30:2 group; 14.7 (11.8-16.1) mmol/l for the CCC group. The differences were not statistically significant. In linear mixed models, there were no significant differences between the groups. The mean arterial pressures from the femoral artery, end-tidal CO2, distributions of ventilation from EIT and mean aeration of lung tissue in post-mortem CTs were similar between the groups. Eight pneumothoraces occurred in the CCC group and 2 in the 30:2 group, a statistically significant difference (p = 0.04).

Conclusion : The 30:2 and CCC protocols with a PEEP of 10 cmH₂O resulted in similar gas exchange and vital sign outcomes in an experimental model of prolonged cardiac arrest with mechanical compressions, but the CCC protocol resulted in more post-mortem pneumothoraces.

Conclusion (proposition de traduction) : Les protocoles de compressions thoraciques 30:2 et continues avec une PEP de 10 cmH₂O ont donné des résultats similaires en matière d'échange gazeux et de signes vitaux dans un modèle expérimental d'arrêt cardiaque prolongé avec compressions mécaniques, mais le protocole de compressions thoraciques continues a entraîné davantage de pneumothorax post-mortem.

Hyperoxemia and hypoxemia impair cellular oxygenation: a study in healthy volunteers.
Hilderink BN, Crane RF, van den Bogaard B, Pillay J, Juffermans NP. | Intensive Care Med Exp.  2024 Apr 15;12(1):37
DOI: https://doi.org/10.1186/s40635-024-00619-6  | Télécharger l'article au format  
Keywords: Cellular oxygenation; Hyperoxemia; Hyperoxia; Hypoxemia; Hypoxia; MitoPO2; Mitochondria; Oxygen therapy.

Research Article

Introduction : Administration of oxygen therapy is common, yet there is a lack of knowledge on its ability to prevent cellular hypoxia as well as on its potential toxicity. Consequently, the optimal oxygenation targets in clinical practice remain unresolved. The novel PpIX technique measures the mitochondrial oxygen tension in the skin (mitoPO₂) which allows for non-invasive investigation on the effect of hypoxemia and hyperoxemia on cellular oxygen availability.

Résultats : During hypoxemia, SpO2 was 80 (77-83)% and PaO₂ 45(38-50) mmHg for 15 min. MitoPO₂ decreased from 42(35-51) at baseline to 6(4.3-9)mmHg (p < 0.001), despite 16(12-16)% increase in cardiac output which maintained global oxygen delivery (DO₂). During hyperoxic breathing, an FiO₂ of 40% decreased mitoPO₂ to 20 (9-27) mmHg. Cardiac output was unaltered during hyperoxia, but perfused De Backer density was reduced by one-third (p < 0.01). A PaO₂ < 100 mmHg and > 200 mmHg were both associated with a reduction in mitoPO₂.

Conclusion : Hypoxemia decreases mitoPO₂ profoundly, despite complete compensation of global oxygen delivery. In addition, hyperoxemia also decreases mitoPO₂, accompanied by a reduction in microcirculatory perfusion. These results suggest that mitoPO₂ can be used to titrate oxygen support.

Conclusion (proposition de traduction) : L'hypoxémie diminue profondément la mitoPO₂ (nouvelle technique PpIX qui mesure la tension d'oxygène mitochondriale au niveau de la peau), malgré une compensation complète de l'apport global d'oxygène. De plus, l'hyperoxémie diminue également la mitoPO₂, accompagnée d'une réduction de la perfusion microcirculatoire. Ces résultats suggèrent que la mitoPO₂ peut être utilisée pour titrer le soutien en oxygène.

Association between smoking and central sensitization pain: a web-based cross-sectional study.
Chiba S, Yamada K, Kawai A, Hamaoka S, Ikemiya H, Hara A, Wakaizumi K, Tabuchi T, Yamaguchi K, Kawagoe I, Iseki M. | J Anesth.  2024 Apr;38(2):198-205
DOI: https://doi.org/10.1007/s00540-023-03302-4  | Télécharger l'article au format  
Keywords: Catastrophic thinking; Central sensitization syndrome; Chronic pain; Smoking.

Original Article

Introduction : This study aimed to investigate whether smoking is an independent risk factor for central sensitization syndrome (CSS) in individuals with pain as measured by the Central Sensitization Inventory (CSI).

Méthode : In 2020, we conducted an Internet survey targeting 2000 ordinary residents of Japan (aged 20-69 years) who had pain symptoms from October to November 2020. A multiple regression analysis was performed on the association between smoking status (nonsmokers and current smokers; Brinkman index) and CSI values. Moreover, compared to nonsmokers, the relative risk (RR) of the CSI cut-off score of 40 points or higher among current smokers was calculated using a modified Poisson regression model. Covariates included age, sex, body mass index, marital status, equivalized income, exercise habits, history of hypertension, history of hyperlipidemia, history of diabetes, pain chronicity, and Pain Catastrophizing Scale score.

Résultats : This study analyzed 1,822 individuals (1,041 men and 781 women). Among those experiencing pain, current smoking was associated with the increase in CSI values (β = 0.07). The Brinkman index was also significantly associated with the increase in CSI values (β = 0.06). Current smoking also increased the risk of being over the CSI cut-off score, with a relative risk (RR) of 1.29 (95% confidence intervals, 1.04-1.60). Younger age, being women, experiencing chronic pain, and higher pain catastrophizing thinking were also significantly associated with increased CSS severity, independent of smoking status.

Conclusion : Smoking is an independent risk factor for CSS. This indicates that smoking may be an important factor in the management of central pain disorders.

Conclusion (proposition de traduction) : Le tabagisme est un facteur de risque indépendant de syndrome de sensibilisation centrale. Cela indique que le tabagisme peut être un facteur important dans la prise en charge des troubles de la douleur modulée par le système nerveux central.

Commentaire : Si le cerveau reçoit de nombreux signaux de danger, il apprend à amplifier le danger, notre système nerveux se sensibilise. On appelle ce phénomène : sensibilisation centrale ou potentialisation à long terme (non-neuropathique). C'est un trouble de la modulation de la douleur par le système nerveux central aboutissant à une augmentation de la perception douloureuse.
Ce mécanisme est impliqué dans les douleurs nociplastiques, celles qui caractérisent la fibromyalgie.
Pour différentier la douleur nociceptive de la sensibilisation centrale, 3 critères de classification sont à rechercher :
1) Douleur, et incapacité en découlant, disproportionnées par rapport à la lésion potentielle ;
2) Présence d’allodynie, d’hyperalgésie et d’une distribution douloureuse diffuse ;
3) Hypersensibilité sensorielle non reliée au système musculo-squelettique.
Nijs J and al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014 Sep-Oct;17(5):447-57  .

Acetaminophen Use During Pregnancy and Children's Risk of Autism, ADHD, and Intellectual Disability.
Ahlqvist VH, Sjöqvist H, Dalman C, Karlsson H, Stephansson O, Johansson S, Magnusson C, Gardner RM, Lee BK. | JAMA.  2024 Apr 9;331(14):1205-1214
DOI: https://doi.org/10.1001/jama.2024.3172
Keywords: Aucun

Original Investigation

Introduction : Several studies suggest that acetaminophen (paracetamol) use during pregnancy may increase risk of neurodevelopmental disorders in children. If true, this would have substantial implications for management of pain and fever during pregnancy.

Méthode : To examine the associations of acetaminophen use during pregnancy with children's risk of autism, attention-deficit/hyperactivity disorder (ADHD), and intellectual disability.
Design, setting, and participants: This nationwide cohort study with sibling control analysis included a population-based sample of 2 480 797 children born in 1995 to 2019 in Sweden, with follow-up through December 31, 2021.
Exposure: Use of acetaminophen during pregnancy prospectively recorded from antenatal and prescription records.
Main outcomes and measures: Autism, ADHD, and intellectual disability based on International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes in health registers.

Résultats : In total, 185 909 children (7.49%) were exposed to acetaminophen during pregnancy. Crude absolute risks at 10 years of age for those not exposed vs those exposed to acetaminophen were 1.33% vs 1.53% for autism, 2.46% vs 2.87% for ADHD, and 0.70% vs 0.82% for intellectual disability. In models without sibling control, ever-use vs no use of acetaminophen during pregnancy was associated with marginally increased risk of autism (hazard ratio [HR], 1.05 [95% CI, 1.02-1.08]; risk difference [RD] at 10 years of age, 0.09% [95% CI, -0.01% to 0.20%]), ADHD (HR, 1.07 [95% CI, 1.05-1.10]; RD, 0.21% [95% CI, 0.08%-0.34%]), and intellectual disability (HR, 1.05 [95% CI, 1.00-1.10]; RD, 0.04% [95% CI, -0.04% to 0.12%]). To address unobserved confounding, matched full sibling pairs were also analyzed. Sibling control analyses found no evidence that acetaminophen use during pregnancy was associated with autism (HR, 0.98 [95% CI, 0.93-1.04]; RD, 0.02% [95% CI, -0.14% to 0.18%]), ADHD (HR, 0.98 [95% CI, 0.94-1.02]; RD, -0.02% [95% CI, -0.21% to 0.15%]), or intellectual disability (HR, 1.01 [95% CI, 0.92-1.10]; RD, 0% [95% CI, -0.10% to 0.13%]). Similarly, there was no evidence of a dose-response pattern in sibling control analyses. For example, for autism, compared with no use of acetaminophen, persons with low (<25th percentile), medium (25th-75th percentile), and high (>75th percentile) mean daily acetaminophen use had HRs of 0.85, 0.96, and 0.88, respectively.

Conclusion : Acetaminophen use during pregnancy was not associated with children's risk of autism, ADHD, or intellectual disability in sibling control analysis. This suggests that associations observed in other models may have been attributable to familial confounding.

Conclusion (proposition de traduction) : La prise de paracétamol pendant la grossesse n'a pas été associée au risque d'autisme, de TDAH ou de déficience intellectuelle chez les enfants dans l'analyse de contrôle de la fratrie. Cela suggère que les associations observées dans d'autres modèles peuvent être attribuables à des facteurs de confusion familiaux.

The Relationship Between Lactate and Lactate Clearance with In-Hospital Mortality in Unselected Emergency Department Patients.
Susur O, Yesіlaras M, Eyler Y. | Prehosp Disaster Med.  2024 Apr;39(2):178-183
DOI: https://doi.org/10.1017/s1049023x24000141  | Télécharger l'article au format  
Keywords: emergency department; in-hospital mortality; lactate; lactate clearance.

ORIGINAL RESEARCH The

Introduction : Lactate is a frequently used biomarker in emergency departments (EDs), especially in critically ill patients. The aim of this study is to investigate the relationship between lactate and lactate clearance with in-hospital mortality in unselected ED patients.

Méthode : This study was carried out retrospectively in the ED of a tertiary hospital. Patients aged 18 years and older whose blood lactate level was obtained in the ED were included in the study. Patients whose lactate value did not have sufficient analytical accuracy, whose lactate value was recorded in the system 180 minutes after admission, who were admitted to the ED as cardiac arrest, and whose ED or hospital outcome was unknown were excluded from the study. According to the first measured lactate value, the patients were divided into three groups: < 2.0mmol/L, 2.0-3.9mmol/L, and ≥ 4.0mmol/L. Lactate clearance was calculated and recorded in patients with one-to-four hours between two lactate values.

Résultats : During the five-year study period, a total of 1,070,406 patients were admitted to the ED, of which 114,438 (10.7%) received blood gas analysis. The median age of 81,449 patients included in the study was 58 years (IQR: 30, min: 18-max: 117) and 54.4% were female. The study found that non-trauma patients with a lactate level between 2.0-3.9mmol/L had a 2.5-times higher mortality risk, while those with a lactate level of ≥ 4.0mmol/L had a 20.8-times higher risk, compared to those with a lactate level < 2.0mmol/L. For trauma patients, the mortality risk was three-times higher for those with lactate levels between 2.0-3.9mmol/L and nine-times higher for those with a lactate level of ≥ 4.0mmol/L, compared to those with a lactate level < 2.0mmol/L. Among patients with a first measured lactate value ≥ 4.0mmol/L and a two-hour lactate clearance < 20%, the mortality rate was 19.7%. In addition, lactate, lactate clearance, and age were independent variables for mortality in this patient group.

Conclusion : The lactate value in unselected patients in the ED is a biomarker that can be used to predict the prognosis of the patients. In addition, lactate, lactate clearance, and age are independent predictors of mortality.

Conclusion (proposition de traduction) : La valeur du lactate chez les patients non sélectionnés des urgences est un biomarqueur qui peut être utilisé pour prédire le pronostic des patients. En outre, le lactate, la clairance du lactate et l'âge sont des facteurs prédictifs indépendants de la mortalité.

Comparison of Intubating Conditions with Succinylcholine Versus Rocuronium in the Prehospital Setting.
Ramsey JT, Pache KM, Sayre MR, Maynard C, Johnson NJ, Counts CR. | Prehosp Emerg Care.  2024;28(4):537-544
DOI: https://doi.org/10.1080/10903127.2023.2285399
Keywords: Aucun

FOCUS ON AIRWAY

Introduction : Rapid sequence intubation (RSI) is frequently performed by emergency medical services (EMS). We investigated the relationship between succinylcholine and rocuronium use and time until first laryngoscopy attempt, first-pass success, and Cormack-Lehane (CL) grades.

Méthode : We included adult patients for whom prehospital RSI was attempted from July 2015 through June 2022 in a retrospective, observational study with pre-post analysis. Timing was verified using recorded defibrillator audio in addition to review of continuous ECG, pulse oximetry, and end-tidal carbon dioxide waveforms. Our primary exposure was neuromuscular blocking agent (NMBA) used, either rocuronium or succinylcholine. Our prespecified primary outcome was the first attempt Cormack-Lehane view. Key secondary outcomes were first laryngoscopy attempt success rate, timing from NMBA administration to first attempt, number of attempts, and hypoxemic events.

Résultats : Of 5,179 patients in the EMS airway registry, 1,475 adults received an NMBA while not in cardiac arrest. Cormack-Lehane grades for succinylcholine and rocuronium were similar: grade I (64%, 59% [95% CI 0.64-1.09]), grade II (16%, 21%), grade III (18%, 16%), grade IV (3%, 3%). The median interval from NMBA administration to start of the first attempt was 57 s for succinylcholine and 83 s for rocuronium (mean difference 28 [95% CI 20-36] seconds). First attempt success was 84% for succinylcholine and 83% for rocuronium. Hypoxemic events were present in 25% of succinylcholine cases and 23% of rocuronium cases.

Conclusion : Prehospital use of either rocuronium or succinylcholine is associated with similar Cormack-Lehane grades, first-pass success rates, and rates of peri-intubation hypoxemia.

Conclusion (proposition de traduction) : L'utilisation préhospitalière du rocuronium ou de la succinylcholine est associée à des grades de Cormack-Lehane, des taux de réussite de la première tentative et des taux d'hypoxémie péri-intubation similaires.

Evidence-Based Guideline for Prehospital Airway Management.
Jarvis JL, Panchal AR, Lyng JW, Bosson N, Donofrio-Odmann JJ, Braude DA, Browne LR, Arinder M, Bolleter S, Gross T, Levy M, Lindbeck G, Maloney LM, Mattera CJ, Wang CT, Crowe RP, Gage CB, Lang ES, Sholl JM. | Prehosp Emerg Care.  2024;28(4):545-557
DOI: https://doi.org/10.1080/10903127.2023.2281363
Keywords: Aucun

FOCUS ON AIRWAY

Editorial : Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Conclusion : While limited high-quality evidence was available, the panel used a systematic review of existing literature to generate recommendations and good practice statements intended to guide practice. Key recommendations or themes include the need to master BVM ventilation as the foundation of care, confirmation of any invasive airway with waveform EtCO2, and the importance of procedural competency and training with invasive airway management, particularly endotracheal intubation, with a focus on prevention of complications, such as peri-intubation hypoxia and hypotension.
These recommendations and good practice statements offer EMS agencies and clinicians an opportunity to review and incorporate the available evidence into their airway management strategies. In recognition of the limited high-quality evidence, the panel recommends increasing focus on research efforts to better inform future evidence-based guidelines.

Conclusion (proposition de traduction) : Bien que les preuves de haute qualité soient limitées, le groupe a utilisé une analyse systématique de la littérature existante pour formuler des recommandations et des déclarations de bonnes pratiques destinées à guider la pratique. Les recommandations ou thèmes clés comprennent la nécessité de maîtriser la ventilation au BAVU comme base des soins, la confirmation de toute intubation par l'EtCO2, et l'importance de la compétence procédurale et de la formation à la gestion des voies aériennes invasives, en particulier l'intubation endotrachéale, en mettant l'accent sur la prévention des complications, telles que l'hypoxie et l'hypotension péri-intubation.
Ces recommandations et déclarations de bonnes pratiques offrent aux services de SAMU et aux cliniciens l'occasion d'examiner et d'intégrer les données disponibles dans leurs stratégies de gestion des voies aériennes. Compte tenu du nombre limité de données de haute qualité, le groupe d'experts recommande de mettre davantage l'accent sur les efforts de recherche afin de mieux informer les futures lignes directrices fondées sur des données probantes.

Is a Positive Prehospital FAST Associated with Severe Bleeding? A Multicenter Retrospective Study.
Stralec G, Fontaine C, Arras S, Omnes K, Ghomrani H, Lecaros P, Le Conte P, Balen F, Bobbia X. | Prehosp Emerg Care.  2024;28(4):572-579
DOI: https://doi.org/10.1080/10903127.2023.2272196
Keywords: Aucun

Focus on Trauma

Introduction : Severe hemorrhage is the leading cause of early preventable death in severe trauma patients. Delayed diagnosis is a poor prognostic factor, and severe hemorrhage prediction is essential. The aim of our study was to investigate if there was an association between the detection of peritoneal or pleural fluid on prehospital sonography for trauma and posttraumatic severe hemorrhage.

Méthode : We retrospectively studied data from records of thoracic or abdominal trauma patients managed in mobile intensive care units from January 2017 to December 2021 in four centers in France. Severe hemorrhage was defined as a condition necessitating transfusion of at least four packed red blood cells or surgical intervention/radioembolization for hemostasis within the first 24 h. Using a multivariate analysis, we investigated the predictive performance of focused assessment with sonography for trauma (FAST) alone or in combination with the five Red Flags criteria validated by Hamada et al.

Résultats : Among the 527 patients analyzed, 371 (71%) were men, the mean age was 41 ± 19 years, and the Injury Severity Score was 11 (Interquartile range = [5; 22]). Seventy-three (14%) patients had severe hemorrhage - of whom 28 (38%) had a positive FAST, compared to 61 (13%) without severe hemorrhage (p < 0.01). For severe hemorrhage prediction, FAST had a sensitivity of 38% (95%CI = [27%; 50%]) and a specificity of 87% (95%CI = [83%; 90%]) (AUC = 0.62, 95%CI = [0.57; 0.68]). The comparison of the other outcomes between positive and negative FAST was: hemostatic procedure, 22 (25%) vs 28 (6%), p < 0.01; intensive care unit admission 71 (80%) vs 190 (43%), p < 0.01; mean length of hospital stay 11 [4; 27] vs 4 [0; 14] days, p = 0.02; 30-day mortality 13 (15%) vs 22 (5%), p < 0.01.

Conclusion : A positive FAST performed in the prehospital setting is associated with severe hemorrhage and all prognostic criteria we studied.

Conclusion (proposition de traduction) : Une échographie FAST positive réalisée en préhospitalier est associé à une hémorragie sévère et à tous les critères pronostiques que nous avons étudiés.

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;28(4):589-597
DOI: https://doi.org/10.1080/10903127.2024.2322014
Keywords: Aucun

FOCUS ON TRAUMA

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 patients jeunes souffrant de fractures du bassin, les blessures graves associées sont fréquentes, mais les fractures pelviennes isolées donnent rarement lieu à un choc profond à l'arrivée du patient. Les protocoles de prise en charge préhospitalière des fractures du bassin devraient donner la priorité à une évacuation rapide et à des mesures de réanimation visant à traiter les lésions associées.

The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest.
Radulovic N, Hillier M, Nisenbaum R, Turner L, Nolan B. | Prehosp Emerg Care.  2024;28(4):580-588
DOI: https://doi.org/10.1080/10903127.2023.2285390
Keywords: Aucun

Focus on Trauma

Introduction : Resuscitative thoracotomy (RT) is a critical procedure performed in certain trauma patients in extremis, with extremely low survival rates. Currently, there is a paucity of data pertaining to prehospital variables and their predictive role in survival outcomes in traumatic cardiac arrest (TCA) patients requiring RT. The aim of the study was to determine the impact of prehospital intubation and out-of-hospital time (OOHT) on return of spontaneous circulation (ROSC) and survival in TCA requiring RT.

Méthode : This was a retrospective cohort study of trauma patients presenting to two level-1 trauma centers, St. Michael's Hospital and Sunnybrook Health Sciences Center, in Toronto, Canada (January 1, 2005-December 31, 2020). Our exposures of interest were any prehospital intubation attempt and OOHT. Primary and secondary outcome measures were ROSC post-RT and survival to hospital discharge, respectively, and data analysis was performed using univariate logistic regression.

Résultats : A total of 195 patients were included, of which 86% were male, and the mean age was 33 years. ROSC and survival to hospital discharge were achieved in 30% and 5% of patients, respectively. Of those who survived to discharge, 89% sustained penetrating trauma. There was no association between OOHT and ROSC (OR = 1.00, 95% CI 0.97-1.03) or survival (OR = 0.99, 95% CI 0.94-1.05). The odds of ROSC were lower in penetrating trauma in the presence of any prehospital intubation attempt (OR = 0.39, 95% CI 0.19-0.82, p = 0.01). ROSC was less likely among all patients with no prehospital signs of life (SOL) compared to those who had prehospital SOL (OR = 0.30, 95% CI 0.13-0.69, p < 0.01).

Conclusion : There was a significant association between prehospital intubation and lower likelihoods of ROSC in the penetrating TCA population requiring RT, as well as with the absence of prehospital SOL in all patients. OOHT did not appear to significantly impact ROSC or survival.

Conclusion (proposition de traduction) : Il existe une association significative entre l'intubation préhospitalière et une probabilité plus faible de retour de la circulation spontanée dans la population des arrêts cardiaques traumatiques pénétrants nécessitant une thoracotomie de réanimation, ainsi qu'avec l'absence de signes de vie préhospitaliers chez tous les patients. Le délai extrahospitalier ne semble pas avoir d'impact significatif sur le retour de la circulation spontanée ou sur la survie.

Development and validation of a prehospital termination of resuscitation (TOR) rule for out - of hospital cardiac arrest (OHCA) cases using general purpose artificial intelligence (AI)..
Kajino K, Daya MR, Onoe A, Nakamura F, Nakajima M, Sakuramoto K, Ong MEH, Kuwagata Y. | Resuscitation.  2024 Apr;197:110165
DOI: https://doi.org/10.1016/j.resuscitation.2024.110165  | Télécharger l'article au format  
Keywords: Artificial intelligence; Out-of-hospital cardiac arrest; Termination of Resuscitation.

Clinical paper

Introduction : Prehospital identification of futile resuscitation efforts (defined as a predicted probability of survival lower than 1%) for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transport. Reliable prediction variables for OHCA 'termination of resuscitation' (TOR) rules are needed to guide treatment decisions. The Universal TOR rule uses only three variables (Absence of Prehospital ROSC, Event not witnessed by EMS and no shock delivered on the scene) has been externally validated and is used by many EMS systems. Deep learning, an artificial intelligence (AI) platform is an attractive model to guide the development of TOR rule for OHCA. The purpose of this study was to assess the feasibility of developing an AI-TOR rule for neurologically favorable outcomes using general purpose AI and compare its performance to the Universal TOR rule.

Méthode : We identified OHCA cases of presumed cardiac etiology who were 18 years of age or older from 2016 to 2019 in the All-Japan Utstein Registry. We divided the dataset into 2 parts, the first half (2016-2017) was used as a training dataset for rule development and second half (2018-2019) for validation. The AI software (Prediction One®) created the model using the training dataset with internal cross-validation. It also evaluated the prediction accuracy and displayed the ranking of influencing variables. We performed validation using the second half cases and calculated the prediction model AUC. The top four of the 11 variables identified in the model were then selected as prognostic factors to be used in an AI-TOR rule, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated from validation cohort. This was then compared to the performance of the Universal TOR rule using same dataset.

Résultats : There were 504,561 OHCA cases, 18 years of age or older, 302,799 cases were presumed cardiac origin. Of these, 149,425 cases were used for the training dataset and 153,374 cases for the validation dataset. The model developed by AI using 11 variables had an AUC of 0.969, and its AUC for the validation dataset was 0.965. The top four influencing variables for neurologically favorable outcome were Prehospital ROSC, witnessed by EMS, Age (68 years old and younger) and nonasystole. The AUC calculated using the 4 variables for the AI-TOR rule was 0.953, and its AUC for the validation dataset was 0.952 (95%CI 0.949 -0.954). Of 80,198 patients in the validation cohort that satisfied all four criteria for the AI-TOR rule, 58 (0.07%) had a neurologically favorable one-month survival. The specificity of AI-TOR rule was 0.990, and the PPV was 0.999 for predicting lack of neurologically favorable survival, both the specificity and PPV were higher than that achieved with the universal TOR (0.959, 0.998).

Conclusion : The accuracy of prediction models using AI software to determine outcomes in OHCA was excellent and the AI-TOR rule's variables from prediction model performed better than the Universal TOR rule. External validation of our findings as well as further research into the utility of using AI platforms for TOR prediction in clinical practice is needed.

Conclusion (proposition de traduction) : La précision des modèles de prédiction utilisant un logiciel d'IA pour déterminer les issues des arrêts cardiaques extrahospitaliers était excellente et les variables du modèle de prédiction de la règle d’interruption de soins de réanimation par l'IA ont donné de meilleurs résultats que la règle universelle d’interruption de soins de réanimation. Une validation externe de nos résultats ainsi que d'autres recherches sur l'utilité de l'utilisation de plateformes d'IA pour la prédiction de l’interruption de soins de réanimation dans la pratique clinique sont nécessaires.

Validation of Utstein-Based score to predict return of spontaneous circulation (UB-ROSC) in patients with out-of-hospital cardiac arrest.
Caputo ML, Baldi E, Burkart R, Wilmes A, Cresta R, Benvenuti C, Oezkartal T, Cianella R, Primi R, Currao A, Bendotti S, Compagnoni S, Gentile FR, Anselmi L, Savastano S, Klersy C, Auricchio A. | Resuscitation.  2024 Apr;197:110113
DOI: https://doi.org/10.1016/j.resuscitation.2024.110113  | Télécharger l'article au format  
Keywords: Out of hospital cardiac arrest; Prediction; Return of spontaneous circulation; Score; Utstein.

Research article

Introduction : The Utstein Based-ROSC (UB-ROSC) score has been developed to predict ROSC in OHCA victims. Aim of the study was to validate the UB-ROSC score using two Utstein-based OHCA registries: the SWiss REgistry of Cardiac Arrest (SWISSRECA) and the Lombardia Cardiac Arrest Registry (Lombardia CARe), northern Italy.

Méthode : Consecutive patients with OHCA of any etiology occurring between January 1st, 2019 and December 31st 2021 were included in this retrospective validation study. UB-ROSC score was computed for each patient and categorized in one of three subgroups: low, medium or high likelihood of ROSC according to the UB-ROSC cut-offs (≤-19; -18 to 12; ≥13). To assess the performance of the UB-ROSC score in this new cohort, we assessed both discrimination and calibration. The score was plotted against the survival to hospital admission.

Résultats : A total of 12.577 patients were included in the study. A sustained ROSC was obtained in 2.719 patients (22%). The UB-ROSC model resulted well calibrated and showed a good discrimination (AUC 0.71, 95% CI 0.70-0.72). In the low likelihood subgroup of UB-ROSC, only 10% of patients achieved ROSC, whereas the proportion raised to 36% for a score between -18 and 12 (OR 5.0, 95% CI 2.9-8.6, p < 0.001) and to 85% for a score ≥13 (OR 49.4, 95% CI 14.3-170.6, p < 0.001).

Conclusion : UB-ROSC score represents a reliable tool to predict ROSC probability in OHCA patients. Its application may help the medical decision-making process, providing a realistic stratification of the probability for ROSC.

Conclusion (proposition de traduction) : Le score UB-ROSC d'Utstein est un outil fiable pour prédire la probabilité de retour à une activité circulatoire spontanée chez les patients ayant présenté un arrêt cardiaque en dehors de l'hôpital. Son application peut faciliter le processus de prise de décision médicale, en fournissant une stratification réaliste de la probabilité de retour à une activité circulatoire spontanée.

Association of pre-hospital tracheal intubation with outcomes after out-of-hospital cardiac arrest by drowning comparing to supraglottic airway device: A nationwide propensity score-matched cohort study.
Yoshimura S, Kiguchi T, Nishioka N, Ikeda N, Takegawa M, Miyamae N, Sumida Y, Kitamura T, Iwami T. | Resuscitation.  2024 Apr;197:110129
DOI: https://doi.org/10.1016/j.resuscitation.2024.110129  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Drowning; Endotracheal intubation; Out-of-hospital cardiac arrest; Supraglottic airway device.

Clinical paper

Introduction : This study aimed to compare the survival outcomes of adult patients with out-of-hospital cardiac arrest (OHCA) by drowning who were treated with either endotracheal intubation (ETI) or a supraglottic airway (SGA) device.

Méthode : We compared the outcomes of patients with OHCA by drowning according to airway management using a Japanese nationwide population-based registry (All-Japan Utstein Registry). Adult patients with OHCA treated in 2014-2020 with advanced airway management (ETI or SGA) were included. Patients who received ETI during cardiopulmonary resuscitation were matched with those treated with SGA based on propensity scores in a 1:1 ratio with a 0.2 calliper width. The outcome measures were the return of spontaneous circulation (ROSC), survival at one month, and favourable neurological outcomes defined as a Cerebral Performance Category Scale score of 1 or 2.

Résultats : Of the 11,703 eligible patients, 4,467 (38.2%) and 7,236 (61.8%) underwent ETI and SGA, respectively. A total of 3,566 patients in each cohort were matched. The ROSC rate was higher in those treated with ETI versus SGA (207/3,566 [5.8%] versus 167/3,566 [4.7%], respectively; adjusted odds ratio, 1.25; 95% confidence interval [CI], 1.02-1.55). There was no intergroup difference in one-month survival or favourable neurological outcome (32/3566 [0.90%] versus 34/3566 [0.95%]; odds ratio, 0.94; 95% CI, 0.58-1.53; and 9/3566 [0.25%] versus 8/3566 [0.22%]; odds ratio, 1.13; 95% CI, 0.43-2.92), respectively.

Conclusion : In this propensity score-matched study of adult OHCA by drowning, ETI compared to SGA was associated with ROSC but not associated with survival and favourable neurological outcomes at one month.

Conclusion (proposition de traduction) : Dans cette étude de cohorte appariée par score de propension portant sur les arrêts cardiaques extrahospitaliers par noyade chez l'adulte, l'intubation endotrachéale comparée à l'utilisation d'un appareil respiratoire supraglottique a été associée au retour de la circulation spontanée, mais pas à la survie ni à des résultats neurologiques favorables à un mois.

Initial cardiac rhythms of out-of-hospital cardiac arrest victims with foreign body airway obstruction.
Norii T, Igarashi Y, Kogure T. | Resuscitation.  2024 Apr;197:110143
DOI: https://doi.org/10.1016/j.resuscitation.2024.110143  | Télécharger l'article au format  
Keywords: Aucun

Letter to the Editor

Editorial : Foreign body airway obstruction (FBAO) is one of the leading causes of preventable accidental death worldwide. Although studies have examined the roles of bystander foreign body removal interventions such as abdominal thrusts, little is known about the initial cardiac rhythm of patients who suffer from out-of-hospital cardiac arrest (OHCA) with FBAO and the role of defibrillation on scene. We describe the incidence of shockable rhythms among OHCA patients with FBAO and identify their characteristics.

Conclusion : With a large out-of-hospital cardiac arrest dataset, we found that a small but unignorable number of out-of-hospital cardiac arrest patients with Foreign body airway obstruction had an initial shockable rhythm. A further study is needed to identify the role of defibrillation on those patients.

Conclusion (proposition de traduction) : À partir d'un vaste ensemble de données sur les arrêts cardiaques extrahospitaliers, nous avons constaté qu'un petit nombre, mais non négligeable, de patients ayant fait un arrêt cardiaque extrahospitalier et présentant une obstruction des voies aériennes par un corps étranger avaient un rythme initial choquable. Une étude complémentaire est nécessaire pour identifier le rôle de la défibrillation chez ces patients.

Impact of delayed mobile medical team dispatch for respiratory distress calls: a propensity score matched study from a French emergency communication center.
Charrin L, Romain-Scelle N, Di-Filippo C, Mercier E, Balen F, Tazarourte K, Benhamed A. | Scand J Trauma Resusc Emerg Med.  2024 Apr 12;32(1):27
DOI: https://doi.org/10.1186/s13049-024-01201-5  | Télécharger l'article au format  
Keywords: Advanced life support; Dyspnea; Emergency communication center; Prehospital.

ORIGINAL RESEARCH

Introduction : Shortness of breath is a common complaint among individuals contacting emergency communication center (EMCCs). In some prehospital system, emergency medical services include an advanced life support (ALS)-capable team. Whether such team should be dispatched during the phone call or delayed until the BLS-capable paramedic team reports from the scene is unclear. We aimed to evaluate the impact of delayed MMT dispatch until receiving the paramedic review compared to immediate dispatch at the time of the call on patient outcomes.

Méthode : A cross-sectional study conducted in Lyon, France, using data obtained from the departmental EMCC during the period from January to December 2019. We included consecutive calls related to adult patients experiencing acute respiratory distress. Patients from the two groups (immediate mobile medical team (MMT) dispatch or delayed MMT dispatch) were matched on a propensity score, and a conditional weighted logistic regression assessed the adjusted odds ratios (ORs) for each outcome (mortality on days 0, 7 and 30).

Résultats : A total of 870 calls (median age 72 [57-84], male 466 53.6%) were sought for analysis [614 (70.6%) "immediate MMT dispatch" and 256 (29.4%) "delayed MMT" groups]. The median time before MMT dispatch was 25.1 min longer in the delayed MMT group (30.7 [26.4-36.1] vs. 5.6 [3.9-8.8] min, p < 0.001). Patients subjected to a delayed MMT intervention were older (median age 78 [66-87] vs. 69 [53-83], p < 0.001) and more frequently highly dependent (16.3% vs. 8.6%, p < 0.001). A higher proportion of patients in the delayed MMT group required bag valve mask ventilation (47.3% vs. 39.1%, p = 0.03), noninvasive ventilation (24.6% vs. 20.0%, p = 0.13), endotracheal intubation (7.0% vs. 4.1%, p = 0.07) and catecholamine infusion (3.9% vs. 1.3%, p = 0.01). After propensity score matching, mortality at day 0 was higher in the delayed MMT group (9.8% vs. 4.2%, p = 0.002). Immediate MMT dispatch at the call was associated with a lower risk of mortality on day 0 (0.60 [0.38;0.82], p < 0.001) day 7 (0.50 [0.27;0.72], p < 0.001) and day 30 (0.56 [0.35;0.78], p < 0.001).

Conclusion : This study suggests that the deployment of an MMT at call in patients in acute respiratory distress may result in decreased short to medium-term mortality compared to a delayed MMT following initial first aid assessment.

Conclusion (proposition de traduction) : Cette étude suggère que le déclenchement d'une équipe médicale mobile dès l'appel d'un patient en détresse respiratoire aiguë peut réduire la mortalité à court et à moyen terme par rapport à une équipe médicale mobile différée après l'évaluation initiale des premiers soins.

Influence of Time to Achieve Target Systolic Blood Pressure on Outcome After Intracerebral Hemorrhage: The Blood Pressure in Acute Stroke Collaboration.
Wang X, Yang J, Moullaali TJ, Sandset EC, Woodhouse LJ, Law ZK, Arima H, Butcher KS, Delcourt C, Edwards L, Gupta S, Jiang W, Koch S, Potter J, Qureshi AI, Robinson TG, Al-Shahi Salman R, Saver JL, Sprigg N, Wardlaw J, Anderson CS, Sakamoto Y, Bath PM, Chalmers J; Blood Pressure in Acute Stroke (BASC) Investigators. | Stroke.  2024 Apr;55(4):849-855
DOI: https://doi.org/10.1161/strokeaha.123.044358
Keywords: adults; blood pressure; cerebral hemorrhage; hematoma; stroke.

RESEARCH ARTICLE

Introduction : To investigate whether an earlier time to achieving and maintaining systolic blood pressure (SBP) at 120 to 140 mm Hg is associated with favorable outcomes in a cohort of patients with acute intracerebral hemorrhage.

Méthode : We pooled individual patient data from randomized controlled trials registered in the Blood Pressure in Acute Stroke Collaboration. Time was defined as time form symptom onset plus the time (hour) to first achieve and subsequently maintain SBP at 120 to 140 mm Hg over 24 hours. The primary outcome was functional status measured by the modified Rankin Scale at 90 to 180 days. A generalized linear mixed models was used, with adjustment for covariables and trial as a random effect.

Résultats : A total of 5761 patients (mean age, 64.0 [SD, 13.0], 2120 [36.8%] females) were included in analyses. Earlier SBP control was associated with better functional outcomes (modified Rankin Scale score, 3-6; odds ratio, 0.98 [95% CI, 0.97-0.99]) and a significant lower risk of hematoma expansion (0.98, 0.96-1.00). This association was stronger in patients with bigger baseline hematoma volume (>10 mL) compared with those with baseline hematoma volume ≤10 mL (0.006 for interaction). Earlier SBP control was not associated with cardiac or renal adverse events.

Conclusion : Our study confirms a clear time relation between early versus later SBP control (120-140 mm Hg) and outcomes in the one-third of patients with intracerebral hemorrhage who attained sustained SBP levels within this range. These data provide further support for the value of early recognition, rapid transport, and prompt initiation of treatment of patients with intracerebral hemorrhage.

Conclusion (proposition de traduction) : Notre étude confirme une relation temporelle claire entre le contrôle précoce ou tardif de la PAS (120-140 mm Hg) et les résultats chez le tiers des patients ayant subi une hémorragie intracérébrale qui ont atteint des niveaux de PAS soutenus dans cette fourchette. Ces données confirment la valeur d'une reconnaissance précoce, d'un transport rapide et d'un traitement rapide des patients souffrant d'hémorragie intracérébrale.

Intravenous Alteplase Versus Best Medical Therapy for Patients With Minor Stroke: A Systematic Review and Meta-Analysis.
Zhang Y, Lv T, Nguyen TN, Wu S, Li Z, Bai X, Chen D, Zhao C, Lin W, Chen S, Sui Y. | Stroke.  2024 Apr;55(4):883-892
DOI: https://doi.org/10.1161/strokeaha.123.045495
Keywords: intracranial hemorrhage; ischemic stroke; odds ratio; prognosis; tissue plasminogen activator.

RESEARCH ARTICLE

Introduction : The efficacy of thrombolysis (IVT) in minor stroke (National Institutes of Health Stroke Scale score, 0-5) remains inconclusive. The aim of this study is to compare the effectiveness and safety of IVT with best medical therapy (BMT) by means of a systematic review and meta-analysis of randomized controlled trials and observational studies.

Méthode : We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to IVT in minor stroke from inception until August 10, 2023. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days. The associations were calculated for the overall and preformulated subgroups by using the odds ratios (ORs). This study was registered with PROSPERO (CRD42023445856).

Résultats : A total of 20 high-quality studies, comprised of 13 397 patients with acute minor ischemic stroke, were included. There were no significant differences observed in the modified Rankin Scale scores of 0 to 1 (OR, 1.10 [95% CI, 0.89-1.37]) and 0 to 2 (OR, 1.16 [95% CI, 0.95-1.43]), mortality rates (OR, 0.67 [95% CI, 0.39-1.15]), recurrent stroke (OR, 0.89 [95% CI, 0.57-1.38]), and recurrent ischemic stroke (OR, 1.09 [95% CI, 0.68-1.73]) between the IVT and BMT group. There were differences between the IVT group and the BMT group in terms of early neurological deterioration (OR, 1.81 [95% CI, 1.17-2.80]), symptomatic intracranial hemorrhage (OR, 7.48 [95% CI, 3.55-15.76]), and hemorrhagic transformation (OR, 4.73 [95% CI, 2.40-9.34]). Comparison of modified Rankin Scale score of 0 to 1 remained unchanged in subgroup patients with nondisabling deficits or compared with those using antiplatelets.

Conclusion : These findings indicate that IVT does not yield significant improvement in the functional prognosis of patients with acute minor ischemic stroke. Additionally, it is associated with an increased risk of symptomatic intracranial hemorrhage when compared with the BMT. Moreover, IVT may not have superiority over BMT in patients with nondisabling deficits or those using antiplatelets.

Conclusion (proposition de traduction) : Ces résultats indiquent que la thrombolyse n'apporte pas d'amélioration significative au pronostic fonctionnel des patients ayant présenté un AVC ischémique aigu mineur. En outre, elle est associée à un risque accru d'hémorragie intracrânienne symptomatique par rapport au meilleur traitement médical. En outre, la thrombolyse pourrait ne pas être supérieure au meilleur traitement médical chez les patients présentant des déficits non invalidants ou utilisant des antiagrégant plaquettaires.

Commentaire : Braksick SA, Rabinstein AA. Thrombolysis Is Not Indicated for Minor Strokes If They Are Truly Nondisabling. Stroke. 2024 Apr;55(4):893-894  .

The usefulness of lactate/albumin ratio, C-reactive protein/albumin ratio, procalcitonin/albumin ratio, SOFA, and qSOFA in predicting the prognosis of patients with sepsis who presented to EDs.
Yoo KH, Choi SH, Suh GJ, Chung SP, Choi HS, Park YS, Jo YH, Shin TG, Lim TH, Kim WY, Lee J; Korean Shock Society (KoSS) Investigators. | Am J Emerg Med.  2024 Apr;78:1-7
DOI: https://doi.org/10.1016/j.ajem.2023.12.028
Keywords: Emergency department; Lactate to albumin ratio; Predictive value; Sepsis; Septic shock; Sequential organ failure assessment.

Research article

Introduction : Early identification of sepsis with a poor prognosis in the emergency department (ED) is crucial for prompt management and improved outcomes. This study aimed to examine the predictive value of sequential organ failure assessment (SOFA), quick SOFA (qSOFA), lactate to albumin ratio (LAR), C-reactive protein to albumin ratio (CAR), and procalcitonin to albumin ratio (PAR), obtained in the ED, as predictors for 28-day mortality in patients with sepsis and septic shock.

Méthode : We included 3499 patients (aged ≥19 years) from multicenter registry of the Korean Shock Society between October 2015 and December 2019. The SOFA score, qSOFA score, and lactate level at the time of registry enrollment were used. Albumin, C-reactive protein, and procalcitonin levels were obtained from the initial laboratory results measured upon ED arrival. We evaluated the predictive accuracy for 28-day mortality using the area under the receiver operating characteristic (AUROC) curve. A multivariable logistic regression analysis of the independent predictors of 28-day mortality was performed. The SOFA score, LAR, CAR, and PAR were converted to categorical variables using Youden's index and analyzed. Adjusting for confounding factors such as age, sex, comorbidities, and infection focus, adjusted odds ratios (aOR) were calculated.

Résultats : Of the 3499 patients, 2707 (77.4%) were survivors, whereas 792 (22.6%) were non-survivors. The median age of the patients was 70 (25th-75th percentiles, 61-78), and 2042 (58.4%) were male. LAR for predicting 28-day mortality had the highest AUROC, followed by the SOFA score (0.715; 95% confidence interval (CI): 0.69-0.74 and 0.669; 95% CI: 0.65-0.69, respectively). The multivariable logistic regression analysis revealed that the aOR of LAR >1.52 was 3.75 (95% CI: 3.16-4.45), and the aOR, of SOFA score at enrollment >7.5 was 2.67 (95% CI: 2.25-3.17).

Conclusion : The results of this study showed that LAR is a relatively strong predictor of sepsis prognosis in the ED setting, indicating its potential as a straightforward and practical prognostic factor. This finding may assist healthcare providers in the ED by providing them with tools to risk-stratify patients and predict their mortality.

Conclusion (proposition de traduction) : Les résultats de cette étude ont montré que le rapport lactate/albumine est un facteur prédictif relativement fort du pronostic du sepsis dans le contexte des urgences, ce qui indique son potentiel en tant que facteur pronostique simple et pratique. Cette étude pourrait aider les urgentistes en leur fournissant des outils pour classer les patients par ordre de risque et prédire leur mortalité.

Commentaire : Il semble que le rapport lactate-albumine soit un biomarqueurs de la gravité infectieuse.
Le lactate est un indicateur de l'hypoperfusion tissulaire et de la détresse microcirculatoire. L'albumine semble être un indicateur de l'apparition des modifications capillaires.
La valeur du rapport lactate/albumine semble permettre d’identifier les patients infectés présentant un risque de mortalité à court terme. Ce paramètres est un des outils pronostiques utiles chez les patients qui se présentent aux Urgences avec des infections et dont les scores de comorbidité ou de gravité sont faibles.
Les valeurs du rapport lactate/albumine à l'admission sont significativement plus élevées dans les groupes de décès que dans les groupes de survie (facteur de risque indépendant pour la mortalité à l'hôpital).

Le seuil optimal du rapport lactate/albumine (albumine en g/L) est de 0,671 (Chen Y, Yang K, Wu B and al. Association between lactate/albumin ratio and mortality in patients with heart failure after myocardial infarction. ESC Heart Fail. 2023 Jun;10(3):1928-1936  ).
Le rapport lactate/albumine médian dans le groupe de sortie et dans le groupe de décès était respectivement de 0,64 et de 1,27. L'aire sous la courbe de la caractéristique d'exploitation du récepteur (AUROC) a indiqué que la performance diagnostique précise était de 0,976 pour prédire le décès par rapport à la sortie pour le rapport lactate/albumine (Kabra R, Acharya S, Shukla S and al. Serum Lactate-Albumin Ratio: Soothsayer for Outcome in Sepsis. Cureus. 2023 Mar 28;15(3):e36816  ).

Prognostic role of albumin, lactate-to-albumin ratio and C-reactive protein-to-albumin ratio in infected patients.
Turcato G, Zaboli A, Sibilio S, Brigo F. | Am J Emerg Med.  2024 Apr;78:42-47
DOI: https://doi.org/10.1016/j.ajem.2023.12.042
Keywords: Albumin; C-reactive protein to albumin; CAR; Infection; LAR; Lactate-to-albumin; Mortality; Sepsis.

Research article

Introduction : The prognostic evaluation of the septic patient has recently been enriched by some predictive indices such as albumin concentration, lactate/albumin ratio (LAR) and C-reactive protein/albumin ratio (CAR). The performance of these indices has been evaluated in septic patients in intensive care, but until now their performance in infected patients in the Emergency Department (ED) has not been evaluated.

Méthode : To investigate the potential prognostic role of albumin, LAR and CAR in patients with infection in the ED.
Methods: Single-centre prospective study performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital (Italy). All patients with infection were enrolled. The study outcome was death within 30 days. The predictive ability of albumin, LAR and CAR was assessed by area under the receiver operating characteristic curves (AUROCs). A multivariate logistic regression model was used to examine the association of the indices with 30-day mortality, with comorbidity, acute urgency and severity of infection as covariates.

Résultats : The study enrolled 962 patients with an infectious status. The overall 30-day mortality rate was 8.9% (86/962). The AUROC of albumin was 0.831 (95% CI 0.795-868), while for LAR this was 0.773 (CI95% 0.719-0.827) and for CAR 0.718 (CI95% 0.664-0.771). The odds ratio for 30-day mortality for albumin was 3.362 (95% CI 1.904-5.936), for ln(LAR) 2.651 (95% CI 1.646-4.270) and for ln(CAR) 1.739 (95% CI 1.326-2.281).

Conclusion : All three indices had a good discriminatory ability for the risk of short-term death in patients with infection, indicating their promising use in the ED as well as in the ICU. Further studies are needed to confirm the better performance of albumin compared to LAR and CAR.

Conclusion (proposition de traduction) : Les trois indices avaient une bonne capacité de discrimination pour le risque de décès à court terme chez les patients infectés, ce qui indique que leur utilisation est prometteuse aux urgences et aux soins intensifs. D'autres études sont nécessaires pour confirmer la meilleure performance de l'albumine par rapport au rapport lactate/albumine et au rapport protéine C-réactive/albumine.

Neurological outcomes in traffic accidents: A propensity score matching analysis of medical and non-medical origin cases of out-of-hospital cardiac arrest.
Miyashita Y, Takei Y, Toyama G, Takahashi T, Adachi T, Omatsu K, Ozaki A. | Am J Emerg Med.  2024 Apr;78:176-181
DOI: https://doi.org/10.1016/j.ajem.2024.01.028
Keywords: Characteristics; Medial origin; Out-of-hospital cardiac arrest; Outcome; Traffic accidents.

Research article

Introduction : This study aimed to comprehensively compare the characteristics of out-of-hospital cardiac arrest (OHCA) with medical and non-medical origins attributed to traffic accidents and explore the potential association between the cases with a medical origin and neurologically favorable outcomes.

Méthode : In this retrospective nationwide population-based study, baseline data were collected between January 2018 and December 2020. We analyzed 5091 OHCA associated with traffic accidents on the road scene. Only those encounters involving treatment or transport by prehospital emergency medical technicians were included. The characteristics of OHCA incidents and their outcomes were analyzed by categorizing patients into "medical origin" and "non-medical origin" groups.

Résultats : Medical-origin cases exhibited several distinct characteristics, including higher frequencies of occurrence during the daytime (79.3% [706/890] vs. 68.9% [2895/4201], p < 0.001), a higher prevalence among male (77.8% [692/890] vs. 68.3% [2871/4201], p < 0.001) and younger patients (median [25-75%]: 63 years [42-77] vs. 66 years [50-76], p = 0.003), a higher proportion of shockable initial rhythms(10.5% [93/890] vs. 1.1% [45/4201], p < 0.001), an increased number of cases requiring advanced airway management (33.8% [301/890] vs. 28.5% [1199/4201], p = 0.002) and adrenaline administration by emergency medical teams (26.9% [239/890] vs. 21.7% [910/4201], p < 0.001), and shorter transport times (55.3% [492/890] vs. 60.9% [2558/4201], p = 0.002) compared to non-medical-origin cases. However, medical-origin cases also had lower witness rates (42.8% [381/890] vs. 27.2% [1142/4201], p < 0.001) and were less likely to be transported to higher-level hospitals (55.3% [492/890] vs. 60.9% [2558/4201], p = 0.002). Propensity score matching analysis identified factors associated with favorable neurological outcomes in medical-origin traffic accidents. The adjusted odds ratios were as follows: 8.46 (3.47-20.61) for cases with shockable initial rhythms, 2.36 (1.01-5.52) for cases involving traffic accidents due to medical origin, and 0.09 (0.01-0.67) for cases where advanced airway management was provided.

Conclusion : In this retrospective study, the occurrence of OHCAs of medical origin involving traffic accidents were associated with favorable neurological outcomes. These cases more frequently demonstrated favorable factors for survival compared to those classified as of non-medical origin. The findings have important implications for public health and EMS professionals, they will guide future research aimed at optimizing prehospital care strategies and improving survival rates for similar cases.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, la survenue d'un arrêt cardiaque extrahospitalier d'origine médicale lors d'un accident de la route a été associée à des résultats neurologiques favorables. Ces cas présentaient plus fréquemment des facteurs de survie favorables que ceux classés comme étant d'origine non médicale. Ces résultats ont des implications importantes pour les professionnels de la santé publique et des services médicaux d'urgence. Ils guideront les recherches futures visant à optimiser les stratégies de soins préhospitaliers et à améliorer les taux de survie pour des cas similaires.

High risk and low prevalence diseases: Myocarditis.
Ediger DS, Brady WJ, Koyfman A, Long B. | Am J Emerg Med.  2024 Apr;78:81-88
DOI: https://doi.org/10.1016/j.ajem.2024.01.007
Keywords: Cardiology; Cardiovascular; Ejection fraction; Fulminant myocarditis; Heart failure; Infectious disease; Myocarditis; Viral myocarditis.

Review article

Introduction : Myocarditis is a serious condition that carries with it a high rate of morbidity and mortality.
Objective: This review highlights the pearls and pitfalls of myocarditis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion : Myocarditis is an inflammatory syndrome of myocardium, most often resulting from a viral infection, that can cause life-threatening cardiovascular collapse. It has a highly variable presentation and no widely available specific diagnostic test, making it a challenging diagnosis. Emergency clinicians should obtain an electrocardiogram and perform bedside ultrasound to assess cardiac function. Treatment in the ED is largely supportive, focusing on resuscitation, cardiovascular support, cardiology specialist consultation, and appropriate disposition.

Conclusion : An understanding of myocarditis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Conclusion (proposition de traduction) : Une bonne compréhension de la myocardite peut aider les médecins urgentistes à diagnostiquer et à prendre en charge cette maladie potentiellement mortelle.

Assessing the impact of pre-hospital airway management on severe traumatic Brain injury: A systematic review and Meta-analysis.
Shafique MA, Haseeb A, Asghar B, Kumar A, Chaudhry ER, Mustafa MS. | Am J Emerg Med.  2024 Apr;78:188-195.
DOI: https://doi.org/10.1016/j.ajem.2024.01.030
Keywords: Emergency medicine; Intubation; Pre-hospital care; Traumatic brain injury.

Review article

Introduction : This study aimed to assess the impact of establishing a pre-hospital definitive airway on mortality and morbidity compared with no prehospital airway in cases of severe traumatic brain injury (TBI).

Méthode : Traumatic brain injury (TBI) is a global health concern that is associated with substantial morbidity and mortality. Prehospital intubation (PHI) has been proposed as a potential life-saving intervention for patients with severe TBI to mitigate secondary insults, such as hypoxemia and hypercapnia. However, their impact on patient outcomes remains controversial.
Methods: A systematic review and meta-analysis were conducted to assess the effects of prehospital intubation versus no prehospital intubation on morbidity and mortality in patients with severe TBI, adhering to the PRISMA guidelines.

Résultats : 24 studies, comprising 56,543 patients, indicated no significant difference in mortality between pre-hospital and In-hospital Intubation (OR 0.89, 95% CI 0.65-1.23, p = 0.48), although substantial heterogeneity was noted. Morbidity analysis also showed no significant difference (OR 0.83, 95% CI 0.43-1.63, p = 0.59). These findings underscore the need for cautious interpretation due to heterogeneity and the influence of specific studies on the results.

Conclusion : In summary, an initial assessment did not reveal any apparent disparity in mortality rates between individuals who received prehospital intubation and those who did not. However, subsequent analyses and randomized controlled trials (RCTs) demonstrated that patients who underwent prehospital intubation had a reduced risk of death and morbidity. The dependence on biased observational studies and the need for further replicated RCTs to validate these findings are evident. Despite the intricacy of the matter, it is crucial to intervene during severe airway impairment.

Conclusion (proposition de traduction) : En résumé, une première évaluation n'a pas révélé de disparité apparente dans les taux de mortalité entre les personnes ayant bénéficié d'une intubation préhospitalière et celles qui n'en ont pas bénéficié. Toutefois, des analyses ultérieures et des essais contrôlés randomisés (ECR) ont démontré que les patients ayant bénéficié d'une intubation préhospitalière présentaient un risque réduit de décès et de morbidité. La dépendance à l'égard d'études d'observation biaisées et la nécessité d'essais contrôlés randomisés supplémentaires pour valider ces résultats est évidente. Malgré la complexité de la question, il est crucial d'intervenir en cas d'altération grave des voies respiratoires.

Acute pain management after trauma: What you need to know.
Klugh JM, Harvin JA. | J Trauma Acute Care Surg.  2024 Apr 1;96(4):537-541
DOI: https://doi.org/10.1097/ta.0000000000004193  | Télécharger l'article au format  
Keywords: Aucun

WHAT YOU NEED TO KNOW SERIES – REVIEWS

Editorial : Effective acute pain control is mandatory after injury. Opioids continue to be a pillar acute pain management of strategies despite not being as effective as some nonnarcotic alternatives. An acute pain management strategy after trauma should be thoughtful, effective, and responsible. A thoughtful approach includes managing a patient's expectations for acute pain control and ensuring that interventions purposefully and rationally affect the domain of pain that is uncontrolled. An effective pain management strategy includes a multimodal approach using acetaminophen, nonsteroidal anti-inflammatory drugs, and regional anesthesia. A responsible acute pain management approach includes knowing the relative strengths of the opioids prescribed and standardized approach to opioid prescribing at discharge to minimize diversion. Acute pain management is quite understudied, and future considerations include a reliable objective measurement of pain and the evaluation of nonmedication acute pain interventions.

Conclusion : Thoughtful, effective, and responsible opioid-minimizing acute pain management is possible by managing expectations, using evidence-based nonopioid medications, and rationally prescribing opioids as needed. Future investigation include developing a more representative measurement of a patient's somatic pain experience that allows providers to specifically treat pain and any concomitant emotional or psychiatric issues and the evaluation of nonmedication acute pain interventions.

Conclusion (proposition de traduction) : Une gestion réfléchie, efficace et responsable de la douleur aiguë réduisant les opioïdes est possible en gérant les anticipations, en utilisant des médicaments non opioïdes fondés sur des preuves et en prescrivant rationnellement des opioïdes en cas de besoin. Les recherches futures incluent le développement d'une mesure plus représentative de l'expérience de la douleur somatique d'un patient qui permette aux soignants de traiter spécifiquement la douleur et tout problème émotionnel ou psychiatrique concomitant, ainsi que l'évaluation des interventions non médicamenteuses contre la douleur aiguë.

Results of the implementation of a double-check protocol with point-of-care ultrasound for acute heart failure in the emergency department.
Villén T, Tung Y, Llamas R, Neria F, Carballo C, Vázquez JL, Monge D. | Ultrasound J.  2024 Apr 17;16(1):25
DOI: https://doi.org/10.1186/s13089-024-00373-6  | Télécharger l'article au format  
Keywords: Diagnosis; Diagnostic errors; Heart failure; Ultrasonography.

Original article

Introduction : To determine the effectiveness of a double-check protocol using Point-of-Care Ultrasound in the management of patients diagnosed with Acute Heart Failure in an Emergency Department.

Méthode : Prospective analytical cross-sectional observational study with patients diagnosed with Acute Heart Failure by the outgoing medical team, who undergo multi-organ ultrasound evaluation including cardiac, pulmonary, and inferior vena cava ultrasound.

Résultats : 96 patients were included. An alternative diagnosis was found in 33% of them. Among the 77% where AHF diagnosis was confirmed, 73.4% had an underlying cause or condition not previously known (Left Ventricular Ejection Fraction less than 40% or moderate-severe valvulopathy). The introduction of the protocol had a clinically relevant impact on 47% of all included patients.

Conclusion : The implementation of a double-check protocol using POCUS, including cardiac, pulmonary, and inferior vena cava assessment in patients diagnosed with Acute Heart Failure, demonstrates a high utility in ensuring accurate diagnosis and proper classification of these patients.

Conclusion (proposition de traduction) : La mise en œuvre d'un protocole de double évaluation utilisant l'échographie au point d'intervention, comprenant l'évaluation cardiaque, pulmonaire et de la veine cave inférieure chez les patients diagnostiqués avec une insuffisance cardiaque aiguë, démontre une grande utilité pour assurer un diagnostic précis et une classification correcte de ces patients.