Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.
Borgundvaag B, Bellolio F, Miles I, Schwarz ES, Sharif S, Su MK, Baumgartner K, Liss DB, Sheikh H, Vogel J, Austin EB, Upadhye S, Klaiman M, Vellend R, Munkley A, Carpenter CR. | Acad Emerg Med. 2024 May;31(5):425-455
DOI: https://doi.org/10.1111/acem.14911  | Télécharger l'article au format  
Keywords: acamprosate; alcohol; alcohol use disorder; alcohol withdrawal syndrome; cannabinoid hyperemesis; cannabinoid hyperemesis syndrome; cannabis; capsaicin; droperidol; gabapentin; haloperidol; naltrexone; phenobarbital.

GRACE CLINICAL PRACTICE GUIDELINE

Editorial : The fourth Society for Academic Emergency Medicine (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) is on the topic of the emergency department (ED) management of nonopioid use disorders and focuses on alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS). The SAEM GRACE-4 Writing Team, composed of emergency physicians and experts in addiction medicine and patients with lived experience, applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding six priority questions for adult ED patients with AWS, AUD, and CHS. The SAEM GRACE-4 Writing Team reached the following recommendations: (1) in adult ED patients (over the age of 18) with moderate to severe AWS who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone [low to very low certainty of evidence]; (2) in adult ED patients (over the age of 18) with AUD who desire alcohol cessation, we suggest a prescription for one anticraving medication [very low certainty of evidence]; (2a) in adult ED patients (over the age of 18) with AUD, we suggest naltrexone (compared to no prescription) to prevent return to heavy drinking [low certainty of evidence]; (2b) in adult ED patients (over the age of 18) with AUD and contraindications to naltrexone, we suggest acamprosate (compared to no prescription) to prevent return to heavy drinking and/or to reduce heavy drinking [low certainty of evidence]; (2c) in adult ED patients (over the age of 18) with AUD, we suggest gabapentin (compared to no prescription) for the management of AUD to reduce heavy drinking days and improve alcohol withdrawal symptoms [very low certainty of evidence]; (3a) in adult ED patients (over the age of 18) presenting to the ED with CHS we suggest the use of haloperidol or droperidol (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence]; and (3b) in adult ED patients (over the age of 18) presenting to the ED with CHS, we also suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence].

Conclusion : There is no high-quality evidence to inform the care of patients with alcohol withdrawal syndrome, alcohol use disorder, and cannabinoid hyperemesis syndrome in the ED setting. Nonetheless, low- to very-low-quality evidence does exist upon which SAEM GRACE-4 bases recommendations for management of alcohol withdrawal syndrome, alcohol use disorder, and cannabinoid hyperemesis syndrome in ED settings. Development and standardization of key outcomes of interest will inform improvements in the care of these patients in the ED. Research that rigorously revaluates the recommendations provided in this article are required to direct care in the ED. While we await high-quality evidence to guide practice, the GRACE-4 Writing Team strongly recommends that all ED patients with substance use disorders be offered brief ED substance use disorder interventions and referral to psychosocial support services/outpatient referrals to community services where such services are available.

Conclusion (proposition de traduction) : Il n'existe pas de données probantes de haute qualité pour guider la prise en charge des patients présentant un syndrome de sevrage alcoolique, un trouble lié à la consommation d'alcool ou un syndrome d'hyperémèse cannabinoïde dans le contexte des urgences. Néanmoins, il existe des données de qualité faible à très faible sur lesquelles SAEM GRACE-4 fonde ses recommandations pour la prise en charge du syndrome de sevrage alcoolique, du trouble lié à la consommation d'alcool et du syndrome d'hyperémèse cannabinoïde dans le contexte des urgences. Le développement et la normalisation des principaux résultats intéressants permettront d'améliorer la prise en charge de ces patients aux urgences. Des recherches qui réévaluent rigoureusement les recommandations formulées dans cet article sont nécessaires pour orienter les soins aux urgences. Dans l'attente de données probantes de haute qualité pour guider la pratique, l'équipe de rédaction de GRACE-4 recommande vivement que tous les patients des urgences présentant des troubles liés à l'utilisation de substances se voient proposer des interventions brèves en matière de troubles liés à l'utilisation de substances et soient orientés vers des services de soutien psychosocial ou vers des services communautaires lorsque de tels services sont disponibles.

Carbazochrome sodium sulfonate and tranexamic acid combination therapy to reduce blood transfusions after 24 h of injury: A retrospective study.
Nagasawa H, Omori K, Ota S, Muramatsu KI, Takeuchi I, Ohsaka H, Yanagawa Y. | Acute Med Surg. 2024 May 6;11(1):e961
DOI: https://doi.org/10.1002/ams2.961  | Télécharger l'article au format  
Keywords: blood transfusions; carbazochrome sodium sulfonate; hemorrhage; injury; tranexamic acid.

ORIGINAL ARTICLE

Introduction : Reducing the blood transfusion volume is important in severe trauma. We hypothesized that carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) would reduce blood transfusions in severe trauma.

Méthode : From April 2017 to March 2023, data were collected from patients (aged ≥16 years) admitted to our hospital for trauma and administered packed red blood cells (pRBC) and plasma transfusions within 12 h postinjury. Patients infused with CSS and TXA (CSS + TXA group) were compared with those infused with TXA alone (TXA group). The outcomes were blood product transfusion volumes within and after 24 h, the number of patients receiving >6 units of pRBC transfusion after 24 h, duration of intensive care unit and in-hospital stays, and 28-day in-hospital mortality.

Résultats : In total, 138 patients were included in the study. In the univariate analyses, the CSS + TXA group (n = 62) showed a significant reduction in the total pRBC transfusion volume, in-hospital days, and number of patients receiving >6 units of pRBCs in the delayed phase. Based on the multivariate logistics regression analysis, only the CSS + TXA group had a significantly lower adjusted odds ratio for receiving >6 units of pRBC transfusion after 24 h. During the in-hospital days, the CSS + TXA group did not experience an increased incidence of major complications when compared with the TXA group.

Conclusion : In patients with trauma, treatment with CSS with TXA may reduce the requirement for blood transfusion after 24 h. Moreover, this treatment can improve admission outcomes without increasing complications.

Conclusion (proposition de traduction) : Chez les patients victimes d'un traumatisme, le traitement par CSS et TXA peut réduire la nécessité d'une transfusion sanguine après 24 heures. De plus, ce traitement peut améliorer les suites au cours de leur hospitalisation sans augmenter les complications (ndlr : thromboembolique).

Commentaire : Carbazochrome Sodium Sulfonate
Nom commercial : Adrenoxyl (laboratoires Sanofi-Synthélabo France)
Produit non commercialisé à ce jour (disponible uniquement pour la recherche).
Vendu en conditionnement de 50 mg/10 ml, solution injectable pour perfusion à diluer, au prix de 205.00 €.
C'est un stabilisateur capillaire utilisé dans le traitement clinique des hémorragies en raison de l'augmentation de la perméabilité capillaire. Il semble améliorer la contraction des extrémités endommagées des capillaires, en augmentant la résistance capillaire et inversant le dysfonctionnement de la barrière endothéliale. Son mécanisme d'action n'est pas entièrement élucidé.
Plusieurs études ont étudié ses effets combinée à l'acide tranexamique, notamment en chirurgie orthopédique, mais aussi en urologie, en ORL…

Voir d'autres articles sur le thème :
• Luo Y, Releken Y, Yang D and al. Effects of carbazochrome sodium sulfonate combined with tranexamic acid on hemostasis and inflammation during perioperative period of total hip arthroplasty: A randomized controlled trial. Orthop Traumatol Surg Res. 2022 Feb;108(1):103092  .
• Okazaki Y, Takada H, Okada I, Hasegawa E. Effect of Carbazochrome Sodium Sulfonate in Addition to Tranexamic Acid in Bleeding Trauma Patients. Cureus. 2022 Feb 8;14(2):e22018  .

Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport.
Olvera DJ, Lauria M, Norman J, Gothard MD, Gothard AD, Weir WB. | Air Med J. 2024 May;43(3):241-247
DOI: https://doi.org/10.1016/j.amj.2023.12.010  | Télécharger l'article au format  
Keywords: Aucun

https://www.airmedicaljournal.com/action/showPdf?pii=S1067-9

Introduction : Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit.

Méthode : This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist.

Résultats : Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation.

Conclusion : The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.

Conclusion (proposition de traduction) : La mise en œuvre d'une checklist standardisée pour l'intubation en séquence rapide a permis une meilleure identification des facteurs dissuasifs, permettant des actions efficaces et précises favorisant la réussite au premier essai. Nos données suggèrent que lorsqu'une difficulté de gestion des voies aériennes est identifiée, l'utilisation de la checklist pour l'intubation en séquence rapide améliore la réussite du premier essai, réduisant ainsi les événements indésirables.

Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial.
Nguyen T, Mai M, Choudhary A, Gitelman S, Drapkin J, Likourezos A, Kabariti S, Hossain R, Kun K, Gohel A, Niceforo P, Silver M, Motov S. | Ann Emerg Med. 2024 May 2:S0196-0644(24)00171-9
DOI: https://doi.org/10.1016/j.annemergmed.2024.03.024
Keywords: Aucun

PAIN MANAGEMENT AND SEDATION/ORIGINAL RESEARCH

Introduction : We aimed to assess and compare the analgesic efficacy and adverse effects of intravenous subdissociative-dose ketamine to nebulized ketamine in emergency department (ED) patients with acute painful conditions.

Méthode : We conducted a prospective, randomized, double-blind, double-dummy clinical trial in adult patients (ages 18 and older) with a numerical rating scale pain score of ≥5. We randomized subjects to receive either a single dose of 0.3 mg/kg of intravenous (IV) ketamine or 0.75 mg/kg of nebulized ketamine through a breath-actuated nebulizer. Primary outcome was the difference in pain scores on the numerical rating scale between groups at 30 minutes postmedication administration. The secondary outcomes included the need for rescue analgesia, occurrences of adverse events in each group, and the difference in pain scores at 15, 30, 60, 90, and 120 minutes. We calculated a 95% confidence interval (CI) for a mean difference at 30 minutes, with a minimum clinically important difference set at 1.3 points.

Résultats : We enrolled 150 subjects (75 per group). Mean pain scores through numerical rating scale were 8.2 for both groups at baseline, which decreased to 3.6 and 3.8 at 30 minutes, yielding a mean difference of 0.23 (95% CI -1.32 to 0.857). We observed no clinically concerning changes in vital signs. No serious adverse events occurred in any of the groups throughout the study period.

Conclusion : We found no difference between the administration of IV and nebulized ketamine for the short-term treatment of moderate to severe acute pain in the ED, with both treatments providing a clinically meaningful reduction in pain scores at 30 minutes.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune différence entre l'administration de kétamine par voie intraveineuse et par nébulisation pour le traitement à court terme de la douleur aiguë modérée à sévère aux urgences, les deux traitements apportant une réduction cliniquement significative des scores de douleur après 30 minutes.

Tranexamic Acid for Traumatic Injury in the Emergency Setting: A Systematic Review and Bias-Adjusted Meta-Analysis of Randomized Controlled Trials.
Fouche PF, Stein C, Nichols M, Meadley B, Bendall JC, Smith K, Anderson D, Doi SA. | Ann Emerg Med. 2024 May;83(5):435-445
DOI: https://doi.org/10.1016/j.annemergmed.2023.10.004  | Télécharger l'article au format  
Keywords: Aucun

TRAUMA/SYSTEMATIC REVIEW/META-ANALYSIS

Introduction : Traumatic injury causes a significant number of deaths due to bleeding. Tranexamic acid (TXA), an antifibrinolytic agent, can reduce bleeding in traumatic injuries and potentially enhance outcomes. Previous reviews suggested potential TXA benefits but did not consider the latest trials.

Méthode : A systematic review and bias-adjusted meta-analysis were performed to assess TXA's effectiveness in emergency traumatic injury settings by pooling estimates from randomized controlled trials. Researchers searched Medline, Embase, and Cochrane Central for randomized controlled trials comparing TXA's effects to a placebo in emergency trauma cases. The primary endpoint was 1-month mortality. The methodological quality of the trials underwent assessment using the MASTER scale, and the meta-analysis applied the quality-effects method to adjust for methodological quality.

Résultats : Seven randomized controlled trials met the set criteria. This meta-analysis indicated an 11% decrease in the death risk at 1 month after TXA use (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84 to 0.95) with a number needed to treat of 61 to avoid 1 additional death. The meta-analysis also revealed reduced 24-hour mortality (OR 0.76, 95% CI 0.65 to 0.88) for TXA. No compelling evidence of increased vascular occlusive events emerged (OR 0.96, 95% CI 0.73 to 1.27). Subgroup analyses highlighted TXA's effectiveness in general trauma versus traumatic brain injury and survival advantages when administered out-of-hospital versus inhospital.

Conclusion : This synthesis demonstrates that TXA use for trauma in emergencies leads to a reduction in 1-month mortality, with no significant evidence of problematic vascular occlusive events. Administering TXA in the out-of-hospital setting is associated with reduced mortality compared to inhospital administration, and less mortality with TXA in systemic trauma is noted compared with traumatic brain injury specifically.

Conclusion (proposition de traduction) : Cette synthèse démontre que l'utilisation de l'acide tranexamique en cas de traumatisme en situation d'urgence entraîne une réduction de la mortalité à un mois, sans qu'il y ait de preuves significatives d'événements occlusifs vasculaires problématiques. L'administration d'acide tranexamique en dehors de l'hôpital est associée à une réduction de la mortalité par rapport à l'administration en milieu hospitalier, et l'acide tranexamique entraîne une réduction de la mortalité dans les traumatismes généralisés par rapport aux lésions cérébrales traumatiques.

External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness.
Pruitt P, Castillo R, Rogers A, Prabhakaran S, Muschong K, Scudder M, McCarthy DM, Holl JL, Courtney DM, Borczuk P, Naidech A. | Ann Emerg Med. 2024 May;83(5):421-431
DOI: https://doi.org/10.1016/j.annemergmed.2023.08.481  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : The SafeSDH Tool was derived to identify patients with isolated (no other type of intracranial hemorrhage) subdural hematoma who are at very low risk of neurologic deterioration, neurosurgical intervention, or death. Patients are low risk by the tool if they have none of the following: use of anticoagulant or nonaspirin antiplatelet agent, Glasgow Coma Score (GCS) <14, more than 1 discrete hematoma, hematoma thickness >5 mm, or midline shift. We attempted to externally validate the SafeSDH Tool.

Méthode : We performed a retrospective chart review of patients aged ≥16 with a GCS ≥13 and isolated subdural hematoma who presented to 1 of 6 academic and community hospitals from 2005 to 2018. The primary outcome, a composite of neurologic deterioration (seizure, altered mental status, or symptoms requiring repeat imaging), neurosurgical intervention, discharge on hospice, and death, was abstracted from discharge summaries. Hematoma thickness, number of hematomas, and midline shift were abstracted from head imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record.

Résultats : The validation data set included 753 patients with isolated subdural hematoma. Mortality during the index admission was 2.1%; 26% of patients underwent neurosurgical intervention. For the composite outcome, sensitivity was 99% (95% confidence interval [CI] 97 to 100), and specificity was 31% (95% CI 27 to 35). The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11).

Conclusion : The SafeSDH Tool identified patients with isolated subdural hematoma who are at low risk for poor outcomes with high sensitivity. With prospective validation, these low-risk patients could be safe for management in less intensive settings.

Conclusion (proposition de traduction) : L'outil SafeSDH a permis d'identifier avec une grande sensibilité les patients présentant un hématome sous-dural isolé et à faible risque d'évolution défavorable. Avec une validation prospective, ces patients à faible risque pourraient être pris en charge en toute sécurité dans des environnements moins intensifs.

Commentaire : Les patients sont considérés à faible risque par l'outil SafeSDH s'ils ne présentent aucune des caractéristiques suivantes :
utilisation d'un anticoagulant ou d'un antiplaquettaire sans aspirine, Glasgow Coma Score (GCS) < 14, plus d'un hématome discret, épaisseur de l'hématome > 5 mm, ou déplacement de la ligne médiane.

Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines From the American College of Emergency Physicians.
Green SM, Tomaszewski C, Valente JH, Lo B, Milne K. | Ann Emerg Med. 2024 May;83(5):477-489
DOI: https://doi.org/10.1016/j.annemergmed.2024.01.004  | Télécharger l'article au format  
Keywords: Aucun

General Medicine

Editorial : The management of corneal abrasions has largely excluded dispensing topical local anesthetics for home use due to concern for corneal toxicity. We have reviewed and critically appraised the available literature evidence regarding the use of topical anesthetics in patients with simple corneal abrasions. Using sequential Delphi review, we have developed these clinical guidelines. Herein are evidentiary summaries and consensus recommendations for 8 specific relevant questions. Our key observation is that for only simple corneal abrasions, as diagnosed and treated in accordance with the full protocol described herein, it appears safe to prescribe or otherwise provide a commercial topical anesthetic (ie, proparacaine, tetracaine, oxybuprocaine) for use up to every 30 minutes as needed during the first 24 hours after presentation, as long as no more than 1.5 to 2 mL total (an expected 24-hour supply) is dispensed and any remainder is discarded after 24 hours. Importantly, although published findings suggest absent harm for short courses, more rigorous studies with a greater cumulative sample size and ophthalmologic follow-up are needed.

Conclusion : Due to concerns regarding potential patient harm, the American Academy of Ophthalmology (AAO) approached the American College of Emergency Physicians (ACEP) with the request to jointly issue guidelines regarding the use of topical anesthetics following a corneal abrasion. Accordingly, a combined workgroup was assembled to review and critically appraise the peer-reviewed literature regarding the benefits and harms of topical anesthetics for home use in the treatment of corneal abrasions as well as to appraise alternative analgesic therapies in this setting.

Conclusion (proposition de traduction) : En raison de craintes concernant les dommages potentiels pour les patients, l'American Academy of Ophthalmology (AAO) a demandé à l'American College of Emergency Physicians (ACEP) de publier conjointement des lignes directrices concernant l'utilisation d'anesthésiques topiques après une érosion cornéenne. En conséquence, un groupe de travail mixte a été constitué pour examiner et évaluer de manière critique la littérature évaluée par les pairs concernant les avantages et les inconvénients des anesthésiques topiques à utiliser à domicile dans le traitement des abrasions cornéennes, ainsi que pour évaluer les traitements analgésiques alternatifs dans ce contexte.

Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness.
Edlow JA, Bellolio F. | Ann Emerg Med. 2024 May 23:S0196-0644(24)00214-2
DOI: https://doi.org/10.1016/j.annemergmed.2024.04.006  | Télécharger l'article au format  
Keywords: Aucun

Neurology/concepts

Editorial : Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack. Because these patients are, by definition, asymptomatic without new neurologic findings on examination, the diagnosis, largely based on history and epidemiologic context, can be challenging. We review literature that addresses the frequency of posterior circulation transient ischemic attack in this group of patients compared with other potential causes of episodic vestibular syndrome. We present ways of distinguishing posterior circulation transient ischemic attack from vestibular migraine, the most common cause of episodic vestibular syndrome. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.

Conclusion : Diagnosing patients with acute episodic dizziness in the ED is challenging. Focused research in this area is needed. To improve identification of posterior circulation transient ischemic attacks presenting with isolated dizziness, we need to better learn to diagnose mimics more accurately and, when they are unlikely, to consider posterior circulation transient ischemic attack, then look for it. If we only look for hay, we will never find the needle in the haystack.

Conclusion (proposition de traduction) : Le diagnostic des patients souffrant de vertiges épisodiques aigus aux urgences est difficile. Des recherches ciblées dans ce domaine sont nécessaires. Pour améliorer l'identification des accidents ischémiques transitoires de la circulation postérieure se manifestant par des vertiges isolés, nous devons apprendre à diagnostiquer plus précisément les symptômes mimétiques et, lorsqu'ils sont peu probables, à envisager un accident ischémique transitoire de la circulation postérieure, puis à le rechercher. Si nous ne cherchons que le foin, nous ne trouverons jamais l'aiguille dans la botte de foin.

Commentaire :  Critères 2022 de diagnostic de la migraine vestibulaire

Variables cliniques permettant de distinguer la migraine vestibulaire de l'accident ischémique transitoire de la circulation postérieure.

Cet algorithme s'applique aux patients qui présentent des épisodes de vertiges, qui sont actuellement asymptomatiques et dont l'examen neurologique est normal (ou de référence) au moment de l'évaluation.

Performance of Febrile Infant Algorithms by Duration of Fever.
Velasco R, Gomez B, Labiano I, Mier A, Ugedo A, Benito J, Mintegi S. | Pediatrics. 2024 May 1;153(5):e2023064342
DOI: https://doi.org/10.1542/peds.2023-064342
Keywords: Aucun

ARTICLE

Introduction : To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever.

Méthode : We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants ≤90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules.

Résultats : We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively.

Conclusion : The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules.

Conclusion (proposition de traduction) : La performance des biomarqueurs sanguins, à l'exception de la procalcitonine, chez les jeunes nourrissons fébriles est plus faible en cas de fièvre de très courte durée, ce qui diminue la précision des règles de décision clinique.

The impact of alternate defibrillation strategies on shock-refractory and recurrent ventricular fibrillation: A secondary analysis of the DOSE VF cluster randomized controlled trial.
Cheskes S, Drennan IR, Turner L, Pandit SV, Dorian P. | Resuscitation. 2024 May;198:110186
DOI: https://doi.org/10.1016/j.resuscitation.2024.110186  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Defibrillation; Double sequential external defibrillation; Recurrent VF; Refractory VF; Resuscitation; Vector change defibrillation.

CLINICAL PAPER

Introduction : The DOSE VF randomized controlled trial (RCT) employed a pragmatic definition of refractory ventricular fibrillation (VF after three successive shocks). However, it remains unclear whether the underlying rhythm during the first three shocks was shock-refractory or recurrent VF.

Méthode : To explore the relationship between alternate defibrillation strategies employed during the DOSE VF RCT and the type of VF, either shock-refractory VF or recurrent VF, on patient outcomes.
We performed a secondary analysis of the DOSE VF RCT. We categorized cases as shock-refractory or recurrent VF based on pre-randomization shocks (shocks 1-3). We then analyzed all subsequent (post-randomization) shocks to assess the impact of standard, vector change (VC) or double sequential external defibrillation (DSED) shocks on clinical outcomes employing logistic regression adjusted for Utstein variables, antiarrhythmics, and epinephrine.

Résultats : We included 345 patients; 60 (17%) shock-refractory VF, and 285 (83%) recurrent VF. Patients in recurrent VF had greater survival than shock-refractory VF (OR: 2.76 95% CI [1.04, 7.27]). DSED was superior to standard defibrillation for survival overall, and for patients with shock-refractory VF (28.6% vs 0%, p = 0.041) but not for those in recurrent VF. DSED was superior to standard defibrillation for return of spontaneous circulation (ROSC) and neurologic survival for shock-refractory and recurrent VF. VC defibrillation was not superior for survival or ROSC overall, for shock-refractory, or recurrent VF groups, but was superior for VF termination across all groups.

Conclusion : DSED appears to be the superior defibrillation strategy in the DOSE VF trial, irrespective of whether the preceding VF is shock-refractory or recurrent.

Conclusion (proposition de traduction) : La défibrillation double séquence semble être la stratégie de défibrillation supérieure dans l'essai DOSE VF, que la FV soit réfractaire au choc ou récidivante.

Commentaire : Cette analyse secondaire de l'essai DOSE VF a montré que la défibrillation double séquence (DDS) était la meilleure stratégie pour obtenir une réanimation et un résultat neurologique fonctionnel, que le patient soit en FV récidivante ou réfractaire aux chocs, après trois chocs de défibrillation standard.

Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants.
Geraghty LE, Dunne EA, Ní Chathasaigh CM, Vellinga A, Adams NC, O'Currain EM, McCarthy LK, O'Donnell CPF. | N Engl J Med. 2024 May 30;390(20):1885-1894
DOI: https://doi.org/10.1056/nejmoa2402785
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Repeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain.

Méthode : In this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection.

Résultats : Data were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively.

Conclusion : Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy.

Conclusion (proposition de traduction) : Parmi les nouveau-nés devant bénéficier d'une intubation endotrachéale en urgence, la vidéolaryngoscopie a permis un plus grand nombre d'intubations réussies dès la première tentative par rapport à la laryngoscopie directe.

Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke.
Li G, Lin Y, Yang J, Anderson CS, Chen C, Liu F, Billot L, Li Q, Chen X, Liu X, Ren X, Zhang C, Xu P, Wu L, Wang F, Qiu D, Jiang M, Peng Y, Li C, Huang Y, Zhao X, Liang J, Wang Y, Wu X, Xu X, Chen G, Huang D, Zhang Y, Zuo L, Ma G, Yang Y, Hao J, Xu X, Xiong X, Tang Y, Guo Y, Yu J, Li S, He S, Mao F, Tan Q, Tan S, Yu N, Xu R, Sun M, Li B, Guo J, Liu L, Liu H, Ouyang M, Si L, Arima H, Bath PM, Ford GA, Robinson T, Sandset EC, Saver JL, Sprigg N, van der. | N Engl J Med. 2024 May 30;390(20):1862-1872
DOI: https://doi.org/10.1056/nejmoa2314741
Keywords: Aucun

Original Article

Introduction : Treatment of acute stroke, before a distinction can be made between ischemic and hemorrhagic types, is challenging. Whether very early blood-pressure control in the ambulance improves outcomes among patients with undifferentiated acute stroke is uncertain.

Méthode : We randomly assigned patients with suspected acute stroke that caused a motor deficit and with elevated systolic blood pressure (≥150 mm Hg), who were assessed in the ambulance within 2 hours after the onset of symptoms, to receive immediate treatment to lower the systolic blood pressure (target range, 130 to 140 mm Hg) (intervention group) or usual blood-pressure management (usual-care group). The primary efficacy outcome was functional status as assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days after randomization. The primary safety outcome was any serious adverse event.

Résultats : A total of 2404 patients (mean age, 70 years) in China underwent randomization and provided consent for the trial: 1205 in the intervention group and 1199 in the usual-care group. The median time between symptom onset and randomization was 61 minutes (interquartile range, 41 to 93), and the mean blood pressure at randomization was 178/98 mm Hg. Stroke was subsequently confirmed by imaging in 2240 patients, of whom 1041 (46.5%) had a hemorrhagic stroke. At the time of patients' arrival at the hospital, the mean systolic blood pressure in the intervention group was 159 mm Hg, as compared with 170 mm Hg in the usual-care group. Overall, there was no difference in functional outcome between the two groups (common odds ratio, 1.00; 95% confidence interval [CI], 0.87 to 1.15), and the incidence of serious adverse events was similar in the two groups. Prehospital reduction of blood pressure was associated with a decrease in the odds of a poor functional outcome among patients with hemorrhagic stroke (common odds ratio, 0.75; 95% CI, 0.60 to 0.92) but an increase among patients with cerebral ischemia (common odds ratio, 1.30; 95% CI, 1.06 to 1.60).

Conclusion : In this trial, prehospital blood-pressure reduction did not improve functional outcomes in a cohort of patients with undifferentiated acute stroke, of whom 46.5% subsequently received a diagnosis of hemorrhagic stroke.

Conclusion (proposition de traduction) : Dans cet essai, la réduction préhospitalière de la pression artérielle n'a pas amélioré les résultats fonctionnels d'une cohorte de patients ayant présenté un AVC aigu indifférencié, dont 46,5 % ont fait l'objet d'un diagnostic d'AVC hémorragique par la suite.

Commentaire : Cela confirme bien qu'avant de traiter un AVC, il faut faire une imagerie médicale.
Introduction à l'article : Le traitement de l'AVC aigu, avant qu'une distinction puisse être faite entre les types ischémique et hémorragique, est un défi. Il n'est pas certain qu'un contrôle très précoce de la pression artérielle dans l'ambulance améliore les résultats chez les patients souffrant d'un AVC aigu indifférencié.

Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage.
Connolly SJ, Sharma M, Cohen AT, Demchuk AM, Członkowska A, Lindgren AG, Molina CA, Bereczki D, Toni D, Seiffge DJ, Tanne D, Sandset EC, Tsivgoulis G, Christensen H, Beyer-Westendorf J, Coutinho JM, Crowther M, Verhamme P, Amarenco P, Roine RO, Mikulik R, Lemmens R, Veltkamp R, Middeldorp S, Robinson TG, Milling TJ Jr, Tedim-Cruz V, Lang W, Himmelmann A, Ladenvall P, Knutsson M, Ekholm E, Law A, Taylor A, Karyakina T, Xu L, Tsiplova K, Poli S, Kallmünzer B, . | N Engl J Med. 2024 May 16;390(19):1745-1755
DOI: https://doi.org/10.1056/nejmoa2313040
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Patients with acute intracerebral hemorrhage who are receiving factor Xa inhibitors have a risk of hematoma expansion. The effect of andexanet alfa, an agent that reverses the effects of factor Xa inhibitors, on hematoma volume expansion has not been well studied.

Méthode : We randomly assigned, in a 1:1 ratio, patients who had taken factor Xa inhibitors within 15 hours before having an acute intracerebral hemorrhage to receive andexanet or usual care. The primary end point was hemostatic efficacy, defined by expansion of the hematoma volume by 35% or less at 12 hours after baseline, an increase in the score on the National Institutes of Health Stroke Scale of less than 7 points (scores range from 0 to 42, with higher scores indicating worse neurologic deficit) at 12 hours, and no receipt of rescue therapy between 3 hours and 12 hours. Safety end points were thrombotic events and death.

Résultats : A total of 263 patients were assigned to receive andexanet, and 267 to receive usual care. Efficacy was assessed in an interim analysis that included 452 patients, and safety was analyzed in all 530 enrolled patients. Atrial fibrillation was the most common indication for factor Xa inhibitors. Of the patients receiving usual care, 85.5% received prothrombin complex concentrate. Hemostatic efficacy was achieved in 150 of 224 patients (67.0%) receiving andexanet and in 121 of 228 (53.1%) receiving usual care (adjusted difference, 13.4 percentage points; 95% confidence interval [CI], 4.6 to 22.2; P = 0.003). The median reduction from baseline to the 1-to-2-hour nadir in anti-factor Xa activity was 94.5% with andexanet and 26.9% with usual care (P<0.001). Thrombotic events occurred in 27 of 263 patients (10.3%) receiving andexanet and in 15 of 267 (5.6%) receiving usual care (difference, 4.6 percentage points; 95% CI, 0.1 to 9.2; P = 0.048); ischemic stroke occurred in 17 patients (6.5%) and 4 patients (1.5%), respectively. There were no appreciable differences between the groups in the score on the modified Rankin scale or in death within 30 days.

Conclusion : Among patients with intracerebral hemorrhage who were receiving factor Xa inhibitors, andexanet resulted in better control of hematoma expansion than usual care but was associated with thrombotic events, including ischemic stroke.

Conclusion (proposition de traduction) : Chez les patients présentant une hémorragie intracérébrale et traités par un inhibiteur du facteur Xa, l'andexanet a permis de mieux contrôler l'expansion de l'hématome que les traitements habituels, mais il était associé à des événements thrombotiques, y compris des accidents vasculaires cérébraux ischémiques.