Conflict in emergency medicine: A systematic review.
Tjan TE, Wong LY, Rixon A. | Acad Emerg Med. 2024 Jun;31(6):538-546
DOI: https://doi.org/10.1111/acem.14874  | Télécharger l'article au format  
Keywords: communication; conflict; consultations; emergency department.

Original article

Introduction : The emergency department (ED) is a demanding and time-pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual-, team-, and systemic-level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research.

Méthode : Online databases PubMed and Web of Science were systematically searched for relevant peer-reviewed journal articles in English with keywords relating to "conflict" and "emergency department," yielding a total of 29 articles.

Résultats : Narrative analysis showed that conflict often occurred during referrals or admissions from ED to inpatient or admitting units. Individual-level contributors to conflict include a lack of trust in ED workup and staff inexperience. Team-level contributors include perceptions of bias between groups, patient complexity, communication errors, and difference in practice. Systems-level contributors include high workload/time pressures, ambiguities around patient responsibility, power imbalances, and workplace culture. Among identified solutions to mitigate conflict are better communication training, standardizing admission guidelines, and improving interdepartmental relationships.

Conclusion : In emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.

Conclusion (proposition de traduction) : En médecine d'urgence, les conflits sont fréquents et se produisent à plusieurs niveaux, reflétant l'interface complexe des tâches et des relations au sein du service des urgences.

Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis.
Schoenfeld DW, Rosen CL, Harris T, Thomas SH. | Acad Emerg Med. 2024 Jun;31(6):590-598
DOI: https://doi.org/10.1111/acem.14882  | Télécharger l'article au format  
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products.

Méthode : The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified.

Résultats : In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I² = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19).

Conclusion : Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

Conclusion (proposition de traduction) : Les données actuelles ne démontrent pas que la transfusion préhospitalière effectuée en milieu civil a un effet bénéfique sur la mortalité à un mois. Cela devrait faire réfléchir les systèmes de SMU qui envisagent d'adopter des programmes de transfusion préhospitalière en milieu civil. D'autres études devraient non seulement se concentrer sur les formulations de produits sanguins susceptibles d'améliorer les résultats, mais aussi sur les patients les plus susceptibles de bénéficier de toute forme de transfusion préhospitalière en milieu civil.

The timing of death in burn patients.
Yoneda K, Osuka A, Ohnishi S, Matsuura H, Oda J. | Acute Med Surg. 2024 Jun 27;11(1):e970
DOI: https://doi.org/10.1002/ams2.970  | Télécharger l'article au format  
Keywords: burn; elderly; mortality; persistent inflammation immunosuppression and catabolism syndrome.

ORIGINAL ARTICLE

Introduction : When treating burn patients, some patients die in the chronic phase, even if they overcome the acute phase of the burn. To elucidate the timing of death and its underlying causes among burn patients.

Méthode : Patients evaluated were admitted to our burn center between January 2015, and December 2019. Patient information, time, and cause of death were retrospectively collected from their medical records.

Résultats : Among 342 admitted patients, 49 died. The time of death was as follows: within 24 h (n = 9), within 3 days (n = 7), within 1 week (n = 5), within 2 weeks (n = 4), within 3 weeks (n = 3), within 30 days (n = 6), within 60 days (n = 5), and after 60 days (n = 9). The causes of death within 3 days were hypoxic encephalopathy, extensive burns (>80%), severe heat stroke, and acute coronary syndrome. The causes of death after 3 days were sepsis, pneumonia, intestinal ischemia, pancreatitis, and worsening of chronic diseases. The mortality rate was similar for patients ≥65 years of age and those with a burn area of ≥20%, with both groups showing a particularly poor prognosis.

Conclusion : The timing of death in hospitalized burn patients showed a bimodal distribution as approximately 40% of patients who survived the resuscitation period died after 30 days. Elderly patients were at particularly high risk for mortality. In burn care, treatment planning should consider not only the short-term but also the long-term prognosis.

Conclusion (proposition de traduction) : Le moment du décès chez les patients brûlés hospitalisés a montré une distribution bimodale, car environ 40% des patients qui ont survécu à la période de réanimation sont décédés après 30 jours. Les patients âgés présentaient un risque de mortalité particulièrement élevé. Dans les soins aux brûlés, la planification du traitement doit tenir compte non seulement du pronostic à court terme, mais aussi du pronostic à long terme.

Guidance for clinical practice using emergency and point-of-care ultrasonography.
Kameda T, Ishii H, Oya S, Katabami K, Kodama T, Sera M, Takei H, Taniguchi H, Nakao S, Funakoshi H, Yamaga S, Senoo S, Kimura A. | Acute Med Surg. 2024 Jun 26;11(1):e974
DOI: https://doi.org/10.1002/ams2.974  | Télécharger l'article au format  
Keywords: acute care physician; core items; ultrasound education.

REVIEW ARTICLE

Editorial : Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned.

Conclusion : This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Conclusion (proposition de traduction) : Ce guide décrit la vue d'ensemble et l'orientation future de l'échographie pour les médecins de soins aigus et peut être utilisé pour la formation à l'échographie d'urgence. Nous espérons que ce guide contribuera à l'utilisation efficace de l'échographie dans les établissements de soins aigus au Japon.

Commentaire :  Schéma de l'échographie au point de service basé sur la méthodologie clinique ABC (airway, breathing, and circulation).
ECMO, oxygénation par membrane extracorporelle ; IVC, veine cave inférieure ; REBOA, occlusion endovasculaire de l'aorte par ballonnet.

The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis.
Raghubeer N, Lahri S, Hendrikse C. | Afr J Emerg Med. 2024 Jun;14(2):65-69
DOI: https://doi.org/10.1016/j.afjem.2024.01.004  | Télécharger l'article au format  
Keywords: ECG/electrocardiography; Emergency centre; LMIC; Mortality; Pulmonary embolism.

ABBREVIATED PAPER

Introduction : Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram.

Méthode : This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality.

Résultats : Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality.

Conclusion : Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.

Conclusion (proposition de traduction) : L'identification précoce des patients atteints d'embolie pulmonaire présentant un risque élevé de détérioration clinique et de mortalité hospitalière reste un défi. Bien qu'aucun résultat clinique ou outil de prédiction isolé ne puisse prédire de manière fiable les résultats chez les patients atteints d'embolie pulmonaire, cette étude a mis en évidence deux résultats d'ECG à la présentation qui étaient associés à une probabilité plus élevée de mortalité chez les patients hospitalisés. Cette étude observationnelle unicentrique avec un petit échantillon ne permet pas de tirer des conclusions concrètes et une étude multicentrique de suivi à grande échelle est conseillée.

Commentaire : Cette étude a identifié deux caractéristiques ECG associées à une mortalité accrue chez les patients hospitalisés : la déviation de l'axe droit et un bloc de branche droit complet, avec un risque respectivement 5,6 et 1,2 fois plus élevé chez les patients qui n'ont pas survécu jusqu'à la sortie de l'hôpital.
Ces modifications de l'ECG reflètent le dysfonctionnement du ventricule droit chez les patients présentant une charge de caillots importante et il a été démontré qu'elles permettaient de prédire une issue moins favorable lorsqu'elles étaient présentes.
Par conséquent, les patients présentant une suspicion d'EP avec l'un de ces signes ECG pourraient nécessiter une surveillance et une prise en charge plus intensives.

Douillet D, Godon A, Rousseau G, Ruiz S, Bounes F, Maistre E De, et al.. | Ann. Fr. Med. Urgence. 2024 May 1;14(3):161–99.
DOI: https://www.jle.com/10.1684/afmu.2024.0588
Keywords: Aucun

RECOMMANDATION POUR LA PRATIQUE CLINIQUE

Editorial : En raison de l’augmentation de l’utilisation des anticoagulants dans la population ces dernières années, la prise en charge de ces patients est devenue une pratique quotidienne. Cela concerne majoritairement les patients âgés. Tous les traitements anticoagulants augmentent le risque hémorragique. Ces recommandations traitent de la prise en charge en contexte d’urgence des patients traités par anticoagulants, ce qui inclut l’identification biologique d’un traitement anticoagulant, la prise en charge des hémorragies, des surdosages asymptomatiques, des procédures invasives des patients traités par anticoagulants, ainsi que les indications de la thrombolyse en cas d’accident vasculaire cérébral ischémique. Ces recommandations concernent les anticoagulants oraux incluant les antivitamines K (AVK), les anticoagulants oraux directs (AOD) dont le dabigatran (AOD anti-IIa), le rivaroxaban, l’apixaban et l’edoxaban (AOD anti-Xa) ; et les anticoagulants parentéraux : héparines de bas poids moléculaire (HBPM), héparine non fractionnée (HNF) et fondaparinux. Ces recommandations n’abordent ni les anticoagulants utilisés de façon peu fréquente en milieu hospitalier (type : danaparoïde, argatroban...), ni les agents antiplaquettaires, ni la gestion des anticoagulants pour les gestes invasifs programmés (ex : endoscopie ou chirurgie programmée). Les indications et modalités d’anticoagulation à dose curative par pathologie ne sont pas reprises car ayant fait l’objet de recommandations spécifiques en fonction des indications.

Conclusion (proposition de traduction) : Le travail de synthèse des experts et l’application de la méthode GRADE ont abouti à 103 recommandations. Après 2 tours de cotation et quelques amendements, un accord fort a été obtenu pour 97 recommandations. Parmi ces recommandations, 19 ont un niveau de preuve élevé (19 GRADE 1), 35 ont un niveau de preuve modéré à faible (35 GRADE 2) et 48 sont des avis d’experts. Enfin, pour 1 question, aucune recommandation n’a pu être formulée. La SFMU, la SFAR, le GIHP, la SFTH incitent tous les méde- cins urgentistes, anesthésistes-réanimateurs et les biolo- gistes à se conformer à ces RFE pour optimiser la qualité des soins dispensés aux patients. Cependant, chaque praticien doit exercer son propre jugement dans l’application de ces recommandations, en prenant en compte son expertise et les spécificités de son établissement, pour déterminer la méthode d’intervention la mieux adaptée à l’état du patient dont il a la charge.

Preprocedural Oxygenation and Procedural Oxygenation During Pediatric Procedural Sedation: Patterns of Use and Association With Interventions.
Li J, Krauss B, Monuteaux MC, Cavallaro S, Fleegler E. | Ann Emerg Med. 2024 Jun 12:S0196-0644(24)00223-3. 2024 Jun 12:S0196-0644(24)00223-3
DOI: https://doi.org/10.1016/j.annemergmed.2024.04.014  | Télécharger l'article au format  
Keywords: Aucun

PEDIATRICS/ORIGINAL RESEARCH

Introduction : Preprocedural oxygenation (pre-emptive oxygenation started during presedation and/or induction) and procedural oxygenation (pre-emptive oxygenation started during any phase of sedation) are easy-to-use strategies with potential to decrease adverse events. Here, we describe practice patterns of preprocedural oxygenation and procedural oxygenation. We hypothesized that patients who received preprocedural oxygenation or procedural oxygenation would have a lower risk of airway/breathing/circulation interventions during sedation compared with patients without procedural oxygenation.

Méthode : We performed a retrospective, multicenter, cross-sectional study of pediatric sedations from April 2020 to July 2023 using the Pediatric Sedation Research Consortium multicenter database. The patient-level and sedation-level characteristics were described using frequencies and proportions, stratified by preprocedural oxygenation and procedural oxygenation status. We determined the site-level frequency of preprocedural oxygenation and procedural oxygenation use. We used inverse probability of treatment weighting to calculate the risk difference for interventions associated with preprocedural oxygenation and procedural oxygenation.

Résultats : This study included a total of 85,599 pediatric sedations; 43,242 (50.5%) patients received preprocedural oxygenation (used oxygen before sedation and/or at induction) and a total of 52,219 (61.0%) received procedural oxygenation pre-emptively at any time during the sedation. There was no statistical difference in overall interventions with either preprocedural oxygenation (risk difference -0.06%; 95% confidence interval -4.26% to 4.14%) or procedural oxygenation (risk difference -1.07%; 95% confidence interval -6.44% to 4.30%).

Conclusion : Pre-emptive preprocedural oxygenation and procedural oxygenation were not associated with a difference in the use of airway/breathing/circulation interventions in pediatric sedations.

Conclusion (proposition de traduction) : L'administration préventive d'un supplément d'oxygène avant la procédure et pendant la procédure n'ont pas été associées à une différence dans le recours à des interventions sur les voies respiratoires, la respiration et la circulation lors de sédations pédiatriques.

Managing Emergency Endotracheal Intubation Utilizing a Bougie.
Barnicle RN, Bracey A, Weingart SD. | Ann Emerg Med. 2024 Jun 22:S0196-0644(24)00232-4
DOI: https://doi.org/10.1016/j.annemergmed.2024.04.021
Keywords: Aucun

AIRWAY/EXPERT CLINICAL MANAGEMENT⁄ARTICLES IN PRESS

Editorial : The endotracheal tube (ETT) introducer, or “bougie,” is used to cannulate the trachea prior to ETT delivery using the Seldinger technique. In most emergency departments, the bougie is not incorporated into a primary intubation strategy and has historically been relegated to an adjunctive role or used as a rescue device for difficult airways. This may be due to inexperience with the optimized technique, difficulty troubleshooting bougie-related challenges, concern of procedure prolongation, or skepticism of its efficacy as a primary intubation device. However, recent literature has demonstrated the clear utility of a bougie-first strategy when combined with standard geometry laryngoscopy, while also underscoring the need for repetitive use in the pursuit of procedural mastery. In the largest trial in which operators did not have increased familiarity with the bougie, first-pass success with a bougie (80.4%) was not significantly different than with a stylet (83%). However, first-pass success for operators who predominantly utilize a bougie-first approach has been shown to be 96% when patients have difficult airway characteristics and 99% in those without difficult airways

Conclusion : A technical overview for the effective use of bougies during endotracheal intubation is presented here and serves as a foundational guide for trainees, educators, and physicians aiming to optimize bougie-related skill and strategy. Our intent is to provide a level of detail not explained in the literature previously, while recognizing that operators may still modify this foundational procedure and incorporate the bougie into various other advanced airway techniques. The following recommendations, when not specifically referenced, are based on our informed practice because there is a dearth of evidence regarding the specific microskills of bougie- assisted intubation.

Conclusion (proposition de traduction) : Nous présentons ici un aperçu technique de l'utilisation optimale des mandrins longs béquillés (bougie) pendant l'intubation endotrachéale. Il s'agit d'un guide de base pour les stagiaires, les éducateurs et les médecins qui cherchent à optimiser les compétences et les stratégies liées aux mandrins longs béquillés (bougies). Notre intention est de fournir un niveau de détail qui n'a pas été expliqué dans la littérature auparavant, tout en reconnaissant que les opérateurs peuvent encore modifier cette procédure de base et incorporer le mandrin long béquillé (bougie) dans diverses autres techniques avancées des voies aériennes. Les recommandations suivantes, lorsqu'elles ne sont pas spécifiquement référencées, sont basées sur notre pratique éclairée parce qu'il y a un manque de preuves concernant les micro-compétences spécifiques de l'intubation assistée à l'aide d'un mandrin long béquillé (bougie).

Commentaire : Pour mémoire :
• Bougie : introducteur de tube trachéal ou mandrin long béquillé, appelé également mandrin d'Eschmann
• stylet : Stylet ou mandrin court malléable

Risk factors for peri-intubation cardiac arrest: A systematic review and meta-analysis.
Yang TH, Shao SC, Lee YC, Hsiao CH, Yen CC. | Biomed J. 2024 Jun;47(3):100656
DOI: https://doi.org/10.1016/j.bj.2023.100656  | Télécharger l'article au format  
Keywords: Airway management; Cardiac arrest; Critical care; Endotracheal intubation; Peri-intubation cardiac arrest.

Original Article

Introduction : Peri-intubation cardiac arrest (PICA) is an uncommon yet serious complication of intubation. Although some associated risk factors have been identified, the results have been inconsistent. The aim of this study was to systematically review the relevant research and examine the associated risk factors of PICA through meta-analysis.

Méthode : Studies examining the risk factors for PICA before 1 Nov. 2022 were identified through searches in MEDLINE (OvidSP) and EMBASE. The reported adjusted or unadjusted odds ratios (ORs) and risk ratios (RRs) were recorded. We calculated pooled ORs and created forest plots using a random-effects model to identify the statistically significant risk factors. We assessed the certainty of evidence for each risk factor.

Résultats : Eight studies were included in the meta-analysis. Pre-intubation hypotension, with a pooled OR of 4.96 (95% confidence interval [C.I.]: 3.75-6.57), pre-intubation hypoxemia, with a pooled OR of 4.43 (95% C.I.: 1.24-15.81), and two or more intubation attempts, with a pooled OR of 1.88 (95% C.I.: 1.09-3.23) were associated with a significantly higher risk of PICA. The pooled incidence of PICA was 2.1% (95% C.I.: 1.5%-3.0%).

Conclusion : Pre-intubation hypotension, hypoxemia, and more intubation attempts are significant risk factors for PICA. The findings could help physicians identify patients at risk under the acute setting.

Conclusion (proposition de traduction) : L'hypotension pré-intubation, l'hypoxémie et la multiplication des tentatives d'intubation sont des facteurs de risque importants pour l'arrêt cardiaque péri-intubation. Ces résultats pourraient aider les médecins à identifier les patients à risque dans un contexte aigu.

Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) And Mortality in Hemorrhagic Shock Associated with Severe Pelvic Fracture: a National Data Analysis.
Ahmed N, Kuo YH. | BMC Emerg Med. 2024 Jun 24;24(1):104
DOI: https://doi.org/10.1186/s12873-024-01020-y  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : The purpose of the study was to evaluate the mortality of patients who received Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) in severe pelvic fracture with hemorrhagic shock.

Méthode : The American College of Surgeon Trauma Quality Improvement Program (ACS-TQIP) database for the calendar years 2017-2019 was accessed for the study. The study included all patients aged 15 years and older who sustained severe pelvic fractures, defined as an injury with an abbreviated injury scale (AIS) score of ≥ 3, and who presented with the lowest systolic blood pressure (SBP) of < 90 mmHg. Patients with severe brain injury were excluded from the study. Propensity score matching was used to compare the patients who received REBOA with similar characteristics to patients who did not receive REBOA.

Résultats : Out of 3,186 patients who qualified for the study, 35(1.1%) patients received REBOA for an ongoing hemorrhagic shock with severe pelvic fracture. The propensity matching created 35 pairs of patients. The pair-matched analysis showed no significant differences between the group who received REBOA and the group that did not receive REBOA regarding patients' demography, injury severity, severity of pelvic fractures, lowest blood pressure at initial assessment and laparotomies. There was no significant difference found between REBOA versus no REBOA group in overall in-hospital mortality (34.3% vs. 28.6, P = 0.789).

Conclusion : Our study did not identify any mortality advantage in patients who received REBOA in hemorrhagic shock associated with severe pelvic fracture compared to a similar cohort of patients who did not receive REBOA. A larger sample size prospective study is needed to validate our results.

Conclusion (proposition de traduction) : Notre étude n'a pas identifié d'avantage en termes de mortalité chez les patients ayant bénéficié d'un REBOA en cas de choc hémorragique associé à une fracture pelvienne grave, par rapport à une cohorte similaire de patients n'ayant pas bénéficié d'un REBOA . Une étude prospective portant sur un échantillon plus important est nécessaire pour valider nos résultats.

The impact of hyperkalemia on ICU admission and mortality: a retrospective study of Chinese emergency department data.
Sun J, Liu Q, Seery S, Sun L, Yuan Y, Wang W, Wang Y, Cui Z, Wang Y, Wang Y, Zhu J, Zhang M, Lai Y, Jin K. | BMC Emerg Med. 2024 Jun 1;24(1):95
DOI: https://doi.org/10.1186/s12873-024-01011-z  | Télécharger l'article au format  
Keywords: Disease severity; Emergency room; Hyperkalemia; Mortality risk.

Research

Introduction : This study assesses the influence of hyperkalemia on both disease severity and the risk of mortality among patients admitted to the emergency room.

Méthode : This retrospective observational study utilized data from the Chinese Emergency Triage Assessment and Treatment database (CETAT, version 2.0), which was designed to evaluate and optimize management strategies for emergency room (ER) patients. Patients were systematically categorized based on serum potassium levels. Relationships between serum potassium levels, risk of mortality, and the severity of illness were then analyzed using multifactorial logistic regression and through Receiver Operating Characteristic (ROC) analysis. The effectiveness of various treatments at lowering potassium levels was also investigated.

Résultats : 12,799 emergency patients were enrolled, of whom 20.1% (n = 2,577) were hypokalemic and 2.98% (n = 381) were hyperkalemic. Among hyperkalemic patients, the leading reasons for visiting the ER were altered consciousness 23.88% (n = 91), cardiovascular symptoms 22.31% (n = 85), and gastrointestinal symptoms 20.47% (n = 78). Comparative analysis with patients exhibiting normal potassium levels revealed hyperkalemia as an independent factor associated with mortality in the ER. Mortality risk appears to positively correlate with increasing potassium levels, reaching peaks when blood potassium levels ranged between 6.5 and 7.0. Hyperkalemia emerged as a strong predictor of death in the ER, with an Area Under the Curve (AUC) of 0.89. The most frequently prescribed treatment for hyperkalemia patients was diuretics (57.32%, n = 188), followed by intravenous sodium bicarbonate (50.91%, n = 167), IV calcium (37.2%, n = 122), insulin combined with high glucose (27.74%, n = 91), and Continuous Renal Replacement Therapy (CRRT) for 19.82% (n = 65). Among these, CRRT appeared to be the most efficacious at reducing potassium levels. Diuretics appeared relatively ineffective, while high-glucose insulin, sodium bicarbonate, and calcium preparations having no significant effect on the rate of potassium decline.

Conclusion : Hyperkalemia is common in emergency situations, especially among patients with altered consciousness. There is a strong positive correlation between the severity of hyperkalemia and mortality risk. CRRT appears to be the most effective potassium reducting strategy, while the use of diuretics should be approached with caution.

Conclusion (proposition de traduction) : L'hyperkaliémie est fréquente dans les situations d'urgence, en particulier chez les patients présentant des troubles de la conscience. Il existe une forte corrélation positive entre la gravité de l'hyperkaliémie et le risque de mortalité. La traitement de substitution rénale continue (hémodialyse) semble être la stratégie de réduction du potassium la plus efficace, tandis que l'utilisation de diurétiques doit être envisagée avec prudence.

External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta-analysis.
Kukendrarajah K, Ahmad M, Carrington M, Ioannou A, Taylor J, Razvi Y, Papageorgiou N, Mead GE, Nevis IF, D'Ascenzo F, Wilton SB, Lambiase PD, Morillo CA, Kwong JS, Providencia R. | Cochrane Database Syst Rev. 2024 Jun 3;6(6):CD013255
DOI: https://doi.org/10.1002/14651858.cd013255.pub2  | Télécharger l'article au format  
Keywords: Aucun

Review - Intervention

Introduction : Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion).

Méthode : To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. Search methods: We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. Selection criteria: We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. Data collection and analysis: We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption.

Résultats : We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremen

Conclusion : Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method.

Conclusion (proposition de traduction) : Malgré la faible qualité des preuves, cette revue systématique fournit des informations importantes sur les stratégies électriques et pharmacologiques destinées à aider les patients et les médecins à traiter la fibrillation auriculaire et le flutter auriculaire. L'évaluation du profil de comorbidité du patient, le délai d'action des médicaments antiarythmiques et leur profil d'effets secondaires par rapport à la nécessité d'un médecin expérimenté en matière de sédation ou d'anesthésie pour la cardioversion électrique sont des aspects clés dans le choix de la méthode de cardioversion.

Haemoglobin values, transfusion practices, and long-term outcomes in critically ill patients with traumatic brain injury: a secondary analysis of CENTER-TBI.
Guglielmi A, Graziano F, Bogossian EG, Turgeon AF, Taccone FS, Citerio G; CENTER-TBI Participants and Investigators. | Crit Care. 2024 Jun 14;28(1):199
DOI: https://doi.org/10.1186/s13054-024-04980-6  | Télécharger l'article au format  
Keywords: Anaemia; Blood transfusion; Haemoglobin; Long-term outcome; Traumatic brain injury.

Research

Editorial : Haemoglobin (Hb) thresholds and red blood cells (RBC) transfusion strategies in traumatic brain injury (TBI) are controversial. Our objective was to assess the association of Hb values with long-term outcomes in critically ill TBI patients. We conducted a secondary analysis of CENTER-TBI, a large multicentre, prospective, observational study of European TBI patients. All patients admitted to the Intensive Care Unit (ICU) with available haemoglobin data on admission and during the first week were included. During the first seven days, daily lowest haemoglobin values were considered either a continous variable or categorised as < 7.5 g/dL, between 7.5-9.5 and > 9.5 g/dL. Anaemia was defined as haemoglobin value < 9.5 g/dL. Transfusion practices were described as "restrictive" or "liberal" based on haemoglobin values before transfusion (e.g. < 7.5 g/dL or 7.5-9.5 g/dL). Our primary outcome was the Glasgow outcome scale extended (GOSE) at six months, defined as being unfavourable when < 5. Of 1590 included, 1231 had haemoglobin values available on admission. A mean Injury Severity Score (ISS) of 33 (SD 16), isolated TBI in 502 (40.7%) and a mean Hb value at ICU admission of 12.6 (SD 2.2) g/dL was observed. 121 (9.8%) patients had Hb < 9.5 g/dL, of whom 15 (1.2%) had Hb < 7.5 g/dL. 292 (18.4%) received at least one RBC transfusion with a median haemoglobin value before transfusion of 8.4 (IQR 7.7-8.5) g/dL. Considerable heterogeneity regarding threshold transfusion was observed among centres. In the multivariable logistic regression analysis, the increase of haemoglobin value was independently associated with the decrease in the occurrence of unfavourable neurological outcomes (OR 0.78; 95% CI 0.70-0.87). Congruous results were observed in patients with the lowest haemoglobin values within the first 7 days < 7.5 g/dL (OR 2.09; 95% CI 1.15-3.81) and those between 7.5 and 9.5 g/dL (OR 1.61; 95% CI 1.07-2.42) compared to haemoglobin values > 9.5 g/dL. Results were consistent when considering mortality at 6 months as an outcome. The increase of hemoglobin value was associated with the decrease of mortality (OR 0.88; 95% CI 0.76-1.00); haemoglobin values less than 7.5 g/dL was associated with an increase of mortality (OR 3.21; 95% CI 1.59-6.49). Anaemia was independently associated with long-term unfavourable neurological outcomes and mortality in critically ill TBI patients.

Conclusion : In this study, anaemia was significantly associated with unfavourable neurological outcomes and mortality rates in TBI patients requiring ICU admission. Transfusion policy was heterogeneous among centers.

Conclusion (proposition de traduction) : Dans cette étude, l'anémie était significativement associée à des résultats neurologiques défavorables et à des taux de mortalité chez les patients victimes d'un traumatisme crânien nécessitant une admission en USI. La politique de transfusion était hétérogène d'un centre à l'autre.

Commentaire : Des résultats concordants ont été observés chez les patients dont les valeurs d'hémoglobine les plus basses au cours des 7 premiers jours étaient < 7,5 g/dL (OR 2,09 ; 95% CI 1,15-3,81) et celles comprises entre 7,5 et 9,5 g/dL (OR 1,61 ; 95% CI 1,07-2,42) par rapport aux valeurs d'hémoglobine > 9,5 g/dL. Les résultats étaient cohérents lorsque l'on considérait la mortalité à 6 mois comme un résultat. L'augmentation de la valeur de l'hémoglobine était associée à une diminution de la mortalité (OR 0.88 ; 95% CI 0.76-1.00) ; les valeurs d'hémoglobine inférieures à 7.5 g/dL étaient associées à une augmentation de la mortalité (OR 3.21 ; 95% CI 1.59-6.49).

Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis.
Fisher T, Hill N, Kalakoutas A, Lahlou A, Rathod K, Proudfoot A, Warren A. | Crit Care. 2024 Jun 6;28(1):192
DOI: https://doi.org/10.1186/s13054-024-04973-5  | Télécharger l'article au format  
Keywords: Cardiogenic shock; Epidemiology; Mechanical circulatory support; Myocardial infarction; Sex differences.

Review

Introduction : Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock.

Méthode : Cochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support.

Résultats : Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26-1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06-1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57-0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71-0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71-0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51-1.33, p = 0.42).

Conclusion : Even when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.

Conclusion (proposition de traduction) : Même après ajustement des facteurs de confusion, la mortalité due au choc cardiogénique est environ 10 % plus élevée chez les femmes que chez les hommes. Cet effet est observé à la fois dans les cas d'infarctus du myocarde aigu et de choc cardiogénique dû à l'insuffisance cardiaque. Les femmes souffrant d'un choc cardiogénique sont moins susceptibles d'être traitées par assistance circulatoire mécanique que les hommes. Les cliniciens doivent faire des efforts immédiats pour assurer un diagnostic rapide et un traitement agressif du choc cardiogénique chez les femmes.

Albumin Versus Balanced Crystalloid for the Early Resuscitation of Sepsis: An Open Parallel-Group Randomized Feasibility Trial. The ABC-Sepsis Trial.
Gray AJ, Oatey K, Grahamslaw J, Irvine S, Cafferkey J, Kennel T, Norrie J, Walsh T, Lone N, Horner D, Appelboam A, Hall P, Skipworth RJE, Bell D, Rooney K, Shankar-Hari M, Corfield AR; Albumin, Balanced, and Crystalloid-Sepsis (ABC-Sepsis) Investigators. | Crit Care Med. 2024 Jun 24
DOI: https://doi.org/10.1097/ccm.0000000000006348
Keywords: Aucun

CLINICAL INVESTIGATION

Introduction : International guidelines recommend IV crystalloid as the primary fluid for sepsis resuscitation, with 5% human albumin solution (HAS) as the second line. However, it is unclear which fluid has superior clinical effectiveness. We conducted a trial to assess the feasibility of delivering a randomized controlled trial comparing balanced crystalloid against 5% HAS as sole early resuscitation fluid in patients with sepsis presenting to hospital.

Méthode : Multicenter, open, parallel-group randomized feasibility trial.
Setting: Emergency departments (EDs) in 15 U.K. National Health Service (NHS) hospitals.
Patients: Adult patients with sepsis and a National Early Warning Score 2 greater than or equal to five requiring IV fluids withing one hour of randomization.
Interventions: IV fluid resuscitation with balanced crystalloid or 5% HAS for the first 6 hours following randomization.

Résultats : Primary feasibility outcomes were recruitment rate and 30-day mortality. We successfully recruited 301 participants over 12 months. Mean (sd) age was 69 years (± 16 yr), and 151 (50%) were male. From 1303 participants screened; 502 participants were potentially eligible and 300 randomized to receive trial intervention with greater than 95% of participants receiving the intervention. The median number of participants per site was 19 (range, 1-63). Thirty-day mortality was 17.9% (n = 53). Thirty-one participants died (21.1%) within 30 days in the 5% HAS arm, compared with 22 participants (14.8%) in the crystalloid arm (adjusted odds ratio, 1.50; 95% CIs, 0.84-2.83).

Conclusion : Our results suggest it is feasible to recruit critically ill patients to a fluid resuscitation trial in U.K. EDs using 5% HAS as a primary resuscitation fluid. There was lower mortality in the balanced crystalloid arm. Given these findings, a definitive trial is likely to be deliverable, but the point estimates suggest such a trial would be unlikely to demonstrate a significant benefit from using 5% HAS as a primary resuscitation fluid in sepsis.

Conclusion (proposition de traduction) : Nos résultats suggèrent qu'il est possible de sélectionner des patients gravement malades pour un essai de réanimation par remplissage vasculaire dans les services d'urgence du Royaume-Uni en utilisant une solution d'albumine humaine à 5 % comme liquide de réanimation primaire. La mortalité a été plus faible dans le groupe des cristalloïdes balancés. Compte tenu de ces résultats, un essai définitif est probablement réalisable, mais les estimations ponctuelles suggèrent qu'il est peu probable qu'un tel essai démontre un avantage significatif de l'utilisation d'une solution d'albumine humaine à 5 % comme liquide de réanimation primaire dans le sepsis.

Efficacy and safety of anticoagulation in cardiac arrest: a systematic review and meta-analysis.
Zong M, Tian R, Zhang J, Li C, Chen Y. | Emerg Crit Care Med [Internet]. June 2024;28:1-7
DOI: https://doi.org/10.1097/EC9.0000000000000121
Keywords: Anticoagulants; Cardiac arrest; Heparin; Meta-analysis

META-ANALYSIS

Introduction : Evidence on the effectiveness of anticoagulation therapy in patients with cardiac arrest is scarce. We aimed to compare the effectiveness of anticoagulation therapy in patients with cardiac arrest by systematic evaluation and meta-analysis.

Méthode : The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed. We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from database inception until December 31, 2022, comparing adjuvant anticoagulation to standard care during cardiac arrest. Odds ratios with 95% confidence intervals were calculated using a random-effects model. The population included adults with cardiac arrest in any setting. Pairs of investigators reviewed studies for relevance, extracted data, and assessed the risk of bias. This study was registered with PROSPERO (International Prospective Register of Systematic Reviews).

Résultats : Four studies were included in the final meta-analysis (1 randomized controlled trial, 1 nonrandomized controlled trial, and 2 observational studies). A total of 1374 patients (412 in the intervention group and 962 in the control group) were included. The results show that anticoagulant interventions increased return of spontaneous circulation compliance compared with control, improved neurological prognosis, and are potentially associated with in-hospital survival. The risk of bleeding in the intervention and control groups and 24-hour survival between these groups were not significantly different.

Conclusion : Anticoagulation during cardiac arrest was associated with achieving return of spontaneous circulation, improving survival to hospitalization, and potentially ameliorating neurologic prognosis in patients. Moreover, anticoagulation did not increase the incidence of bleeding events.

Conclusion (proposition de traduction) : L'anticoagulation pendant un arrêt cardiaque a été associée à un retour de la circulation spontanée, à une amélioration de la survie jusqu'à l'hospitalisation et à une amélioration potentielle du pronostic neurologique chez les patients. En outre, l'anticoagulation n'a pas augmenté l'incidence des événements hémorragiques.

Effect of early initiation of noninvasive ventilation in patients transported by emergency medical service for acute heart failure.
Gorlicki J, Masip J, Gil V, Llorens P, Jacob J, Alquézar-Arbé A, Domingo Baldrich E, Fortuny MJ, Romero M, Esquivias MA, Moyano García R, Gómez García Y, Noceda J, Rodríguez P, Aguirre A, López-Díez MP, Mir M, Serrano L, Fuentes de Frutos M, Curtelín D, Freund Y, Miró Ò; ICA-SEMES research group. | Eur J Emerg Med. 2024 Jun 7
DOI: https://doi.org/10.1097/mej.0000000000001141
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : While the indication for noninvasive ventilation (NIV) in severely hypoxemic patients with acute heart failure (AHF) is often indicated and may improve clinical course, the benefit of early initiation before patient arrival to the emergency department (ED) remains unknown.

Méthode : This study aimed to assess the impact of early initiation of NIV during emergency medical service (EMS) transportation on outcomes in patients with AHF.
Design: A secondary retrospective analysis of the EAHFE (Epidemiology of AHF in EDs) registry.
Setting: Fifty-three Spanish EDs.
Participants: Patients with AHF transported by EMS physician-staffed ambulances who were treated with NIV at any time during of their emergency care were included and categorized into two groups based on the place of NIV initiation: prehospital (EMS group) or ED (ED group).
titrOutcome measurese_en_plus: Primary outcome was the composite of in-hospital mortality and 30-day postdischarge death, readmission to hospital or return visit to the ED due to AHF. Secondary outcomes included 30-day all-cause mortality after the index event (ED admission) and the different component of the composite primary endpoint considered individually. Multivariate logistic regressions were employed for analysis.

Résultats : Out of 2406 patients transported by EMS, 487 received NIV (EMS group: 31%; EMS group: 69%). Mean age was 79 years, 48% were women. The EMS group, characterized by younger age, more coronary artery disease, and less atrial fibrillation, received more prehospital treatments. The adjusted odds ratio (aOR) for composite endpoint was 0.66 (95% CI: 0.42-1.05). The aOR for secondary endpoints were 0.74 (95% CI: 0.38-1.45) for in-hospital mortality, 0.74 (95% CI: 0.40-1.37) for 30-day mortality, 0.70 (95% CI: 0.41-1.21) for 30-day postdischarge ED reconsultation, 0.80 (95% CI: 0.44-1.44) for 30-day postdischarge rehospitalization, and 0.72 (95% CI: 0.25-2.04) for 30-day postdischarge death.

Conclusion : In this ancillary analysis, prehospital initiation of NIV in patients with AHF was not associated with a significant reduction in short-term outcomes. The large confidence intervals, however, may preclude significant conclusion, and all point estimates consistently pointed toward a potential benefit from early NIV initiation.

Conclusion (proposition de traduction) : Dans cette analyse complémentaire, l'initiation préhospitalière de la VNI chez les patients présentant une insuffisance cardiaque aiguë n'a pas été associée à une réduction significative des résultats à court terme. Les larges intervalles de confiance, cependant, peuvent empêcher une conclusion significative, et toutes les estimations ponctuelles ont constamment pointé vers un bénéfice potentiel de l'initiation précoce de la VNI.

Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study.
Morello F, Bima P, Castelli M, Capretti E, de Matos Soeiro A, Cipriano A, Costantino G, Vanni S, Leidel BA, Kaufmann BA, Osman A, Candelli M, Capsoni N, Behringer W, Capuano M, Ascione G, Leal TCAT, Ghiadoni L, Pivetta E, Grifoni S, Lupia E, Nazerian P; PROFUNDUS Study Investigators. | Eur J Intern Med. 2024 Jun 12:S0953-6205(24)00234-6
DOI: https://doi.org/10.1016/j.ejim.2024.05.029  | Télécharger l'article au format  
Keywords: Aorta; Diagnosis; Dissection; Probability; Score; Ultrasound; d-dimer.

ORIGINAL ARTICLE

Introduction : In patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting.

Méthode : We assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of-care ultrasound (POCUS) and d-dimer (single/age-adjusted cutoff), to select patients for AAI.
Methods: This prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and d-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes.

Résultats : Within 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0 % (95 % CI, 0-0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46-50 %) and AAI was averted in 41 % of patients. Using age-adjusted d-dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4-9 %, vs standard cutoff).

Conclusion : The integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted d-dimer maximized efficiency.

Conclusion (proposition de traduction) : L'algorithme intégré a permis un triage rapide des patients à forte probabilité, tout en permettant d'exclure de manière sûre et efficace les syndromes aortiques aigus. Les d-dimères ajustés à l'âge ont maximisé l'efficacité.

European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness.
Holland AE, Spathis A, Marsaa K, Bausewein C, Ahmadi Z, Burge AT, Pascoe A, Gadowski AM, Collis P, Jelen T, Reilly CC, Reinke LF, Romero L, Russell AM, Saggu R, Solheim J, Vagheggini G, Vandendungen C, Wijsenbeek M, Tonia T, Smallwood N, Ekström M. | Eur Respir J. 2024 Jun 28;63(6):2400335
DOI: https://doi.org/10.1183/13993003.00335-2024  | Télécharger l'article au format  
Keywords: Aucun

Clinical practice guideline

Editorial : Respiratory symptoms are ubiquitous and impair health-related quality of life in people with respiratory disease. This European Respiratory Society (ERS) task force aimed to provide recommendations for symptomatic treatment in people with serious respiratory illness. The ERS task force comprised 16 members, including representatives of people with serious respiratory illness and informal caregivers. Seven questions were formulated, six in the PICO (Population, Intervention, Comparison, Outcome) format, which were addressed with full systematic reviews and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). One question was addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. To treat symptoms in people with serious respiratory illness, the task force suggests the use of graded exercise therapy (conditional recommendation, low certainty of evidence); and suggests the use of a multicomponent services, handheld fan and breathing techniques (conditional recommendations, very low certainty of evidence). The task force suggests not to use opioids (conditional recommendation, very low certainty of evidence); and suggests either administering or not administering supplemental oxygen therapy (conditional recommendation, low certainty of evidence). The task force suggests that needs assessment tools may be used as part of a comprehensive needs assessment, but do not replace patient-centred care and shared decision making (conditional recommendation, low certainty of evidence). The low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.

Conclusion : This clinical practice guideline provides evidence to guide prescription of symptom management interventions in people with serious respiratory illness, and highlights the importance of comprehensive assessment to individualise treatment. The low certainty of evidence underpinning these recommendations compels clinicians and researchers to investigate new approaches to reduce symptoms and enhance wellbeing for the many individuals who live with serious respiratory illness.

Conclusion (proposition de traduction) : Cette recommandation de pratique clinique fournit des preuves pour guider la prescription d'interventions de gestion des symptômes chez les personnes souffrant de maladies respiratoires graves, et souligne l'importance d'une évaluation complète pour individualiser le traitement. Le faible niveau de certitude des preuves étayant ces recommandations oblige les cliniciens et les chercheurs à étudier de nouvelles approches pour réduire les symptômes et améliorer le bien-être des nombreuses personnes qui vivent avec une maladie respiratoire grave.

European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids.
Arabi YM, Belley-Cote E, Carsetti A, De Backer D, Donadello K, Juffermans NP, Hammond N, Laake JH, Liu D, Maitland K, Messina A, Møller MH, Poole D, Mac Sweeney R, Vincent JL, Zampieri FG, AlShamsi F; European Society of Intensive Care Medicine. | Intensive Care Med. 2024 Jun;50(6):813-831
DOI: https://doi.org/10.1007/s00134-024-07369-9
Keywords: Albumin; Colloid solutions; Critical care; Crystalloid solutions; Fluid therapy; Practice guidelines.

Guideline

Introduction : This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal.

Méthode : This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision.

Résultats : For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence).

Conclusion : This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.

Conclusion (proposition de traduction) : Ce guide fournit onze recommandations pour guider les médecins dans le choix des liquides de réanimation chez les patients gravement malades.

Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age- disaggregated analysis.
Girardello C, Carron PN, Dami F, Darioli V, Pasquier M, Ageron FX. | Emerg Med J. 2024 Jun 14:emermed-2023-213806
DOI: https://doi.org/10.1136/emermed-2023-213806
Keywords: Observational Study; pre-hospital; trauma.

Original research

Introduction : Tranexamic acid (TXA) decreases mortality in injured patients and should be administered as soon as possible. Despite international guidelines recommending TXA in the prehospital setting, its use remains low. The aim of this study was to assess the prehospital administration of TXA for injured patients in a Swiss region.

Méthode : We conducted a retrospective observational study in Switzerland between 2018 and 2021. Inclusion criteria were injured patients ≥18 years for whom an ambulance or helicopter was dispatched. The exclusion criterion was minor injury defined by a National Advisory Committee for Aeronautics score <3. The primary outcome was the proportion of patients treated with TXA according to guidelines. The European guidelines were represented by the risk of death from bleeding (calculated retrospectively using the Bleeding Audit for Trauma and Triage (BATT) score). Factors impacting the likelihood of receiving TXA were assessed by multivariate analysis.

Résultats : Of 13 944 patients included in the study, 2401 (17.2%) were considered at risk of death from bleeding. Among these, 257 (11%) received prehospital TXA. This represented 38% of those meeting US guidelines. For European guidelines, the treatment rate increased with the risk of death from bleeding: 6% (95% CI 4.4% to 7.0%) for low risk (BATT score 3-4); 13% (95% CI 11.1% to 15.9%) for intermediate risk (BATT score 5-7); and 21% (95% CI 17.6% to 25.6%) for high risk (BATT score ≥8) (p<0.01). Women and the elderly were treated less often than men and younger patients, irrespective of the risk of death from bleeding and the mechanism of injury.

Conclusion : The proportion of injured patients receiving TXA in the prehospital setting of the State of Vaud in Switzerland was low, with even lower rates for women and older patients. The reasons for this undertreatment are probably multifactorial and would require specific studies to clarify and correct them.

Conclusion (proposition de traduction) : La proportion de patients blessés recevant de l'acide tranexamique dans le cadre préhospitalier de l'Etat de Vaud en Suisse était faible, avec des taux encore plus bas pour les femmes et les patients plus âgés. Les raisons de ce sous-traitement sont probablement multifactorielles et nécessiteraient des études spécifiques pour les clarifier et les corriger.

Timing of P2Y₁₂ Inhibitor Administration in Patients With STEMI Undergoing Primary PCI.
Almendro-Delia M, Hernández-Meneses B, Padilla-Rodríguez G, Blanco-Ponce E, Arboleda-Sánchez JA, Rodríguez-Yáñez JC, Soto-Blanco JM, Fernández-García I, Castillo-Caballero JM, García-Rubira JC, Hidalgo-Urbano R . | J Am Coll Cardiol. 2024 Jun, 83 (25) 2629–2639
DOI: https://doi.org/10.1016/j.jacc.2024.04.036
Keywords: Aucun

Original Research

Introduction : This analysis from a prospective multicenter registry sought to assess the safety and effectiveness of P2Y₁₂ inhibitor pretreatment in patients transferred for primary percutaneous coronary intervention (PCI) within a regional STEMI network.

Méthode : Pretreatment was defined as P2Y₁₂ inhibitor administration before coronary angiography. Endpoints were major adverse cardiac events (MACE), major bleeding, and net adverse clinical events, a composite of MACE or major bleeding, within 30 days of index admission. Association of P2Y₁₂ inhibitor pretreatment with outcomes was modeled using doubly robust weighted estimators based on propensity score analysis.

Résultats : Of 1,624 patients included, 1,033 received P2Y₁₂ inhibitors before angiography and 591 in the catheterization laboratory (cath lab). The non-pretreated cohort more often had history of coronary artery disease and were more likely to receive antiplatelet therapy before the index admission. After adjustment for confounding and dependent censoring, pretreatment with P2Y₁₂ inhibitors predicted lower risk of MACE (adjusted HR: 0.53; 95% CI: 0.37-0.76), without increasing bleeding risk (adjusted HR: 0.62; 95% CI: 0.36-1.05), resulting in superior net clinical benefit (adjusted HR: 0.47; 95% CI: 0.26-0.86) compared with in-cath lab administration of P2Y₁₂ inhibitors. There was a significant treatment-by-time interaction for MACE risk, whereby the observed benefits of pretreatment only became apparent when time between P2Y₁₂ inhibitor administration and PCI was longer than 80 minutes.

Conclusion : In contemporary patients with STEMI transferred for primary PCI, pretreatment with P2Y₁₂ inhibitors was associated with a significant time-dependent reduction of 30-day MACE without increasing bleeding risk.

Conclusion (proposition de traduction) : Chez les patients présentant un infarctus du myocarde avec sus-décalage du segment ST transférés pour une angioplastie primaire, le prétraitement par un inhibiteur de P2Y12 a été associé à une réduction significative, en fonction du temps, des évènements cardiaques indésirables majeurs à 30 jours, sans augmenter le risque de saignement.

Commentaire : Dans l'infarctus du myocarde avec élévation du segment ST (STEMI), le prétraitement par anti P2Y12 peut être considéré avant l’intervention (Classe IIb).
Byrne RA and al.; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12;44(38):3720-3826  .

EDITORIAL COMMENT: Antiplatelet Therapy, Pretreatment, and Primary PCI: Every Minute Counts  

Presence of Microscopic Hematuria Does Not Predict Clinically Important Intra-Abdominal Injury in Children.
Papillon SC, Pennell CP, Bauer SE, DiBello A, Master SA, Prasad R, Arthur LG, Grewal H. | Pediatr Emerg Care. 2024 Jun 7
DOI: https://doi.org/10.1097/pec.0000000000003210
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Screening for blunt intra-abdominal injury in children often includes directed laboratory evaluation that guides need for computed tomography. We sought to evaluate the use of urinalysis in identifying patients with clinically important intraabdominal injury (ci-IAI).

Méthode : A retrospective chart review was performed for all patients less than 18 years who presented with blunt mechanisms at a level I trauma center between 2016 and 2019. Exclusion criteria included transfer from an outside facility, physical abuse, and death within thirty minutes of arrival. Demographics, physical exam findings, serum chemistries, urinalysis, and imaging were reviewed. Clinically important intraabdominal injury was defined as injury requiring ≥2 nights admission, blood transfusion, angiography with embolization, or therapeutic surgery.

Résultats : Two hundred forty patients were identified. One hundred sixty-five had a completed urinalysis. For all patients an abnormal chemistry panel and abnormal physical exam had a sensitivity of 88.9% and a negative predictive value of 99.3%. Nine patients had a ci-IAI. Patients with a ci-IAI were more likely to have abdominal pain, tenderness on exam, and elevated hepatic enzymes. When patients were stratified by the presence of an abnormal chemistry or physical exam with or without microscopic hematuria, urinalysis did not improve the ability to identify patients with a ci-IAI. In fact, presence of microscopic hematuria increased the rate of false positives by 12%.

Conclusion : Microscopic hematuria was not a useful marker for ci-IAI and may lead to falsely assuming a more serious injury.

Conclusion (proposition de traduction) : L'hématurie microscopique n'est pas un marqueur utile pour les lésions intra-abdominales importantes sur le plan clinique et peut conduire à supposer à tort une lésion plus grave.

Fever phobia - where are we now.
Pereira C G, Machado S N, Pereira R L, Rebelo A, Salgado M.. | Pediatr Oncall J. 2024 April-June:21(2):49-55
DOI: https://doi.org/10.7199/ped.oncall.2024.22  | Télécharger l'article au format  
Keywords: Fever; Phobia; Antipyretic.

ORIGINAL ARTICLE

Introduction : Fever is a common complaint in the Emergency Department. Despite being frequently benign, it’s still a cause for anxiety for caregivers. This study aimed to characterize parents’ knowledge and attitudes towards fever.

Méthode : A cross sectional and descriptive survey was conducted by applying a questionnaire to pediatric patients’ caregivers that attended consultation from April to August 2021. It included questions regarding sociodemographic data, knowledge and myths about fever and interventions used to treat it. Descriptive analysis was performed.

Résultats : A total of 1014 questionnaires were considered valid. The thermometer was used by 97.7% caregivers to measure fever, with armpit being the preferred location (80.9%). Around 87% wrongly defined fever. About 11.8% didn’t offer antipyretics before seeking health care, mostly because of fear of masking the disease (47.7%). Approximately 91% undressed the child in thermal ascent and 49% used sponging with cold water to decrease temperature. Caregivers sought help mainly in primary care (66.2%). The physician was the preferred source of information (75.8%). Seizures (83.4%) were named as the main complication, 10.3% thought death was a possible effect. Around 78% answered dental eruption was a cause of fever, 54.8% considered it to be harmful for children’s health, 67% believed temperature will go up indefinitely if not treated and 85.2% answered that temperature should always reach normal values after taking antipyretics.

Conclusion : Fever phobia is still a reality, with wrong beliefs and misconceptions about its consequences and treatment. It’s important to inform parents about this subject to improve the management of fever and reduce caregivers’ anxiety.

Conclusion (proposition de traduction) : La phobie de la fièvre est toujours une réalité, avec des croyances et des idées fausses sur ses conséquences et son traitement. Il est important d'informer les parents sur ce sujet afin d'améliorer la gestion de la fièvre et de réduire l'anxiété des soignants.

Effects of mild hypercapnia on myocardial injury after out-of-hospital cardiac arrest. A sub-study of the TAME trial.
Baumann Melberg M, Flaa A, Øystein Andersen G, Sunde K, Bellomo R, Eastwood G, Mariero Olasveengen T, Qvigstad E. | Resuscitation. 2024 Jun 25:110295
DOI: https://doi.org/10.1016/j.resuscitation.2024.110295  | Télécharger l'article au format  
Keywords: Out-of-hospital cardiac arrest; acute myocardial infarction; high-sensitive cardiac Troponin T; mild hypercapnia.

CLINICAL PAPER

Introduction : Mild hypercapnia did not improve neurological outcomes for resuscitated out-of-hospital cardiac arrest (OHCA) patients in the Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial. However, the effects of hypercapnic acidosis on myocardial injury in patients with cardiac arrest is unexplored. We investigated whether mild hypercapnia compared to normocapnia, following emergency coronary intervention, increased myocardial injury in comatose OHCA-patients with AMI.

Méthode : Single-centre, prospective, pre-planned sub-study of the TAME trial. Patients were randomised to targeted mild hypercapnia (PaCO2 =6.7-7.3 kPa) or normocapnia (PaCO₂ =4.7-6.0 kPa) for 24 hours. Myocardial injury was assessed with high-sensitive cardiac troponin T (hs-cTnT) measured at baseline, 24, 48 and 72 hours. Haemodynamics were assessed with right heart catheterisation and blood-gas analyses every 4_th hour for 48 hours.

Résultats : We included 125 OHCA-patients. 57 (46%) had an AMI, with 31 and 26 patients randomised to hypercapnia and normocapnia, respectively. Median peak hs-cTnT in AMI-patients was 58% lower in the hypercapnia-group: 2136 (IQR: 861-4462) versus 5165 ng/L (IQR: 2773-7519), p =0.007. Lower average area under the hs-cTnT curve was observed in the hypercapnia-group: 2353 (95% CI 1388-3319) versus 4953 ng/L (95% CI 3566-6341), P-group =0.002. Hypercapnia was associated with increased cardiac power output (CPO) and lower lactate levels in patients with AMI (P-group <0.05). hs-cTnT, lactate and CPO were not significantly different between intervention groups in OHCA-patients without AMI (p >0.05).

Conclusion : Mild hypercapnia was not associated with increased myocardial injury in resuscitated OHCA-patients. In AMI-patients, mild hypercapnia was associated with lower hs-cTnT and lactate, and improved cardiac performance.
Take-home-message: In this single-centre, prospective sub-study of a randomised cardiac arrest trial targeting mild hypercapnia was not associated with increased myocardial injury after out-of-hospital cardiac arrest. Compared to targeted normocapnia, mild hypercapnia was associated with lower hs-cTnT levels in patients with acute myocardial infarction as the cause of cardiac arrest.

Conclusion (proposition de traduction) : L'hypercapnie légère n'a pas été associée à une augmentation des lésions myocardiques chez les patients réanimés ayant subi un arrêt cardiaque hors de l'hôpital. Chez les patients victimes d'un infarctus aigu du myocarde, l'hypercapnie légère a été associée à une diminution de la hs-cTnT et du lactate, et à une amélioration des performances cardiaques.
Message de conclusion : Dans cette sous-étude prospective unicentrique d'un essai randomisé sur les arrêts cardiaques, le ciblage de l'hypercapnie légère n'a pas été associé à une augmentation des lésions myocardiques après un arrêt cardiaque extrahospitalier. Comparée à la normocapnie ciblée, l'hypercapnie légère a été associée à des niveaux plus faibles de hs-cTnT chez les patients ayant subi un infarctus aigu du myocarde à la suite d'un arrêt cardiaque.

Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest.
Palatinus HN, Johnson MA, Wang HE, Hoareau GL, Youngquist ST. | Resuscitation. 2024 Jun 9;201:110266
DOI: https://doi.org/10.1016/j.resuscitation.2024.110266  | Télécharger l'article au format  
Keywords: Adrenaline; Advanced Life Support; Cardiopulmonary Resuscitation; Prehospital; Resuscitation; Vasopressor.

Clinical paper

Introduction : Early administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA.

Méthode : We conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024.
Setting: Single-center urban, two-tiered EMS agency.
Participants: Adult, nontraumatic OHCA meeting criteria for adrenaline use.
Intervention: Single dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines.
Main outcomes and measures: The primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge.

Résultats : Among 1450 OHCAs, 372 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0-6.0) vs. 7.8 min (IQR 5.8-10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10-2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07-2.76).

Conclusion : Dans cette étude de mise en œuvre avant-après réalisée dans un seul centre, une dose initiale d'adrénaline administrée par voie intramusculaire en complément des soins habituels a été associée à une amélioration de la survie jusqu'à l'admission à l'hôpital, de la survie jusqu'à la sortie de l'hôpital et de la survie fonctionnelle. Un essai contrôlé randomisé est nécessaire pour évaluer pleinement les avantages potentiels de l'administration d'adrénaline par voie IM en cas d'arrêt cardiaque extrahospitalier.

Conclusion (proposition de traduction) : In this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA.

Commentaire : L'injection IM, avant l'accès vasculaire, consistait en l'injection d'une dose initiale d'adrénaline 5 mg à la face latéroexterne du tiers moyen de la cuisse, cette dose étant considérée comme équivalente à une dose IV de 0,5 mg.
L'adrénaline en IM permet une administration d'adrénaline 3,5 minutes, avant l'administration IV ou IO.

Contemporary diagnosis and management of mild TBI (concussions): What you need to know.
Panzera JC, Podolak OE, Master CL. | J Trauma Acute Care Surg. 2024 Jun 1;96(6):865-869
DOI: https://doi.org/10.1097/ta.0000000000004297  | Télécharger l'article au format  
Keywords: Aucun

WHAT YOU NEED TO KNOW SERIES – REVIEWS

Editorial : Concussion is a common injury in children and adolescents and is a form of mild traumatic brain injury that surgeons will see in their acute care practice. With a rapidly changing evidence base for diagnosis and management, we will focus on the importance of timely identification and diagnosis, as well as the early initiation of active management of pediatric concussion immediately after injury through recovery. This approach involves the application of targeted therapies for specific deficits identified after concussion, addressing the individual pattern of symptoms experienced by patients following concussion. We will review what is known about the underlying pathophysiology that drives the clinical manifestations of concussion, the targeted clinical assessments that can both aid in the diagnosis of concussion, as well as drive the active rehabilitation of deficits seen after concussion. The standardized approach to the return to activities will also be described, including return to learning and sports.

Conclusion : Concussion, a form of mild traumatic brain injury often seen in pediatric and adolescent populations, and by acute care surgeons, often in sports and recreational settings, involves the disruption of the homeostasis of neuronal cells of the brain in the absence of neuronal cell death. Despite scientific advances in the field, the diagnosis remains a clinical one, relying on clinician judgment through proper identification, diagnosis, and management. A visio-vestibular examination can help identify deficits and can both support diagnosis and help guide individualized multi-modal management plans. While most pediatric concussions resolve within 4 weeks, some patients may require specialized therapeutic rehabilitative interventions to achieve full resolution ofconcussion symptoms. Aerobic, vestibular, vision, behavioral, and sleep rehabilitation all play a critical role in pediatric concussion recovery and should be utilized when indicated. Focus on academic return and performance should be prioritized to minimize negative academic sequelae in pediatric patients. Effective management of the complex myriad of symptoms exhibited by pediatric and adolescent patients can help improve time to recovery and return patients to academic and athletic activity safely. The concussion evidence base continues to rapidly evolve, highlighting the need for clinicians to keep up-to-date on emerging translational clinical research and consensus guidelines for implementation to optimally diagnosis and manage pediatric concussion.

Conclusion (proposition de traduction) : La commotion cérébrale, une forme de lésion cérébrale traumatique légère souvent observée chez les enfants et les adolescents, et par les chirurgiens en soins aigus, souvent dans des contextes sportifs et récréatifs, implique la perturbation de l'homéostasie des cellules neuronales du cerveau en l'absence de mort des cellules neuronales. Malgré les avancées scientifiques dans ce domaine, le diagnostic reste clinique et repose sur le jugement du clinicien pour une identification, un diagnostic et une prise en charge appropriés. Un examen visio-vestibulaire peut aider à identifier les déficits et peut à la fois étayer le diagnostic et aider à orienter les plans de gestion multimodaux individualisés. Bien que la plupart des commotions cérébrales pédiatriques disparaissent dans les 4 semaines, certains patients peuvent avoir besoin d'interventions thérapeutiques spécialisées de réadaptation pour parvenir à une résolution complète des symptômes de la commotion cérébrale. La rééducation aérobique, vestibulaire, visuelle, comportementale et du sommeil joue un rôle essentiel dans le rétablissement des enfants victimes de commotions cérébrales et doit être utilisée lorsqu'elle est indiquée. La priorité doit être donnée à la reprise des études et aux performances scolaires afin de minimiser les séquelles scolaires négatives chez les patients pédiatriques. Une prise en charge efficace de la myriade complexe de symptômes présentés par les enfants et les adolescents peut aider à améliorer le temps de récupération et à permettre aux patients de reprendre leurs études et leurs activités sportives en toute sécurité. Les données probantes sur les commotions cérébrales continuent d'évoluer rapidement, soulignant la nécessité pour les cliniciens de se tenir au courant de la recherche clinique et des lignes directrices consensuelles émergentes à mettre en œuvre pour diagnostiquer et gérer au mieux les commotions cérébrales chez les enfants.

Reteplase versus Alteplase for Acute Ischemic Stroke.
Li S, Gu HQ, Li H, Wang X, Jin A, Guo S, Lu G, Che F, Wang W, Wei Y, Wang Y, Li Z, Meng X, Zhao X, Liu L, Wang Y; RAISE Investigators. | N Engl J Med. 2024 Jun 27;390(24):2264-2273
DOI: https://doi.org/10.1056/nejmoa2400314
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Alteplase is the standard agent used in early reperfusion therapy, but alternative thrombolytic agents are needed. The efficacy and safety of reteplase as compared with alteplase in patients with acute ischemic stroke are unclear.

Méthode : We randomly assigned patients with ischemic stroke within 4.5 hours after symptom onset in a 1:1 ratio to receive intravenous reteplase (a bolus of 18 mg followed 30 minutes later by a second bolus of 18 mg) or intravenous alteplase (0.9 mg per kilogram of body weight; maximum dose, 90 mg). The primary efficacy outcome was an excellent functional outcome, defined as a score of 0 or 1 on the modified Rankin scale (range, 0 [no neurologic deficit, no symptoms, or completely recovered] to 6 [death]) at 90 days. The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours after symptom onset.

Résultats : A total of 707 patients were assigned to receive reteplase, and 705 were assigned to receive alteplase. An excellent functional outcome occurred in 79.5% of the patients in the reteplase group and in 70.4% of those in the alteplase group (risk ratio, 1.13; 95% confidence interval [CI], 1.05 to 1.21; P<0.001 for noninferiority and P = 0.002 for superiority). Symptomatic intracranial hemorrhage within 36 hours after disease onset was observed in 17 of 700 patients (2.4%) in the reteplase group and in 14 of 699 (2.0%) of those in the alteplase group (risk ratio, 1.21; 95% CI, 0.54 to 2.75). The incidence of any intracranial hemorrhage at 90 days was higher with reteplase than with alteplase (7.7% vs. 4.9%; risk ratio, 1.59; 95% CI, 1.00 to 2.51), as was the incidence of adverse events (91.6% vs. 82.4%; risk ratio, 1.11; 95% CI, 1.03 to 1.20).

Conclusion : Among patients with ischemic stroke within 4.5 hours after symptom onset, reteplase was more likely to result in an excellent functional outcome than alteplase.

Conclusion (proposition de traduction) : Chez les patients ayant présenté un AVC ischémique dans les 4,5 heures suivant l'apparition des symptômes, la reteplase (Rapilysin^®) était plus à même d'aboutir à un excellent résultat fonctionnel que l'alteplase (Actilyse^®).

Tenecteplase for Ischemic Stroke at 4.5 to 24 Hours without Thrombectomy.
Xiong Y, Campbell BCV, Schwamm LH, Meng X, Jin A, Parsons MW, Fisher M, Jiang Y, Che F, Wang L, Zhou L, Dai H, Liu X, Pan Y, Duan C, Xu Y, Xu A, Zong L, Tan Z, Ye W, Wang H, Wang Z, Hao M, Cao Z, Wang L, Wu S, Li H, Li Z, Zhao X, Wang Y; TRACE-III Investigators. | N Engl J Med. 2024 Jun 14
DOI: https://doi.org/10.1056/nejmoa2402980  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Tenecteplase is an effective thrombolytic agent for eligible patients with stroke who are treated within 4.5 hours after the onset of stroke. However, data regarding the effectiveness of tenecteplase beyond 4.5 hours are limited.

Méthode : In a trial conducted in China, we randomly assigned patients with large-vessel occlusion of the middle cerebral artery or internal carotid artery who had salvageable brain tissue as identified on perfusion imaging and who did not have access to endovascular thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or standard medical treatment within 4.5 to 24 hours after the time that the patient was last known to be well (including after stroke on awakening and unwitnessed stroke). The primary outcome was the absence of disability, which was defined as a score of 0 or 1 on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability), at day 90. The key safety outcomes were symptomatic intracranial hemorrhage and death.

Résultats : A total of 516 patients were enrolled; 264 were randomly assigned to receive tenecteplase and 252 to receive standard medical treatment. Less than 2% of the patients (4 in the tenecteplase group and 5 in the standard-treatment group) underwent rescue endovascular thrombectomy. Treatment with tenecteplase resulted in a higher percentage of patients with a modified Rankin scale score of 0 or 1 at 90 days than standard medical treatment (33.0% vs. 24.2%; relative rate, 1.37; 95% confidence interval, 1.04 to 1.81; P = 0.03). Mortality at 90 days was 13.3% with tenecteplase and 13.1% with standard medical treatment, and the incidence of symptomatic intracranial hemorrhage within 36 hours after treatment was 3.0% and 0.8%, respectively.

Conclusion : In this trial involving Chinese patients with ischemic stroke due to large-vessel occlusion, most of whom did not undergo endovascular thrombectomy, treatment with tenecteplase administered within 4.5 to 24 hours after stroke onset resulted in less disability and similar survival as compared with standard medical treatment, and the incidence of symptomatic intracranial hemorrhage appeared to be higher.

Conclusion (proposition de traduction) : Dans cet essai portant sur des patients chinois victimes d'un accident vasculaire cérébral ischémique dû à une occlusion de gros vaisseaux, dont la plupart n'ont pas bénéficié d'une thrombectomie endovasculaire, le traitement par le ténecteplase (Métalyse^®) administré dans les 4,5 à 24 heures suivant l'apparition de l'accident vasculaire cérébral a permis de réduire le degré d'invalidité et d'assurer une survie similaire par rapport au traitement médical standard, et l'incidence de l'hémorragie intracrânienne symptomatique s'est avérée plus élevée.

Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury.
Turgeon AF, Fergusson DA, Clayton L, Patton MP, Neveu X, Walsh TS, Docherty A, Malbouisson LM, Pili-Floury S, English SW, Zarychanski R, Moore L, Bonaventure PL, Laroche V, Verret M, Scales DC, Adhikari NKJ, Greenbaum J, Kramer A, Rey VG, Ball I, Khwaja K, Wise M, Harvey D, Lamontagne F, Chabanne R, Algird A, Krueper S, Pottecher J, Zeiler F, Rhodes J, Rigamonti A, Burns KEA, Marshall J, Griesdale DE, Sisconetto LS, Kutsogiannis DJ, Roger C, Green R, Boyd J. | N Engl J Med. 2024 Jun 13
DOI: https://doi.org/10.1056/nejmoa2404360
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : The effect of a liberal transfusion strategy as compared with a restrictive strategy on outcomes in critically ill patients with traumatic brain injury is unclear.

Méthode : We randomly assigned adults with moderate or severe traumatic brain injury and anemia to receive transfusion of red cells according to a liberal strategy (transfusions initiated at a hemoglobin level of ≤10 g per deciliter) or a restrictive strategy (transfusions initiated at ≤7 g per deciliter). The primary outcome was an unfavorable outcome as assessed by the score on the Glasgow Outcome Scale-Extended at 6 months, which we categorized with the use of a sliding dichotomy that was based on the prognosis of each patient at baseline. Secondary outcomes included mortality, functional independence, quality of life, and depression at 6 months.

Résultats : A total of 742 patients underwent randomization, with 371 assigned to each group. The analysis of the primary outcome included 722 patients. The median hemoglobin level in the intensive care unit was 10.8 g per deciliter in the group assigned to the liberal strategy and 8.8 g per deciliter in the group assigned to the restrictive strategy. An unfavorable outcome occurred in 249 of 364 patients (68.4%) in the liberal-strategy group and in 263 of 358 (73.5%) in the restrictive-strategy group (adjusted absolute difference, restrictive strategy vs. liberal strategy, 5.4 percentage points; 95% confidence interval, -2.9 to 13.7). Among survivors, a liberal strategy was associated with higher scores on some but not all the scales assessing functional independence and quality of life. No association was observed between the transfusion strategy and mortality or depression. Venous thromboembolic events occurred in 8.4% of the patients in each group, and acute respiratory distress syndrome occurred in 3.3% and 0.8% of patients in the liberal-strategy and restrictive-strategy groups, respectively.

Conclusion : In critically ill patients with traumatic brain injury and anemia, a liberal transfusion strategy did not reduce the risk of an unfavorable neurologic outcome at 6 months.

Conclusion (proposition de traduction) : Chez les patients en état critique souffrant de lésions cérébrales traumatiques et d'anémie, une stratégie transfusionnelle libérale n'a pas réduit le risque d'une évolution neurologique défavorable à 6 mois.

Noninvasive Ventilation for Preoxygenation during Emergency Intubation.
Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, Mohamed A, Prekker ME, Khan A, Gaillard JP, Andrea L, Aggarwal NR, Brainard JC, Barnett LH, Halliday SJ, Blinder V, Dagan A, Whitson MR, Schauer SG, Walker JE Jr, Barker AB, Palakshappa JA, Muhs A, Wozniak JM, Kramer PJ, Withers C, Ghamande SA, Russell DW, Schwartz A, Moskowitz A, Hansen SJ, Allada G, Goranson JK, Fein DG, Sottile PD, Kelly . | N Engl J Med. 2024 Jun 13
DOI: https://doi.org/10.1056/nejmoa2313680
Keywords: Aucun

Original Article

Introduction : Among critically ill adults undergoing tracheal intubation, hypoxemia increases the risk of cardiac arrest and death. The effect of preoxygenation with noninvasive ventilation, as compared with preoxygenation with an oxygen mask, on the incidence of hypoxemia during tracheal intubation is uncertain.

Méthode : In a multicenter, randomized trial conducted at 24 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults (age, ≥18 years) undergoing tracheal intubation to receive preoxygenation with either noninvasive ventilation or an oxygen mask. The primary outcome was hypoxemia during intubation, defined by an oxygen saturation of less than 85% during the interval between induction of anesthesia and 2 minutes after tracheal intubation.

Résultats : Among the 1301 patients enrolled, hypoxemia occurred in 57 of 624 patients (9.1%) in the noninvasive-ventilation group and in 118 of 637 patients (18.5%) in the oxygen-mask group (difference, -9.4 percentage points; 95% confidence interval [CI], -13.2 to -5.6; P<0.001). Cardiac arrest occurred in 1 patient (0.2%) in the noninvasive-ventilation group and in 7 patients (1.1%) in the oxygen-mask group (difference, -0.9 percentage points; 95% CI, -1.8 to -0.1). Aspiration occurred in 6 patients (0.9%) in the noninvasive-ventilation group and in 9 patients (1.4%) in the oxygen-mask group (difference, -0.4 percentage points; 95% CI, -1.6 to 0.7).

Conclusion : Among critically ill adults undergoing tracheal intubation, preoxygenation with noninvasive ventilation resulted in a lower incidence of hypoxemia during intubation than preoxygenation with an oxygen mask.

Conclusion (proposition de traduction) : Chez les adultes de réanimation nécessitant une intubation trachéale, la préoxygénation par ventilation non invasive a permis de réduire l'incidence de l'hypoxémie pendant l'intubation par rapport à la préoxygénation par masque à oxygène.