Fluid volumes in adults with sepsis.
Long B, Gottlieb M. | Acad Emerg Med. 2024 Jul;31(7):716-717
DOI: https://doi.org/10.1111/acem.14912
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Sepsis, defined by organ dysfunction and a dysregulated re- sponse to infection, accounts for up to one in six hospital admis- sions in the United States and nearly 270,000 deaths annually. Treatment includes source control, antibiotics, and ensuring oxy- genated blood flow supported by intravenous (IV) fluid adminis- tration. However, limited evidence on “more versus less” IV fluids has led to conflicting, uncertain recommendations. The 2021 international guidelines for management of sepsis and septic shock “Surviving Sepsis Campaign” suggests administering 30 mL/ kg of fluids in the first 3 h. However, other studies have shown either no benefit or potentially increased mortality with such a strategy. A systematic review published in 2020 found no dif- ference in mortality between lower and higher fluid volumes,7 but several large, highquality randomized trials have been published since then.

Conclusion : In both trials, mortality, the primary outcome, was unchanged by fluid strategy. Based on current data, it seems highly likely there is no meaningful difference in clinical outcomes between less versus more IV fluid strategies for people experiencing severe sepsis. We have therefore selected a color recommendation of red (no benefits) for the choice of fluid volumes in adult patients with sepsis. Further randomized controlled trials using well-defined fluid protocols in well-defined populations, as well as those comparing timing of vasopressors, will hopefully shed further light on this topic.

Conclusion (proposition de traduction) : Dans les deux essais, la mortalité, le critère principal, n'a pas changé en fonction de la stratégie de remplissage vasculaire. Sur la base des données actuelles, il semble très probable qu'il n'y ait pas de différence significative dans les résultats cliniques entre les stratégies de réduction et d'augmentation des volumes de remplissage IV chez les personnes présentant un sepsis sévère. Nous avons donc choisi une recommandation de couleur rouge (pas de bénéfices) pour le choix des volumes de remplissage vasculaire chez les patients adultes présentant un sepsis. D'autres essais contrôlés randomisés utilisant des protocoles de remplissage bien définis dans des populations bien définies, ainsi que des essais comparant le moment de l'administration des vasopresseurs, permettront, nous l'espérons, de faire la lumière sur ce sujet.

Seizure occurrences among hypoglycemic patients in the emergency department.
Urushidani S, Tanabe M, Baek K, Miyaguchi K, Ikegami T. | Acute Med Surg. 2024 Jul 4;11(1):e979
DOI: https://doi.org/10.1002/ams2.979  | Télécharger l'article au format  
Keywords: diabetes mellitus; hypoglycemia; insulin; paramedics; seizures.

ORIGINAL ARTICLE

Introduction : Symptomatic hypoglycemia is a common problem in the emergency department (ED). However, without appropriate recognition and management, hypoglycemia remains a potentially fatal condition. The cause of sudden death associated with hypoglycemia might be attributed to cardiac arrhythmias and hypoxia with seizures. Despite advances in diabetes mellitus management and social background, the frequency and characteristics of patients with hypoglycemia-related seizures have remained unknown. Hence, our study aimed to investigate the frequency and characteristics of patients with hypoglycemia presenting with seizures in the ED.

Méthode : This retrospective observational study was conducted in a single tertiary care center. Patient information was retrieved from the final diagnostic records in the ED. We reviewed all medical records and included patients with symptomatic hypoglycemia aged 16 years or older. The primary outcome was the frequency of seizures in patients with hypoglycemia. We also compared the initial blood sugar levels of the patients with and without seizures.

Résultats : We included a total of 380 patients (median age, 72 years, IQR 64-80 years; median initial blood sugar, 34 mg/dL, IQR 24-46; 62.9% male). Nineteen of 380 patients (5.0%) had seizures. Although 16 of the 19 patients had diabetes mellitus, none of the 19 patients had a history of epilepsy. The initial blood sugar levels of the patients with and without seizures were not significantly different (p = 0.97).

Conclusion : Approximately 5% of the patients with hypoglycemia presented with seizures. Blood glucose levels of hypoglycemic patients with and without seizures did not differ.

Conclusion (proposition de traduction) : Environ 5 % des patients souffrant d'hypoglycémie ont présenté des crises d'épilepsie. Les taux de glycémie des patients hypoglycémiques avec et sans crises ne différaient pas.

Effects of an Early Intensive Blood Pressure–lowering Strategy Using Remifentanil and Dexmedetomidine in Patients with Spontaneous Intracerebral Hemorrhage: A Multicenter, Prospective, Superiority, Randomized Controlled Trial .
Dong R, Li F, Li B, Chen Q, Huang X, Zhang J, Huang Q, Zhang Z, Cao Y, Yang M, Li J, Li Z, Li C, Liu G, Zhong S, Feng G, Zhang M, Xiao Y, Lin K, Shen Y, Shao H, Shi Y, Yu X, Li X, Yao L, Du X, Xu Y, Kang P, Gao G, Ouyang B, Chen W, Zeng Z, Chen P, Chen C, Yang H. | Anesthesiology. 2024 Jul 1;141(1):100-115
DOI: https://doi.org/10.1097/aln.0000000000004986  | Télécharger l'article au format  
Keywords: Aucun

Critical Care Medicine

Introduction : Although it has been established that elevated blood pressure and its variability worsen outcomes in spontaneous intracerebral hemorrhage, antihypertensives use during the acute phase still lacks robust evidence. A blood pressure-lowering regimen using remifentanil and dexmedetomidine might be a reasonable therapeutic option given their analgesic and antisympathetic effects. The objective of this superiority trial was to validate the efficacy and safety of this blood pressure-lowering strategy that uses remifentanil and dexmedetomidine in patients with acute intracerebral hemorrhage.

Méthode : In this multicenter, prospective, single-blinded, superiority randomized controlled trial, patients with intracerebral hemorrhage and systolic blood pressure (SBP) 150 mmHg or greater were randomly allocated to the intervention group (a preset protocol with a standard guideline management using remifentanil and dexmedetomidine) or the control group (standard guideline-based management) to receive blood pressure-lowering treatment. The primary outcome was the SBP control rate (less than 140 mmHg) at 1 h posttreatment initiation. Secondary outcomes included blood pressure variability, neurologic function, and clinical outcomes.

Résultats : A total of 338 patients were allocated to the intervention (n = 167) or control group (n = 171). The SBP control rate at 1 h posttreatment initiation in the intervention group was higher than that in controls (101 of 161, 62.7% vs. 66 of 166, 39.8%; difference, 23.2%; 95% CI, 12.4 to 34.1%; P < 0.001). Analysis of secondary outcomes indicated that patients in the intervention group could effectively reduce agitation while achieving lighter sedation, but no improvement in clinical outcomes was observed. Regarding safety, the incidence of bradycardia and respiratory depression was higher in the intervention group.

Conclusion : Among intracerebral hemorrhage patients with a SBP 150 mmHg or greater, a preset protocol using a remifentanil and dexmedetomidine-based standard guideline management significantly increased the SBP control rate at 1 h posttreatment compared with the standard guideline-based management.

Conclusion (proposition de traduction) : Parmi les patients présentant une hémorragie intracérébrale avec une PAS de 150 mmHg ou plus, un protocole préétabli utilisant une prise en charge standard basée sur le remifentanil et la dexmedetomidine a augmenté de manière significative le taux de contrôle de la PAS 1 h après le traitement par rapport à la prise en charge standard basée sur les lignes directrices.

Development of Clinically Validated Artificial Intelligence Model for Detecting ST-segment Elevation Myocardial Infarction.
Lee SH, Jeon KL, Lee YJ, You SC, Lee SJ, Hong SJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Hong MK. | Ann Emerg Med. 024 Jul 25:S0196-0644(24)00327-5
DOI: https://doi.org/10.1016/j.annemergmed.2024.06.004  | Télécharger l'article au format  
Keywords: Aucun

Cardiology/original research

Introduction : Although the importance of primary percutaneous coronary intervention has been emphasized for ST-segment elevation myocardial infarction (STEMI), the appropriateness of the cardiac catheterization laboratory activation remains suboptimal. This study aimed to develop a precise artificial intelligence (AI) model for the diagnosis of STEMI and accurate cardiac catheterization laboratory activation.

Méthode : We used electrocardiography (ECG) waveform data from a prospective percutaneous coronary intervention registry in Korea in this study. Two independent board-certified cardiologists established a criterion standard (STEMI or Not STEMI) for each ECG based on corresponding coronary angiography data. We developed a deep ensemble model by combining 5 convolutional neural networks. In addition, we performed clinical validation based on a symptom-based ECG data set, comparisons with clinical physicians, and external validation.

Résultats : We used 18,697 ECGs for the model development data set, and 1,745 (9.3%) were STEMI. The AI model achieved an accuracy of 92.1%, sensitivity of 95.4%, and specificity of 91.8 %. The performances of the AI model were well balanced and outstanding in the clinical validation, comparison with clinical physicians, and the external validation.

Conclusion : The deep ensemble AI model showed a well-balanced and outstanding performance. As visualized with gradient-weighted class activation mapping, the AI model has a reasonable explainability. Further studies with prospective validation regarding clinical benefit in a real-world setting should be warranted.

Conclusion (proposition de traduction) : Le modèle d'intelligence artificielle à ensemble profond a montré une performance bien établie et excellente. Comme le montre la cartographie de l'activation des classes pondérée par le gradient, le modèle d'intelligence artificielle est raisonnablement compréhensible. D'autres études avec validation prospective concernant les avantages cliniques dans un contexte réel devraient être justifiées.

A Simple Scoring System for Identifying Favorable Neurologic Outcomes Among Out-of-Hospital Cardiac Arrest Patients With Asystole.
Park H, Kim SM, Kwon H, Kim D, Kim YJ, Kim WY. | Ann Emerg Med. 2024 Jul 25:S0196-0644(24)00350-0
DOI: https://doi.org/10.1016/j.annemergmed.2024.06.016  | Télécharger l'article au format  
Keywords: Aucun

Cardiology/original research

Introduction : Asystole is the most common initial rhythm in out-of-hospital cardiac arrest (OHCA) but indicates a low likelihood of neurologic recovery. This study aimed to develop a novel scoring system to be easily applied at the time of emergency department arrival for identifying favorable neurologic outcomes in OHCA survivors with an asystole rhythm.

Méthode : This study is a secondary analysis based on a previously collected nationwide database, targeting nontraumatic adult OHCA patients aged ≥18 years with an asystole rhythm who achieved return of spontaneous circulation (ROSC) between January 2016 and December 2020. The primary outcome was a favorable neurologic outcome defined as Cerebral Performance Categories scores of 1 or 2 at hospital discharge. A prediction model was developed through multivariable logistic regression analysis in a derivation cohort in the form of a scoring system (WBC-ASystole). The performance and calibration of the model were tested using an internal validation cohort.

Résultats : Among 19,803 OHCA patients with survival to hospital admission, 6,322 had asystole, and 285 (4.5%) achieved good neurologic outcomes. Factors associated with favorable outcomes included age, witness arrest, bystander cardiopulmonary resuscitation, time from call to hospital arrival, and out-of-hospital ROSC achievement. The WBC-ASystole score, totaling 11 points, exhibited a predictive performance with an area under the receiver operating characteristic curve of 0.80 (95% confidence interval [CI] 0.76 to 0.83) and 0.79 (95% CI 0.74 to 0.83) in the derivation and validation cohorts, respectively. After categorizing patients into 3 groups based on probability for good neurologic outcomes, the sensitivity and specificity were as follows: 0.98 (95% CI 0.97 to 0.99) and 0.09 (95% CI 0.09 to 0.10) for the very low predicted probability group (WBC-ASystole ≤2), 0.85 (95% CI 0.82 to 0.89) and 0.54 (95% CI 0.53 to 0.55) for the low predicted probability group (WBC-ASystole 3 to 4), and 0.36 (95% CI 0.34 to 0.39) and 0.93 (95% CI 0.92 to 0.93) for fair predicted probability group (WBC-ASystole≥5), respectively.

Conclusion : Although external validation studies must be performed, among OHCA patients with asystole, the WBC-ASystole scoring system may identify those patients who are likely to have a favorable neurologic outcome.

Conclusion (proposition de traduction) : Bien que des études de validation externes doivent être réalisées, le système de notation WBC-ASystole peut permettre d'identifier les patients susceptibles d'avoir une évolution neurologique favorable parmi les patients ayant subi un arrêt cardiaque extrahospitalier et présentant une asystolie.

Are the HINTS and HINTS Plus Examinations Accurate for Identifying a Central Cause of Acute Vestibular Syndrome?.
Smiley K, Yoo MJ, Long B. | Ann Emerg Med. 2024 Jul;84(1):60-62
DOI: https://doi.org/10.1016/j.annemergmed.2024.01.027  | Télécharger l'article au format  
Keywords: Aucun

NEUROLOGY/SYSTEMATIC REVIEW SNAPSHOT

Introduction : When performed by properly trained clinicians, the head impulse, nystagmus, and test of skew (HINTS) examination demonstrates high sensitivity and moderate specificity in identifying patients with a central cause of acute vestibular syndrome. However, the quality of evidence supporting these findings was low suggesting that further prospective study is needed before widespread clinical implementation.

Méthode : The meta-analysis authors searched the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE Ovid, Embase Ovid, clinicaltrials.gov, the World Health Organization International Clinical Trails Registry Platform, International Health Technology Assessment Database, and Google Scholar from inception to September 26, 2022, for both retrospective and prospective studies evaluating the HINTS and HINTS Plus (HINTS with the addition of finger rub for hearing loss detection) examinations with and without video assistance in patients with acute vestibular syndrome. The authors also checked reference lists and citations from searched articles.

Résultats : The meta-analysis comprised 16 studies, including 14 prospective and 2 retrospective studies that evaluated 2,024 patients, of which 569 (28.1%) had a central cause of acute vestibular syndrome. Among the selected studies, a neurologist most frequently performed the HINTS examination (7/16), followed by a neuro-otologist (3/16), and an emergency physician (2/16). The ED was the most common study setting (13/16). In the meta-analysis, 12 studies evaluated the HINTS examination, 5 studies evaluated the HINTS Plus examination, 3 studies evaluated HINTS with video assistance, and 2 studies evaluated HINTS Plus with video assistance (Table). The most common standard comparison was magnetic resonance imaging (MRI) (13/16). Both the HINTS and HINTS Plus examinations demonstrated high sensitivity in identifying a central cause of acute vestibular syndrome, with the HINTS with video assistance yielding the highest sensitivity (Table). Overall, the HINTS test demonstrated the highest specificity in identifying a central cause of acute vestibular syndrome. Individual components of the HINTS examination did not demonstrate high sensitivity. The presence of vertical or direction-changing nystagmus or a positive skew test were highly specific for a central cause of acute vestibular syndrome.

Conclusion : Despite its limitations, this meta-analysis suggests that both the HINTS and HINTS Plus examinations have high sensitivity in diagnosing a central cause of acute vestibular syndrome compared with MRI and/or final diagnosis by a neurologist. However, individual elements of the HINTS examination do not perform well in isolation. Importantly, clinicians must also assess for other neurologic deficits, including cranial nerves, gait, motor, and sensation. Prospective, randomized controlled trials evaluating the HINTS and HINTS Plus examinations versus MRI are necessary to better characterize the accuracy of these physical examination components, particularly in the ED setting.

Conclusion (proposition de traduction) : Malgré ses limites, cette méta-analyse suggère que les examens HINTS et HINTS Plus ont une sensibilité élevée pour diagnostiquer une cause centrale de syndrome vestibulaire aigu par rapport à l'IRM et/ou au diagnostic final d'un neurologue. Cependant, les éléments individuels de l'examen HINTS ne sont pas performants isolément. Il est important que les cliniciens évaluent également d'autres déficits neurologiques, notamment au niveau des nerfs crâniens, de la démarche, de la motricité et de la sensibilité. Des essais prospectifs contrôlés et randomisés évaluant les examens HINTS et HINTS Plus par rapport à l'IRM sont nécessaires pour mieux caractériser la précision de ces éléments de l'examen physique, en particulier dans le contexte des urgences.

Commentaire : Cette revue systématique a montré que lorsque l'examen HINTS est utilisé par des cliniciens correctement formés, il présente une sensibilité élevée et une spécificité modérée pour identifier les causes centrales du syndrome vestibulaire aigu.

Fluid accumulation syndrome in sepsis and septic shock: pathophysiology, relevance and treatment-a comprehensive review.
Pfortmueller CA, Dabrowski W, Wise R, van Regenmortel N, Malbrain MLNG. | Ann Intensive Care. 2024 Jul 20;14(1):115
DOI: https://doi.org/10.1186/s13613-024-01336-9  | Télécharger l'article au format  
Keywords: De-resuscitation; Fluid accumulation; Fluids; Monitoring; Resuscitation; Safety.

REVIEW

Editorial : In this review, we aimed to comprehensively summarize current literature on pathophysiology, relevance, diagnosis and treatment of fluid accumulation in patients with sepsis/septic shock. Fluid accumulation syndrome (FAS) is defined as fluid accumulation (any degree, expressed as percentage from baseline body weight) with new onset organ-failure. Over the years, many studies have described the negative impact of FAS on clinically relevant outcomes. While the relationship between FAS and ICU outcomes is well described, uncertainty exists regarding its diagnosis, monitoring and treatment. A stepwise approach is suggested to prevent and treat FAS in patients with septic shock, including minimizing fluid intake (e.g., by limiting intravenous fluid administration and employing de-escalation whenever possible), limiting sodium and chloride administration, and maximizing fluid output (e.g., with diuretics, or renal replacement therapy). Current literature implies the need for a multi-tier, multi-modal approach to de-resuscitation, combining a restrictive fluid management regime with a standardized early active de-resuscitation, maintenance fluid reduction (avoiding fluid creep) and potentially using physical measures such as compression stockings.

Conclusion : This comprehensive review underlines the importance of FAS in patients with sepsis/septic shock. There is currently a lack of international consensus on diagnosis and monitoring tools of FAS. Prevention of FAS is as important as treatment. Therefore, a differentiated individualized stepwise approach, including minimizing fluid intake (e.g., limiting IV fluids and de-escalation whenever possible) and maximizing fluid output (e.g., by diuretics or combination therapy or renal replacement therapy with net ultrafiltration) depending on the patient’s current phase of septic shock and fluid requirement is needed. Treatment of FAS is symptomatic as there are currently no viable treatment options for the underlying problem of capillary leakage/increased vascular permeability. This huge knowledge gap requires research and evidence for clinicians to be able to therapeutically target the underlying disease and pathophysiology. However, with no such therapeutic targets and targeted inventions available, the only option is symptomatic treatment. Symptomatic treatment is extremely complex and requires a personalized approach as we try to treat the right patient (depending on the underlying disease, i.e. sepsis/septic shock) at the right time (i.e., stages of the ROSE model) with the right intervention (fluids, preventive measures, de-resuscitation measures). Thus, fluid management strategies should not be “liberal” or “restrictive” but patient-centered and individualized.
Future studies should focus on the different triggers, targets and safety limits to initiate and stop de-resuscitation, as well as the potential side effects of de-resuscitation that is inappropriately early, late, too rapid, too long, too little, or too liberal. The impact of FAS and de-resuscitation on capillary leak and the integrity of the endothelial glycocalyx requires further investigation, as does the joint application of vasopressors with fluid therapy (indication, dose, duration, and how to balance with fluid therapy).

Conclusion (proposition de traduction) : Cette revue exhaustive souligne l'importance du syndrome d'accumulation des liquides de remplissage vasculaire chez les patients présentant un sepsis ou un choc septique. Il n'existe actuellement aucun consensus international sur le diagnostic et les outils de surveillance du syndrome d'accumulation des liquides de remplissage vasculaire. La prévention du syndrome d'accumulation des liquides de remplissage vasculaire est aussi importante que le traitement. Par conséquent, il convient d'adopter une approche différenciée, individualisée et par étapes, comprenant la réduction de l'apport de fluides de remplissage (par exemple, en limitant les solutés IV et en procédant à une désescalade chaque fois que cela est possible) et la maximisation du débit de soluté (par exemple, au moyen de diurétiques ou d'une thérapeutique combinée ou d'un traitement de remplacement rénal avec ultrafiltration nette) en fonction de la phase actuelle du choc septique du patient et de ses besoins en liquides de remplissage. Le traitement du syndrome d'accumulation des solutés de remplissage est symptomatique car il n'existe actuellement aucune option thérapeutique viable pour le problème sous-jacent de la fuite capillaire ou de l'augmentation de la perméabilité vasculaire. Cette énorme lacune dans les connaissances nécessite des recherches et des preuves pour que les cliniciens puissent cibler thérapeutiquement la maladie et la physiopathologie sous-jacentes. Cependant, en l'absence de cibles thérapeutiques et d'inventions ciblées, la seule option est le traitement symptomatique. Le traitement symptomatique est extrêmement complexe et nécessite une approche personnalisée car nous essayons de traiter le bon patient (en fonction de la maladie sous-jacente, c'est-à-dire le sepsis/choc septique) au bon moment (c'est-à-dire les étapes du modèle ROSE) avec la bonne intervention (solutés, mesures préventives, mesures de réanimation). Ainsi, les stratégies de gestion des solutés de remplissage ne doivent pas être "libérales" ou "restrictives", mais centrées sur le patient et individualisées. Les études futures devraient se concentrer sur les différents déclencheurs, cibles et limites de sécurité pour initier et arrêter la réanimation, ainsi que sur les effets secondaires potentiels d'une réanimation inappropriée, précoce, tardive, trop rapide, trop longue, trop faible ou trop libérale. L'impact du syndrome d'accumulation des solutés de remplissage et de la réanimation sur la fuite capillaire et l'intégrité du glycocalyx endothélial doit faire l'objet d'études plus approfondies, tout comme l'application conjointe des vasopresseurs et du remplissage vasculaire (indication, dose, durée et comment équilibrer les apports de solutés).

Commentaire :  L'accumulation de de solutés de remplissage vasculaire peut être définie et calculée en divisant le bilan hydrique cumulé par le poids corporel de base. Le syndrome d'accumulation de solutés de remplissage vasculaire est défini comme tout volume d'accumulation de soluté de remplissage (exprimé en pourcentage) accompagné d'une nouvelle défaillance d'organe (qui peut être décrite par un sous-score d'organe SOFA [Sequential Organ Failure Assessment] égal ou supérieur à 3) qui peut être due à l'accumulation de soluté de remplissage. La plupart des organes, y compris les poumons, le cœur et le tractus gastro-intestinal, sont affectés par le syndrome d'accumulation de solutés de remplissage vasculaire.

Conséquences négatives potentielles de l'accumulation de liquide. Adapté avec l'autorisation de Malbrain et al. selon la licence Open Access CC BY License 4.0 [15-17].
Les effets mentionnés sont liés au sepsis, à la fuite capillaire et à l'accumulation de soluté de remplissage. Par exemple, la sensation d'engourdissement est liée à la présence d'un œdème périphérique et d'une anasarque qui peuvent provoquer des troubles de la conduction cutanée, une compression des nerfs, une diminution du flux sanguin et une réduction de la mobilité. En outre, les déséquilibres liquidiens sévères et prolongés peuvent entraîner toute une série de problèmes de santé et de complications, notamment des troubles électrolytiques, qui peuvent indirectement affecter la capacité de l'organisme à répondre au stress, y compris la production de cortisol par les glandes surrénales.
APP : pression de perfusion abdominale (MAP moins IAP), RSB : respiration superficielle rapide, HCS : congestion hépatique, GRV : reflux gastro-œsophagien, CARS : syndrome cardio-rénal, AKI : lésion rénale aiguë, JVP : pression veineuse jugulaire, HJR : reflux hépato-jugulaire.

Diagnostic performance of coronary calcifications on CT to rule out acute coronary syndrome in the emergency department.
Sentagne JP, Ohana M, Severac F, Le Borgne P, Sauleau EA, Bilbault P, Kepka S. | BMC Emerg Med. 2024 Jul 12;24(1):116
DOI: https://doi.org/10.1186/s12873-024-01038-2  | Télécharger l'article au format  
Keywords: Acute coronary syndrome; Chest pain; Coronary artery calcifications; Emergency department; Ultra low dose chest Computed Tomography.

Research

Introduction : At present, the diagnosis of acute coronary syndrome (ACS) can be made by emergency physicians using the usual complementary tests, since the current troponin and electrocardiogram (ECG) protocols have been extensively tested for their safety. However, the detection of coronary calcifications on CT associated with coronary obstruction may be of interest for the diagnostic strategy in the emergency department (ED). The aim of this study was to evaluate a strategy combining a non-ischemic ECG with an initial normal troponin assay and the diagnostic accuracy of chest CT in detecting coronary calcifications to rule out the presence of an acute coronary event in patients presenting with chest pain in the ED.

Méthode : This was a retrospective, single-center study carried out in an ED in France and included all patients over 18 years of age presenting with chest pain between 1 June 2021 and 31 December 2021 with a non-ischemic ECG and a negative first troponin assay. The primary endpoint was the diagnostic performance of the combing strategy in ruling out ACS. The secondary endpoints were the sensitivity and specificity of calcifications in acute coronary syndrome, comparison with the diagnostic performance of a second troponin assay and the rate of reconsultation, rehospitalisation and investigations within 2 months of the ED.

Résultats : Of the 280 patients included, 141 didn't have calcifications. A total of 14 events were found with a negative predictive value for the combining strategy of 99.8% [95%CI: 98.2 - 100]. Sensitivity and specificity were 98.4% [95%CI: 83.8 - 100] and 53% [95%CI: 47 - 58.9], respectively. Among patients with no calcification, 8.2% were admitted to hospital and none suffered an acute coronary event. A total of 36 patients (12.8%) consulted a doctor within 2 months, with 23 investigations, all of which were negative in the non-calcification group.

Conclusion : A strategy combining the detection of coronary calcifications on chest CT in patients with a non-ischemic ECG and a single troponin assay is effective to rule out ACS in the ED, and may perform better then ECG and troponin alone.

Conclusion (proposition de traduction) : Une stratégie combinant la détection de calcifications coronaires au scanner thoracique chez les patients présentant un ECG non ischémique et un dosage unique de troponine est efficace pour exclure un SCA aux urgences, et peut être plus performante que l'ECG et la troponine seuls.

Comparison of prognosis between extracorporeal CPR and conventional CPR for patients in cardiac arrest: a systematic review and meta-analysis.
Zhong H, Yin Z, Wang Y, Shen P, He G, Huang S, Wang J, Huang S, Ding L, Luo Z, Zhou M. | BMC Emerg Med. 2024 Jul 27;24(1):128
DOI: https://doi.org/10.1186/s12873-024-01058-y  | Télécharger l'article au format  
Keywords: Cardiac arrest; Conventional cardiopulmonary resuscitation; Extracorporeal cardiopulmonary resuscitation; Extracorporeal life support; Prognosis.

Systematic Review

Introduction : Compared to the conventional cardiopulmonary resuscitation (CCPR), potential benefits of extracorporeal cardiopulmonary resuscitation (ECPR) for patients with cardiac arrest (CA) are still controversial. We aimed to determine whether ECPR can improve the prognosis of CA patients compared with CCPR.

Méthode : We systematically searched PubMed, EMBASE, and Cochrane Library from database's inception to July 2023 to identify randomized controlled trials (RCTs) or cohort studies that compared ECPR with CCPR in adults (aged ≥ 16 years) with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). This meta-analysis was performed using a random-effects model. Two researchers independently reviewed the relevance of the study, extracted data, and evaluated the quality of the included literature. The primary outcome was short-term (from hospital discharge to one month after cardiac arrest) and long-term (≥ 90 days after cardiac arrest) survival with favorable neurological status (defined as cerebral performance category scores 1 or 2). Secondary outcomes included survival at 1 months, 3-6 months, and 1 year after cardiac arrest.

Résultats : The meta-analysis included 3 RCTs and 14 cohort studies involving 167,728 patients. We found that ECPR can significantly improve good neurological prognosis (RR 1.82, 95%CI 1.42-2.34, I² = 41%) and survival rate (RR 1.51, 95%CI 1.20-1.89, I2 = 62%). In addition, the results showed that ECPR had different effects on favorable neurological status in patients with OHCA (short-term: RR 1.50, 95%CI 0.98- 2.29, I² = 55%; long-term: RR 1.95, 95% CI 1.06-3.59, I² = 11%). However, ECPR had significantly better effects on neurological status than CCPR in patients with IHCA (short-term: RR 2.18, 95%CI 1.24- 3.81, I² = 9%; long-term: RR 2.17, 95% CI 1.19-3.94, I² = 0%).

Conclusion : This meta-analysis indicated that ECPR had significantly better effects on good neurological prognosis and survival rate than CCPR, especially in patients with IHCA. However, more high-quality studies are needed to explore the role of ECPR in patients with OHCA.

Conclusion (proposition de traduction) : Cette méta-analyse indique que la ECPR CP a des effets significativement meilleurs sur le pronostic neurologique et le taux de survie que la réanimation cardio-pulmonaire conventionnelle, en particulier chez les patients ayant présenté un arrêt cardiaque à l'hôpital. Cependant, d'autres études de haute qualité sont nécessaires pour explorer le rôle de l'ECPR chez les patients en arrêt cardiaque en dehors de l'hôpital.

Fracture pain in children in the emergency department: the impact of a new pain management procedure.
Liber M, De Jorna C, Abidji D, Ramdane N, Avez-Couturier J, Dubos F. | BMC Emerg Med. 2024 Jul 29;24(1):132
DOI: https://doi.org/10.1186/s12873-024-01052-4  | Télécharger l'article au format  
Keywords: Acute fracture pain; Children; ED; Pain management.

Research

Introduction : To compare compliance with the French national guidelines before and after the implementation (in 2018) of a new protocol on acute fracture pain management in the pediatric emergency department of a French university medical center.

Méthode : We conducted a retrospective, before-after study in patients aged below 16 years presenting at the pediatric emergency department with a fracture. We compared pain management before (in 2017) and after (in 2019 and 2020) implementation of the new procedure. The primary endpoint was appropriate pain management, defined as (i) an appropriate initial assessment of pain, (ii) appropriate treatment with analgesic drugs (acetaminophen for mild pain, acetaminophen and ibuprofen for moderate pain, ibuprofen and morphine for severe pain) and (iii) reassessment of the pain intensity.

Résultats : 572 patients were included (mean age: 6.5 years; male: 60%). 190 in 2017 and 382 in 2019-2020. Pain management was appropriate for 40% of the patients in 2017 and 52% in 2019-2020 (p = 0.004). Pain was rated for 98% of patients in 2017 vs. 100% in 2019-2020 (p = 0.04). The frequency of appropriate treatment for mild pain and moderate pain increased significantly from 52 to 76% and from 0 to 44%, respectively. The administration of ibuprofen increased by 26% points (from 3 to 20 patients treated) and the administration of morphine increased by 29% points (from 1 to 17 patients treated). Pain reassessment rose significantly from 21 to 43%. Levels of compliance with the guidelines were similar in 2019 and 2020. Analgesia was significantly more effective in 2019-2020 than in 2017 (in 20% vs. 14% of the patients, respectively; p = 0.005).

Conclusion : After the implementation of a new protocol for the management of acute fracture pain, we observed an increase in compliance with the guidelines. Although the use of ibuprofen and morphine rose significantly as did the frequency of pain reassessment, further improvements are required.

Conclusion (proposition de traduction) : Après la mise en œuvre du nouveau protocole de prise en charge de la douleur aiguë liée à une fracture, nous avons observé une augmentation de la conformité aux directives. Bien que l'utilisation de l'ibuprofène et de la morphine ait augmenté de manière significative, tout comme la fréquence de la réévaluation de la douleur, d'autres améliorations sont nécessaires.

Recognition and initial management of acute aortic dissection.
Kesieme EB, Iruolagbe CO, Ngaage DL. | Br J Hosp Med (Lond). 2024 Jul 30;85(7):1-12
DOI: https://doi.org/10.12968/hmed.2024.0004  | Télécharger l'article au format  
Keywords: Aortic dissection; Type A dissection; Type B dissection; Malperfusion syndrome

Doctors in Training

Editorial : Acute aortic dissection is a cardiovascular emergency that should be recognised on presentation in the Emergency Department (ED) because clinical outcome is time-dependent. In suspected cases of acute aortic dissection, immediate imaging with chest computed tomography scan followed by transthoracic echocardiography (TTE) is essential to confirm diagnosis.
Immediate medical management is aimed at controlling the heart rate (60–80 beats/min), systolic blood pressure (100–120 mmHg) and pain. Patients with Type A acute aortic dissection should immediately be referred to the cardiothoracic surgeons for emergency aortic surgery while those with Type B acute aortic dissection should be referred to the vascular surgeons for surgical/endovascular interventions if indicated.

Conclusion : Acute aortic dissection can be rapidly fatal, hence prompt recognition and institution of appropriate line of management remain vital. Immediate surgical repair is indicated for Type A AAD. Uncomplicated Type B dissection is treated medically while the complicated cases will require open surgical or endovascular intervention.

Conclusion (proposition de traduction) : La dissection aortique aiguë peut être rapidement fatale, d'où la nécessité d'une reconnaissance rapide et de la mise en place d'une prise en charge appropriée. Une réparation chirurgicale immédiate est indiquée pour les dissections aortiques aiguës de type A. La dissection de type B non compliquée est traitée médicalement, tandis que les cas compliqués nécessitent une intervention chirurgicale ouverte ou endovasculaire.

Commentaire : POINTS CLÉS
■ La dissection aortique aiguë est une urgence vitale et la mortalité dépend du temps.
■ Un indice de suspicion élevé est nécessaire. Une tomodensitométrie avec ECG ± échocardiographie est nécessaire pour établir un diagnostic.
■ Une prise en charge médicale appropriée doit être mise en place et un transfert rapide vers un service cardiothoracique ou vasculaire en fonction du type de dissection aortique aiguë.

Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial).
Ko YC, Lin HY, Huang EP, Lee AF, Hsieh MJ, Yang CW, Lee BC, Wang YC, Yang WS, Chien YC, Sun JT, Ma MH, Chiang WC. | BMJ. 2024 Jul 23;386:e079878
DOI: https://doi.org/10.1136/bmj-2024-079878  | Télécharger l'article au format  
Keywords: Aucun

RESEARCH

Introduction : To compare the effectiveness of intraosseous versus intravenous vascular access in the treatment of adult patients with out-of-hospital cardiac arrest.

Méthode : Cluster randomised controlled trial. Setting: The VICTOR (Venous Injection Compared To intraOsseous injection during resuscitation of patients with out-of-hospital cardiac arrest) trial involved emergency medical service agencies with all four advanced life support ambulance teams in Taipei City, Taiwan. The enrolment period spanned 6 July 2020 to 30 June 2023 and was temporarily suspended between 20 May 2021 and 31 July 2021 owing to the covid-19 pandemic. Participants: Adult (age 20-80 years) patients with non-traumatic out-of-hospital cardiac arrest. Interventions: Biweekly randomised clusters of four participating advanced life support ambulance teams were assigned to insert either intravenous or intraosseous access. Main outcome measures: The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, sustained return of spontaneous circulation (≥2 hours), and survival with favourable neurological outcomes (cerebral performance category score ≤2) at hospital discharge.

Résultats : Among 1771 enrolled patients, 1732 (741 in the intraosseous group and 991 in the intravenous group) were included in the primary analysis (median age 65.0 years; 1234 (71.2%) men). In the intraosseous group, 79 (10.7%) patients were discharged alive, compared with 102 (10.3%) patients in the intravenous group (odds ratio 1.04, 95% confidence interval 0.76 to 1.42; P=0.81). The odds ratio of intraosseous versus intravenous access was 1.23 (0.89 to 1.69; P=0.21) for pre-hospital return of spontaneous circulation, 0.92 (0.75 to 1.13; P=0.44) for sustained return of spontaneous circulation, and 1.17 (0.82 to 1.66; P=0.39) for survival with favourable neurological outcomes.

Conclusion : Among adults with non-traumatic out-of-hospital cardiac arrest, initial attempts to establish vascular access through the intraosseous route did not result in different outcomes compared with intravenous access in terms of the proportion of patients surviving to hospital discharge, pre-hospital return of spontaneous circulation, sustained return of spontaneous circulation, and favourable neurological outcomes.

Conclusion (proposition de traduction) : Chez les adultes ayant fait un arrêt cardiaque non traumatique en dehors de l'hôpital, les tentatives initiales pour établir un accès vasculaire par voie intra-osseuse n'ont pas donné de résultats différents de ceux de l'accès intraveineux en termes de proportion de patients survivant jusqu'à la sortie de l'hôpital, de reprises pré-hospitalier d’activité circulatoire spontanée, dde reprises d’activité circulatoire spontanée et d'évolution favorable de l'état neurologique.

Evaluation and management of hypertensive emergency.
Miller JB, Hrabec D, Krishnamoorthy V, Kinni H, Brook RD. | BMJ. 2024 Jul 26;386:e077205
DOI: https://doi.org/10.1136/bmj-2023-077205
Keywords: Aucun

Clinical Review

Editorial : Hypertensive emergencies cause substantial morbidity and mortality, particularly when acute organ injury is present. Careful and effective strategies to reduce blood pressure and diminish the effects of pressure-mediated injury are essential. While the selection of specific antihypertensive medications varies little across different forms of hypertensive emergencies, the intensity of blood pressure reduction to the target pressure differs substantially. Treatment hinges on balancing the positive effects of lowering blood pressure with the potential for negative effects of organ hypoperfusion in patients with altered autoregulatory mechanisms. When patients do not have acute organ injury in addition to severe hypertension, they benefit from a conservative, outpatient approach to blood pressure management. In all cases, long term control of blood pressure is paramount to prevent recurrent hypertensive emergencies and improve overall prognosis. This review discusses the current evidence and guidelines on the evaluation and management of hypertensive emergency.

Conclusion : Hypertensive emergency is a major global public health problem. When hypertensive emergencies are present, immediate attention toward careful blood pressure reduction with intravenous antihypertensive medications is indicated to reduce morbidity. When an emergency is absent and patients have acute severe hypertension, attention shifts to optimizing outpatient management with oral agents. Given the lack of randomized trials to guide management of hypertensive emergency, there remains a large unmet need for further research in these areas.

Conclusion (proposition de traduction) : L'urgence hypertensive est un problème majeur de santé publique à l'échelle mondiale. En cas d'urgence hypertensive, une attention immédiate à la réduction de la pression artérielle avec des médicaments antihypertenseurs par voie intraveineuse est indiquée pour réduire la morbidité. Lorsqu'il n'y a pas d'urgence et que les patients souffrent d'hypertension aiguë sévère, l'attention se porte sur l'optimisation de la prise en charge ambulatoire avec des médicaments par voie orale. Étant donné l'absence d'essais randomisés pour guider la prise en charge de l'urgence hypertensive, il reste un grand besoin non satisfait de recherche dans ces domaines.

Commentaire : Approches thérapeutiques des syndromes d'urgence hypertendus

Does delayed sequence intubation with ketamine decrease the incidence of peri-intubation hypoxemia in trauma patients?.
Love A, Briggs A, Greenfield G, Hurdle H. | CJEM. CJEM. 2024 Jul 13. doi: 10.1007/s43678-024-00730-3
DOI: https://doi.org/10.1007/s43678-024-00730-3  | Télécharger l'article au format  
Keywords: Agitation; Critically ill; Delayed sequence intubation; Direct laryngoscopy; Hypoxemia; Hypoxia; Intubation; Ketamine; Pre-oxygenation; Rapid sequence intubation; Succinylcholine; Trauma.

Need to Know: CJEM Journal Club

Introduction : Agitated and delirious trauma patients pose a challenge with pre-oxygenation in the peri-intubation period. Peri-intubation hypoxemia is associated with negative outcomes like cardiac arrest, dysrhythmias, hemodynamic decompensation, and hypoxic brain injury. RSI is currently the preferred technique among many providers for emergency intubations.
• DSI—technique designed to improve oxygenation prior to intubation by providing controlled sedation to patients with altered mental status.
• RSI—administration of induction agent followed by neuromuscular blocking agent to create optimal intubating conditions while limiting duration of apnea and unprotected airway time.

Méthode : To determine if DSI with IV Ketamine decreases peri-intubation hypoxemia in trauma patients requiring definitive airway control compared to RSI.

Résultats : There were 100 patients in each intervention group. The indication for intubation was altered mental status in 97.5% of the patients. The most common mechanism of injury was motor vehicle accidents. The median Glasgow Coma Scale score in both groups was 6.
Oxygen saturation for each group was recorded at baseline and every 1 min for 3 min during pre-oxygenation and 1 min after intubation. The primary outcome, incidence of peri-intubation hypoxemia, was higher in the RSI group (35% vs. 8%; P < 0.001). Differences between groups occurred at the 1-min and 2-min marks pre-intubation. There was no difference in the primary outcome at the 3-min mark or 1-min post-intubation. The adjusted odds ratio of hypoxemia in the RSI group was 6.8 (95% CI 2.8–16.5).
With respect to secondary outcomes, the first pass intubation success rate was higher in the DSI group (83% vs. 69%; P = 0.02). Adverse events were comparable in both groups.

Conclusion : Airway management of critically ill trauma patients is a vital resuscitation procedure performed in the ED. Traumainduced factors such as agitation, soiled airways, facial fractures etc. pose significant challenges to procedural preparation and pre-oxygenation. RSI is currently the provider preferred technique for emergency intubations. According to Merelman et al., RSI may potentially harm patients who are inadequately pre-oxygenated. DSI utilizes dissociative doses of ketamine to relieve pain and agitation while maintaining spontaneous respirations and airway reflexes allowing for pre-oxygenation prior to intubation. An Australian prehospital study Waack et al. found that DSI was a safe and effective approach to pre-oxygenate agitated hypoxemic patients. A local trauma anesthetist commented that ketamine was used in this small study to help with the pre-oxygenation of trauma patients with severely depressed GCS scores who were randomized to delayed sequence or rapid sequence intubation. The use of ketamine to facilitate pre-oxygenation and subsequently a DSI may be a useful technique in certain trauma situations, but like all pharmacologic agents used in airway management the nuances of each clinical situation will dictate its appropriateness and dosing.

Conclusion (proposition de traduction) : La gestion des voies aériennes des patients traumatisés en état critique est une procédure de réanimation vitale pratiquée aux urgences. Les facteurs induits par le traumatisme, tels que l'agitation, les voies aériennes obstruées, les fractures faciales, etc. posent des défis importants à la préparation de la procédure et à la pré-oxygénation. L'intubation en séquence rapide est actuellement la technique préférée des prestataires pour les intubations d'urgence. Selon Merelman et al, l'intubation en séquence rapide peut potentiellement nuire aux patients qui ne sont pas suffisamment pré-oxygénés. L'intubation en séquence retardée utilise des doses dissociatives de kétamine pour soulager la douleur et l'agitation tout en maintenant les respirations spontanées et les réflexes des voies aériennes, ce qui permet une pré-oxygénation avant l'intubation. Une étude préhospitalière australienne menée par Waack et al. a montré que l'intubation en séquence retardée était une approche sûre et efficace pour pré-oxygéner les patients hypoxémiques agités. Un anesthésiste local spécialisé en traumatologie a indiqué que la kétamine avait été utilisée dans cette petite étude pour faciliter la préoxygénation des patients traumatisés dont le score de Glasgow était très bas et qui avaient été randomisés entre une intubation à séquence retardée et une intubation à séquence rapide. L'utilisation de la kétamine pour faciliter la pré-oxygénation puis l'intubation en séquence retardée peut être une technique utile dans certaines situations de traumatisme, mais comme pour tous les agents pharmacologiques utilisés dans la gestion des voies aériennes, les nuances de chaque situation clinique dicteront son adéquation et son dosage.

Opioid prescribing requirements to minimize unused medications after an emergency department visit for acute pain: a prospective cohort study.
Daoust R, Paquet J, Émond M, Iseppon M, Williamson D, Yan JW, Perry JJ, Huard V, Lavigne G, Lee J, Lessard J, Lang E, Cournoyer A; Quantity of Opioids for Acute Pain and Limit Unused Medication (OPUM) group on behalf of the Network of Canadian Emergency Researchers. | CMAJ. 2024 Jul 14;196(25):E866-E874
DOI: https://doi.org/10.1503/cmaj.231640  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : Unused opioid prescriptions can be a driver of opioid misuse. Our objective was to determine the optimal quantity of opioids to prescribe to patients with acute pain at emergency department discharge, in order to meet their analgesic needs while limiting the amount of unused opioids.

Méthode : In a prospective, multicentre cohort study, we included consecutive patients aged 18 years and older with an acute pain condition present for less than 2 weeks who were discharged from emergency department with an opioid prescription. Participants completed a pain medication diary for real-time recording of quantity, doses, and names of all analgesics consumed during a 14-day follow-up period.

Résultats : We included 2240 participants, who had a mean age of 51 years; 48% were female. Over 14 days, participants consumed a median of 5 (quartiles, 1-14) morphine 5 mg tablet equivalents, with significant variation across pain conditions (p < 0.001). Most opioid tablets prescribed (63%) were unused. To meet the opioid need of 80% of patients for 2 weeks, we found that those experiencing renal colic or abdominal pain required fewer opioid tablets (8 morphine 5 mg tablet equivalents) than patients who had fractures (24 tablets), back pain (21 tablets), neck pain (17 tablets), or other musculoskeletal pain (16 tablets).

Conclusion : Two-thirds of opioid tablets prescribed at emergency department discharge for acute pain were unused, whereas opioid requirements varied significantly based on the cause of acute pain. Smaller, cause-specific opioid prescriptions could provide adequate pain management while reducing the risk of opioid misuse.

Conclusion (proposition de traduction) : Deux tiers des comprimés de morphiniques prescrits à la sortie des urgences pour une douleur aiguë n'ont pas été administrés, alors que les besoins en morphiniques varient considérablement en fonction de la cause de la douleur aiguë. Des prescriptions de morphiniques moindres et spécifiques à la cause pourraient permettre un traitement adéquat de la douleur tout en réduisant le risque de mésusage des morphiniques.

Comparison of early and late norepinephrine administration in patients with septic shock: a systematic review and meta-analysis.
Ahn C, Yu G, Shin TG, Cho Y, Park S, Suh GY. | Chest. 2024 Jul 5:S0012-3692(24)04581-1.
DOI: https://doi.org/10.1016/j.chest.2024.05.042
Keywords: Meta-analysis; Norepinephrine; Sepsis; Septic shock; Timing; Vasopressor.

Critical Care: Original Research

Introduction : Vasopressor administration at an appropriate time is crucial but the optimal timing remains controversial.
Research question: Does early versus late norepinephrine (NE) administration impact the prognosis of septic shock?

Méthode : Searches were conducted on PubMed, EMBASE, the Cochrane Library, and KMBASE. We included studies of adults with sepsis and categorized patients into early and late NE group according to specific time points or differences in norepinephrine use protocols. The primary outcome was overall mortality. The secondary outcomes included length of stay in the intensive care unit, days free from ventilator use, days free from renal replacement therapy, days free from vasopressor use, adverse events, and total fluid volume.

Résultats : Twelve studies (4 randomized controlled trials [RCTs], 8 observational) comprising 7,281 patients were analyzed. For overall mortality, no significant difference was found between the early NE group and late NE group in RCTs (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.41-1.19) or observational studies (OR, 0.83; 95% CI, 0.54-1.29). In the two RCTs without a restrictive fluid strategy that prioritized vasopressors and lower intravenous fluid volumes, the early NE group showed significantly lower mortality than the late NE group (OR 0.49, 95%, CI, 0.25-0.96). The early NE group demonstrated more mechanical ventilator-free days in observational studies (MD, 4.06; 95% CI, 2.82-5.30). The incidence of pulmonary edema was lower in the early NE group in the three RCTs that reported this outcome (OR 0.43; 95% CI, 0.25-0.74). No differences were found in the other secondary outcomes.

Conclusion : Overall mortality did not differ significantly between early and late NE administration for septic shock. However, early NE administration appeared to reduce pulmonary edema incidence, and mortality improvement was observed in studies without fluid restriction interventions, favoring early NE use.

Conclusion (proposition de traduction) : La mortalité globale ne diffère pas de manière significative entre l'administration précoce et tardive de noradrénaline dans le cas d'un choc septique. Cependant, l'administration précoce de norépinéphrine semble réduire l'incidence de l'œdème pulmonaire, et une amélioration de la mortalité a été observée dans les études sans intervention de restriction hydrique, ce qui plaide en faveur d'une utilisation précoce de la norépinéphrine.

Mechanical versus manual cardiopulmonary resuscitation (CPR): an umbrella review of contemporary systematic reviews and more.
El-Menyar A, Naduvilekandy M, Rizoli S, Di Somma S, Cander B, Galwankar S, Lateef F, Abdul Rahman MA, Nanayakkara P, Al-Thani H. | Crit Care. 2024 Jul 30;28(1):259
DOI: https://doi.org/10.1186/s13054-024-05037-4  | Télécharger l'article au format  
Keywords: CPR; Cardiac arrest; IHCA; Manual CPR; Mechanical CPR; OHCA; ROSC; Survival.

Review

Introduction : High-quality cardiopulmonary resuscitation (CPR) can restore spontaneous circulation (ROSC) and neurological function and save lives. We conducted an umbrella review, including previously published systematic reviews (SRs), that compared mechanical and manual CPR; after that, we performed a new SR of the original studies that were not included after the last published SR to provide a panoramic view of the existing evidence on the effectiveness of CPR methods.

Méthode : PubMed, EMBASE, and Medline were searched, including English in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) SRs, and comparing mechanical versus manual CPR. A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) and GRADE were used to assess the quality of included SRs/studies. We included both IHCA and OHCA, which compared mechanical and manual CPR. We analyzed at least one of the outcomes of interest, including ROSC, survival to hospital admission, survival to hospital discharge, 30-day survival, and survival to hospital discharge with good neurological function. Furthermore, subgroup analyses were performed for age, gender, initial rhythm, arrest location, and type of CPR devices.

Résultats : We identified 249 potentially relevant records, of which 238 were excluded. Eleven SRs were analyzed in the Umbrella review (January 2014-March 2022). Furthermore, for a new, additional SR, we identified eight eligible studies (not included in any prior SR) for an in-depth analysis between April 1, 2021, and February 15, 2024. The higher chances of using mechanical CPR for male patients were significantly observed in three studies. Two studies showed that younger patients received more mechanical treatment than older patients. However, studies did not comment on the outcomes based on the patient's gender or age. Most SRs and studies were of low to moderate quality. The pooled findings did not show the superiority of mechanical compared to manual CPR except in a few selected subgroups.

Conclusion : Given the significant heterogeneity and methodological limitations of the included studies and SRs, our findings do not provide definitive evidence to support the superiority of mechanical CPR over manual CPR. However, mechanical CPR can serve better where high-quality manual CPR cannot be performed in selected situations.

Conclusion (proposition de traduction) : Compte tenu de l'hétérogénéité significative et des limites méthodologiques des études et des revues systématiques incluses, nos résultats ne fournissent pas de preuves définitives de la supériorité de la RCP mécanique par rapport à la RCP manuelle. Toutefois, la RCP mécanique peut s'avérer plus efficace lorsqu'une RCP manuelle de haute qualité ne peut être réalisée dans certaines situations.

High flow nasal cannula oxygen therapy versus non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: a randomized controlled non-inferiority trial.
Tan D, Wang B, Cao P, Wang Y, Sun J, Geng P, Walline JH, Wang Y, Wang C. | Crit Care. 2024 Jul 18;28(1):250
DOI: https://doi.org/10.1186/s13054-024-05040-9  | Télécharger l'article au format  
Keywords: Chronic obstructive pulmonary diseases; High-flow nasal cannula oxygen therapy; Non-invasive ventilation; Randomized controlled trial; Respiratory failure.

Research

Introduction : Although cumulative studies have demonstrated a beneficial effect of high-flow nasal cannula oxygen (HFNC) in acute hypercapnic respiratory failure, randomized trials to compare HFNC with non-invasive ventilation (NIV) as initial treatment in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients with acute-moderate hypercapnic respiratory failure are limited. The aim of this randomized, open label, non-inferiority trial was to compare treatment failure rates between HFNC and NIV in such patients.

Méthode : Patients diagnosed with AECOPD with a baseline arterial blood gas pH between 7.25 and 7.35 and PaCO₂ ≥ 50 mmHg admitted to two intensive care units (ICUs) at a large tertiary academic teaching hospital between March 2018 and December 2022 were randomly assigned to HFNC or NIV. The primary endpoint was the rate of treatment failure, defined as endotracheal intubation or a switch to the other study treatment modality. Secondary endpoints were rates of intubation or treatment change, blood gas values, vital signs at one, 12, and 48 h, 28-day mortality, as well as ICU and hospital lengths of stay.

Résultats : 225 total patients (113 in the HFNC group and 112 in the NIV group) were included in the intention-to-treat analysis. The failure rate of the HFNC group was 25.7%, while the NIV group was 14.3%. The failure rate risk difference between the two groups was 11.38% (95% CI 0.25-21.20, P = 0.033), which was higher than the non-inferiority cut-off of 9%. In the per-protocol analysis, treatment failure occurred in 28 of 110 patients (25.5%) in the HFNC group and 15 of 109 patients (13.8%) in the NIV group (risk difference, 11.69%; 95% CI 0.48-22.60). The intubation rate in the HFNC group was higher than in the NIV group (14.2% vs 5.4%, P = 0.026). The treatment switch rate, ICU and hospital length of stay or 28-day mortality in the HFNC group were not statistically different from the NIV group (all P > 0.05).

Conclusion : HFNC was not shown to be non-inferior to NIV and resulted in a higher incidence of treatment failure than NIV when used as the initial respiratory support for AECOPD patients with acute-moderate hypercapnic respiratory failure.

Conclusion (proposition de traduction) : L'oxygénothérapie par canules nasales à haut débit ne s'est pas révélée non inférieure à la VNI et a entraîné une incidence plus élevée d'échecs thérapeutiques que la VNI lorsqu'elle était utilisée comme soutien respiratoire initial lors d'exacerbations aiguës de patients atteints de bronchopneumopathie chronique obstructive et présentant une insuffisance respiratoire hypercapnique aiguë et modérée.

Andexanet alpha versus four-factor prothrombin complex concentrate in DOACs anticoagulation reversal: an updated systematic review and meta-analysis.
Orso D, Fonda F, Brussa A, Comisso I, Auci E, Sartori M, Bove T. | Crit Care. 2024 Jul 5;28(1):221
DOI: https://doi.org/10.1186/s13054-024-05014-x  | Télécharger l'article au format  
Keywords: 4F-PCC; Andexanet alpha; Anticoagulation reversal; DOACs; Haemorrhage; Meta-analysis.

Review

Introduction : There is currently a lack of evidence for the comparative effectiveness of Andexanet alpha and four-factor prothrombin complex concentrate (4F-PCC) in anticoagulation reversal of direct oral anticoagulants (DOACs). The primary aim of our systematic review was to verify which drug is more effective in reducing short-term all-cause mortality. The secondary aim was to determine which of the two reverting strategies is less affected by thromboembolic events.

Méthode : A systematic review and meta-analysis was performed.

Résultats : Twenty-two studies were analysed in the systematic review and quantitative synthesis. In all-cause short-term mortality, Andexanet alpha showed a risk ratio (RR) of 0.71(95% CI 0.37-1.34) in RCTs and PSMs, compared to 4F-PCC (I² = 81%). Considering the retrospective studies, the pooled RR resulted in 0.84 (95% CI 0.69-1.01) for the common effects model and 0.82 (95% CI 0.63-1.07) for the random effects model (I² = 34.2%). Regarding the incidence of thromboembolic events, for RCTs and PSMs, the common and the random effects model exhibited a RR of 1.74 (95% CI 1.09-2.77), and 1.71 (95% CI 1.01-2.89), respectively, for Andexanet alpha compared to 4F-PCC (I² = 0%). Considering the retrospective studies, the pooled RR resulted in 1.21 (95% CI 0.87-1.69) for the common effects model and 1.18 (95% CI 0.86-1.62) for the random effects model (I² = 0%).

Conclusion : Considering a large group of both retrospective and controlled studies, Andexanet alpha did not show a statistically significant advantage over 4F-PCC in terms of mortality. In the analysis of the controlled studies alone, Andexanet alpha is associated with an increased risk of thromboembolic events.

Conclusion (proposition de traduction) : Sur la base d'un large groupe d'études rétrospectives et contrôlées, Andexanet alpha n'a pas montré d'avantage statistiquement significatif par rapport au concentré de complexe prothrombique à quatre facteurs en termes de mortalité. Dans l'analyse des seules études contrôlées, Andexanet alpha est associé à un risque accru d'événements thromboemboliques.

Fluid management for sepsis-induced hypotension in patients with advanced chronic kidney disease: a secondary analysis of the CLOVERS trial.
Jorda A, Douglas IS, Staudinger T, Heinz G, Bergmann F, Oberbauer R, Sengölge G, Zeitlinger M, Jilma B, Shapiro NI, Gelbenegger G. | Crit Care. 2024 Jul 11;28(1):231
DOI: https://doi.org/10.1186/s13054-024-05019-6  | Télécharger l'article au format  
Keywords: Bacteremia; Chronic kidney disease; Dialysis; Hypervolemia; Septic shock; Vasopressor.

Research

Introduction : Early fluid management in patients with advanced chronic kidney disease (CKD) and sepsis-induced hypotension is challenging with limited evidence to support treatment recommendations. We aimed to compare an early restrictive versus liberal fluid management for sepsis-induced hypotension in patients with advanced CKD.

Méthode : This post-hoc analysis included patients with advanced CKD (eGFR of less than 30 mL/min/1.73 m² or history of end-stage renal disease on chronic dialysis) from the crystalloid liberal or vasopressor early resuscitation in sepsis (CLOVERS) trial. The primary endpoint was death from any cause before discharge home by day 90.

Résultats : Of 1563 participants enrolled in the CLOVERS trial, 196 participants had advanced CKD (45% on chronic dialysis), with 92 participants randomly assigned to the restrictive treatment group and 104 assigned to the liberal fluid group. Death from any cause before discharge home by day 90 occurred significantly less often in the restrictive fluid group compared with the liberal fluid group (20 [21.7%] vs. 41 [39.4%], HR 0.5, 95% CI 0.29-0.85). Participants in the restrictive fluid group had more vasopressor-free days (19.7 ± 10.4 days vs. 15.4 ± 12.6 days; mean difference 4.3 days, 95% CI, 1.0-7.5) and ventilator-free days by day 28 (21.0 ± 11.8 vs. 16.5 ± 13.6 days; mean difference 4.5 days, 95% CI, 0.9-8.1).

Conclusion : In patients with advanced CKD and sepsis-induced hypotension, an early restrictive fluid strategy, prioritizing vasopressor use, was associated with a lower risk of death from any cause before discharge home by day 90 as compared with an early liberal fluid strategy.

Conclusion (proposition de traduction) : Chez les patients présentant une IRC avancée et une hypotension induite par le sepsis, une stratégie de remplissage vasculaire restrictive précoce, donnant la priorité à l'utilisation de vasopresseurs, a été associée à un risque plus faible de décès, quelle qu'en soit la cause, avant la sortie à domicile au 90^e jour, par rapport à une stratégie de remplissage vasculaire libérale précoce.

Analgesia and Sedation Use During Noninvasive Ventilation for Acute Respiratory Failure.
Dunbar PJ, Peterson R, McGrath M, Pomponio R, Kiser TH, Ho PM, Vandivier RW, Burnham EL, Moss M, Sottile PD; Colorado Pulmonary Outcomes Research Group. | Crit Care Med. 2024 Jul 1;52(7):1043-1053
DOI: https://doi.org/10.1097/ccm.0000000000006253
Keywords: Aucun

FEATURE ARTICLE

Introduction : To describe U.S. practice regarding administration of sedation and analgesia to patients on noninvasive ventilation (NIV) for acute respiratory failure (ARF) and to determine the association of this practice with odds of intubation or death.

Méthode : A retrospective multicenter cohort study.
Setting: A total of 1017 hospitals contributed data between January 2010 and September 2020 to the Premier Healthcare Database, a nationally representative healthcare database in the United States.
Patients: Adult (≥ 18 yr) patients admitted to U.S. hospitals requiring NIV for ARF.
Interventions: None.

Résultats : We identified 433,357 patients on NIV of whom (26.7% [95% CI] 26.3%-27.0%) received sedation or analgesia. A total of 50,589 patients (11.7%) received opioids only, 40,646 (9.4%) received benzodiazepines only, 20,146 (4.6%) received opioids and benzodiazepines, 1.573 (0.4%) received dexmedetomidine only, and 2,639 (0.6%) received dexmedetomidine in addition to opioid and/or benzodiazepine. Of 433,357 patients receiving NIV, 50,413 (11.6%; 95% CI, 11.5-11.7%) patients underwent invasive mechanical ventilation on hospital days 2-5 or died on hospital days 2-30. Intubation was used in 32,301 patients (7.4%; 95% CI, 7.3-7.6%). Further, death occurred in 24,140 (5.6%; 95% CI, 5.5-5.7%). In multivariable analysis adjusting for relevant covariates, receipt of any medication studied was associated with increased odds of intubation or death. In inverse probability weighting, receipt of any study medication was also associated with increased odds of intubation or death (average treatment effect odds ratio 1.38; 95% CI, 1.35-1.40).

Conclusion : The use of sedation and analgesia during NIV is common. Medication exposure was associated with increased odds of intubation or death. Further investigation is needed to confirm this finding and determine whether any subpopulations are especially harmed by this practice.

Conclusion (proposition de traduction) : Le recours à la sédation et à l'analgésie pendant la ventilation non invasive est courant. L'exposition aux médicaments a été associée à un risque accru d'intubation ou de décès. D'autres études sont nécessaires pour confirmer ces résultats et déterminer si des sous-populations sont particulièrement affectées par cette pratique.

Beneficial Effect of Calcium Treatment for Hyperkalemia Is Not Due to "Membrane Stabilization".
Piktel JS, Wan X, Kouk S, Laurita KR, Wilson LD. | Crit Care Med. 2024 Jul 24
DOI: https://doi.org/10.1097/ccm.0000000000006376
Keywords: Aucun

LABORATORY INVESTIGATION

Introduction : Hyperkalemia is a common life-threatening condition causing severe electrophysiologic derangements and arrhythmias. The beneficial effects of calcium (Ca2+) treatment for hyperkalemia have been attributed to "membrane stabilization," by restoration of resting membrane potential (RMP). However, the underlying mechanisms remain poorly understood. Our objective was to investigate the mechanisms underlying adverse electrophysiologic effects of hyperkalemia and the therapeutic effects of Ca2+ treatment.

Méthode : Controlled experimental trial.
Setting: Laboratory investigation.
Subjects: Canine myocytes and tissue preparations.
Interventions and measurements: Optical action potentials and volume averaged electrocardiograms were recorded from the transmural wall of ventricular wedge preparations (n = 7) at baseline (4 mM potassium), hyperkalemia (8-12 mM), and hyperkalemia + Ca2+ (3.6 mM). Isolated myocytes were studied during hyperkalemia (8 mM) and after Ca2+ treatment (6 mM) to determine cellular RMP.

Résultats : Hyperkalemia markedly slowed conduction velocity (CV, by 67% ± 7%; p < 0.001) and homogeneously shortened action potential duration (APD, by 20% ± 10%; p < 0.002). In all preparations, this resulted in QRS widening and the "sine wave" pattern observed in severe hyperkalemia. Ca2+ treatment restored CV (increase by 44% ± 18%; p < 0.02), resulting in narrowing of the QRS and normalization of the electrocardiogram, but did not restore APD. RMP was significantly elevated by hyperkalemia; however, it was not restored with Ca2+ treatment suggesting a mechanism unrelated to "membrane stabilization." In addition, the effect of Ca2+ was attenuated during L-type Ca2+ channel blockade, suggesting a mechanism related to Ca2+-dependent (rather than normally sodium-dependent) conduction.

Conclusion : These data suggest that Ca2+ treatment for hyperkalemia restores conduction through Ca2+-dependent propagation, rather than restoration of membrane potential or "membrane stabilization." Our findings provide a mechanistic rationale for Ca2+ treatment when hyperkalemia produces abnormalities of conduction (i.e., QRS prolongation).

Conclusion (proposition de traduction) : Ces données suggèrent que le traitement de l'hyperkaliémie par le Ca²⁺ rétablit la conduction par une propagation dépendante du Ca²⁺, plutôt que par le rétablissement du potentiel de membrane ou la « stabilisation de membrane ». Nos résultats fournissent une justification mécaniste du traitement par Ca2+ lorsque l'hyperkaliémie entraîne des anomalies de la conduction (c'est-à-dire un allongement du QRS).

Association of intravenous digoxin use in acute heart failure with rapid atrial fibrillation and short-term mortality according to patient age, renal function, and serum potassium.
Miró Ò, Martín Mojarro E, Lopez-Ayala P, Llorens P, Gil V, Alquézar-Arbé A, Bibiano C, Pavón J, Massó M, Strebel I, Espinosa B, Mínguez Masó S, Jacob J, Millán J, Andueza JA, Alonso H, Herrero-Puente P, Mueller C; (on behalf of the investigators of the ICA-SEMES research group). | Eur J Emerg Med. 2024 Jul 8
DOI: https://doi.org/10.1097/mej.0000000000001153
Keywords: Aucun

Original article

Introduction : Intravenous digoxin is still used in emergency departments (EDs) to treat patients with acute heart failure (AHF), especially in those with rapid atrial fibrillation. We investigated whether intravenous digoxin used to treat rapid atrial fibrillation in patients with AHF may influence mortality.

Méthode : A secondary analysis of patients included in the Spanish EAHFE (Epidemiology of Acute Heart Failure in Emergency Departments) cohort, which includes patients diagnosed with AHF in 45 Spanish EDs. The relationships between age, estimated glomerular filtration rate, and potassium with 30-day mortality were investigated using restricted cubic spline models adjusted for relevant patient and episode variables.

Résultats : From the 19 947 patients included, we analyzed 2194 patients with AHF and rapid atrial fibrillation that not receiving digoxin at home, divided according to whether they were or were not treated with intravenous digoxin in the ED. The median age of the patients was 82 years (interquartile range=76-87), 61.4% were women and 65.2% had previous episodes of atrial fibrillation. Digoxin and no digoxin groups were formed by 864 (39.4%) and 1330 (60.6%) patients, respectively. There were 191 deaths within the 30-day follow-up period (8.9%), with no differences between patients receiving or not receiving digoxin (8.5 vs. 9.1%, P = 0.636). Although analysis of restricted cubic spline curves showed that death was associated with advanced age, worse renal function, and hypokalemia and hyperkalemia, the use of intravenous digoxin did not interact with any of these relationships (P = 0.156 for age, P = 0.156 for estimated glomerular filtration rate, P = 0.429 for potassium).

Conclusion : The use of intravenous digoxin in the ED was not associated with significant changes in 30-day mortality, which was confirmed irrespective of patient age or the existence of renal dysfunction or serum potassium disturbances.

Conclusion (proposition de traduction) : L'utilisation de digoxine intraveineuse aux urgences n'a pas été associée à des changements significatifs de la mortalité à 30 jours, ce qui a été confirmé indépendamment de l'âge du patient ou de l'existence d'un dysfonctionnement rénal ou de troubles du potassium sérique.

Effect of the 1-h bundle on mortality in patients with suspected sepsis in the emergency department: a stepped wedge cluster randomized clinical trial.
Freund Y, Cancella de Abreu M, Lebal S, Rousseau A, Lafon T, Yordanov Y, Macrez R, Coisy F, Le Borgne P, Femy F, Douillet D, Boter NR, Eyer X, Bouillon-Minois JB, Ogereau C, Bouzid D, Goulet H, Roussel M, Rousseau G, Guénézan J, Occelli C, Chouihed T, Osorio Quispe G, Renard MC, Gorlicki J, Bloom B, Simon T, Gerlier C. | Intensive Care Med. 2024 Jul;50(7):1086-1095
DOI: https://doi.org/10.1007/s00134-024-07509-1
Keywords: Emergency department; Fluids resuscitation; Sepsis; Shock.

Original

Introduction : The efficacy of the 1-h bundle for emergency department (ED) patients with suspected sepsis, which includes lactate measurement, blood culture, broad-spectrum antibiotics administration, administration of 30 mL/kg crystalloid fluid for hypotension or lactate ≥ 4 mmol/L, remains controversial.

Méthode : We carried out a pragmatic stepped-wedge cluster-randomized trial in 23 EDs in France and Spain. Adult patients with Sepsis-3 criteria or a quick sequential organ failure assessment (SOFA) score ≥ 2 or a lactate > 2 mmol/L were eligible. The intervention was the implementation of the 1-h sepsis bundle. The primary outcome was in-hospital mortality truncated at 28 days. Secondary outcomes included volume of fluid resuscitation at 24 h, acute heart failure at 24 h, SOFA score at 72 h, intensive care unit (ICU) length of stay, number of days on mechanical ventilation or renal replacement therapy, vasopressor free days, unnecessary antibiotic administration, and mortality at 28 days. 1148 patients were planned to be analysed; the study period ended after 873 patients were included.

Résultats : 872 patients (mean age 66, 42% female) were analyzed: 387 (44.4%) in the intervention group and 485 (55.6%) in the control group. Median SOFA score was 3 [1–5]. Median time to antibiotic administration was 40 min in the intervention group vs 113 min in the control group (difference − 73 [95% confidence interval (CI) − 93 to − 53]). There was a significantly higher rate, volume, and shorter time to fluid resuscitation within 3 h in the intervention group. There were 47 (12.1%) in-hospital deaths in the intervention group compared to 61 (12.6%) in the control group (difference in percentage − 0.4 [95% CI − 5.1 to 4.2], adjusted relative risk (aRR) 0.81 [95% CI 0.48 to 1.39]). There were no differences between groups for other secondary endpoints.

Conclusion : Among patients with suspected sepsis in the ED, the implementation of the 1-h sepsis bundle was not associated with significant difference in in-hospital mortality. However, this study may be underpowered to report a statistically significant difference between groups.

Conclusion (proposition de traduction) : Chez les patients suspects de sepsis aux urgences, la mise en œuvre de l'ensemble de mesures relatives à la prise en charge du sepsis en une heure n'a pas été associée à une différence significative en termes de mortalité à l'hôpital. Toutefois, cette étude n'a peut-être pas la puissance nécessaire pour faire état d'une différence statistiquement significative entre les groupes.

The MINUTES bundle for the initial 30 min management of undifferentiated circulatory shock: an expert opinion.
Hasanin A, Sanfilippo F, Dünser MW, Ahmed HM, Zieleskiewicz L, Myatra SN, Mostafa M. | Int J Emerg Med. 2024 Jul 25;17(1):96
DOI: https://doi.org/10.1186/s12245-024-00660-y  | Télécharger l'article au format  
Keywords: Congestion; Fluids; Hypotension; Norepinephrine; Shock; Ultrasound; Vasopressors.

REVIEW

Editorial : Acute circulatory shock is a life-threatening emergency requiring an efficient and timely management plan, which varies according to shock etiology and pathophysiology. Specific guidelines have been developed for each type of shock; however, there is a need for a clear timeline to promptly implement initial life-saving interventions during the early phase of shock recognition and management. A simple, easily memorable bundle of interventions could facilitate standardized management with clear targets and specified timeline. The authors propose the "MINUTES" acronym which summarizes essential interventions which should be performed within the first 30 min following shock recognition. All the interventions in the MINUTES bundle are suitable for any patient with undifferentiated shock. In addition to the acronym, we suggest a timeline for each step, balancing the feasibility and urgency of each intervention. The MINUTES acronym includes seven sequential steps which should be performed in the first 30 min following shock recognition: Maintain "ABCs", INfuse vasopressors and/or fluids (to support hemodynamic/perfusion) and INvestigate with simple blood tests, Ultrasound to detect the type of shock, Treat the underlying Etiology, and Stabilize organ perfusion.

Conclusion (proposition de traduction) : Les premières phases de la prise en charge du choc indifférencié nécessitent un plan clair avec des étapes, des objectifs et un planning bien définis. Bien qu'il existe des directives spécifiques pour la prise en charge de certains types de chocs, le plan initial de prise en charge du choc indifférencié doit être unifié. Nous proposons l'acronyme MINUTES pour fournir un schéma simplifié et simultanément mémorisable des étapes initiales de la prise en charge du choc à mettre en œuvre dans les 30 premières minutes suivant l'identification du choc.
L'acronyme comprend les éléments suivants : Maintenir les "ABC", Perfuser des vasopresseurs et/ou des solutés de remplissage (pour améliorer l'hémodynamique et la perfusion) et procéder à des examens sanguins simples et à une échographie pour détecter le type de choc, traiter l'étiologie sous-jacente et stabiliser la perfusion des organes.
Nous pensons que MINUTES aiderait les médecins urgentistes à organiser leur prise en charge et leurs priorités dans les premiers moments critiques de l'état de choc. De futures études sont nécessaires pour valider l'impact de l'application de MINUTES sur les résultats des patients.

Commentaire : MINUTES : Maintain "ABCs", INfuse vasopressors and/or fluids (to support hemodynamic/perfusion) and INvestigate with simple blood tests, Ultrasound to detect the type of shock, Treat the underlying Etiology, and Stabilize organ perfusion.

Description de l'acronyme MINUTES.
PNX : pneumothorax

Mortality of Patients With Sepsis Administered Piperacillin-Tazobactam vs Cefepime.
Chanderraj R, Admon AJ, He Y, Nuppnau M, Albin OR, Prescott HC, Dickson RP, Sjoding MW. | JAMA Intern Med. 2024 Jul 1;184(7):769-777
DOI: https://doi.org/10.1001/jamainternmed.2024.0581
Keywords: Aucun

Original Investigation | Less Is More

Introduction : Experimental and observational studies have suggested that empirical treatment for bacterial sepsis with antianaerobic antibiotics (eg, piperacillin-tazobactam) is associated with adverse outcomes compared with anaerobe-sparing antibiotics (eg, cefepime). However, a recent pragmatic clinical trial of piperacillin-tazobactam and cefepime showed no difference in short-term outcomes at 14 days. Further studies are needed to help clarify the empirical use of these agents.

Méthode : To examine the use of piperacillin-tazobactam compared with cefepime in 90-day mortality in patients treated empirically for sepsis, using instrumental variable analysis of a 15-month piperacillin-tazobactam shortage.
Design, setting, and participants: In a retrospective cohort study, hospital admissions at the University of Michigan from July 1, 2014, to December 31, 2018, including a piperacillin-tazobactam shortage period from June 12, 2015, to September 18, 2016, were examined. Adult patients with suspected sepsis treated with vancomycin and either piperacillin-tazobactam or cefepime for conditions with presumed equipoise between piperacillin-tazobactam and cefepime were included in the study. Data analysis was conducted from December 17, 2022, to April 11, 2023.
Main outcomes and measures: The primary outcome was 90-day mortality. Secondary outcomes included organ failure-free, ventilator-free, and vasopressor-free days. The 15-month piperacillin-tazobactam shortage period was used as an instrumental variable for unmeasured confounding in antibiotic selection.

Résultats : Among 7569 patients (4174 men [55%]; median age, 63 [IQR 52-73] years) with sepsis meeting study eligibility, 4523 were treated with vancomycin and piperacillin-tazobactam and 3046 were treated with vancomycin and cefepime. Of patients who received piperacillin-tazobactam, only 152 (3%) received it during the shortage. Treatment groups did not differ significantly in age, Charlson Comorbidity Index score, Sequential Organ Failure Assessment score, or time to antibiotic administration. In an instrumental variable analysis, piperacillin-tazobactam was associated with an absolute mortality increase of 5.0% at 90 days (95% CI, 1.9%-8.1%) and 2.1 (95% CI, 1.4-2.7) fewer organ failure-free days, 1.1 (95% CI, 0.57-1.62) fewer ventilator-free days, and 1.5 (95% CI, 1.01-2.01) fewer vasopressor-free days.

Conclusion : Among patients with suspected sepsis and no clear indication for antianaerobic coverage, administration of piperacillin-tazobactam was associated with higher mortality and increased duration of organ dysfunction compared with cefepime. These findings suggest that the widespread use of empirical antianaerobic antibiotics in sepsis may be harmful.

Conclusion (proposition de traduction) : Chez les patients suspects de septicémie et sans indication claire de couverture antianaérobie, l'administration de pipéracilline-tazobactam a été associée à une mortalité plus élevée et à une durée plus longue de défaillance des organes, par rapport au céfépime. Ces résultats suggèrent que l'utilisation généralisée d'antibiotiques antianaérobies empiriques en cas de septicémie peut être préjudiciable.

Commentaire : Chez les patients adultes présentant une septicémie, l'utilisation empirique de vancomycine et de pipéracilline/tazobactam par rapport à la vancomycine et au céfépime, lorsqu'une couverture anti-anaérobie n'était pas cliniquement indiquée, a été associée à une augmentation de 5 % de la mortalité.

Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians.
Wu L, Rodriguez M, El Hachem K, Krittanawong C. | J Clin Med. 2024 Jul 30;13(15):4470
DOI: https://doi.org/10.3390/jcm13154470  | Télécharger l'article au format  
Keywords: diuretic; heart failure

Review

Editorial : Congestion and fluid retention are the hallmarks of decompensated heart failure and the major reason for the hospitalization of patients with heart failure. Diuretics have been used in heart failure for decades, and they remain the backbone of the contemporary management of heart failure. Loop diuretics is the preferred diuretic, and it has been given a class I recommendation by clinical guidelines for the relief of congestion symptoms. Although loop diuretics have been used virtually among all patients with acute decompensated heart failure, there is still very limited clinical evidence to guide the optimized diuretics use. This is a sharp contrast to the rapidly growing evidence of the rest of the guideline-directed medical therapy of heart failure and calls for further studies. The loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency. However, many of these approaches have not been evaluated in randomized clinical trials. In recent years, a stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy. Diuretic resistance has been a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Recently, therapy options have emerged to help overcome diuretic resistance to loop diuretics and have been evaluated in randomized clinical trials. In this review, we aim to provide a comprehensive review of the pharmacology and clinical use of loop diuretics in the context of heart failure, with attention to its side effects, and adjuncts, as well as the challenges and future direction.

Conclusion : Diuretics have been the cornerstone for the management of heart failure for decades and have undoubtedly improved the outcome of patients with heart failure. In the era of evidence-based medicine, further studies are needed to better delineate the optimized diuretic strategy for acute decompensated heart failure, diuretic resistance, and chronic congestive heart failure. The standardized and protocol-driving diuretics strategy and measurement of decongestion, as shown in recent clinical studies, have been proven to provide more consistent outcomes and allow for a comparison of clinical outcomes between clinical trials. Its impact on survival benefits and the long-term outcome of heart failure is still unclear. The early identification of patients at risk for diuretic resistance and the involvement of multidisciplinary care is crucial in patients with high-risk heart failure. With more and more evidence emerging for newer adjuncts to traditional diuretics, it is also important to study the long-term CV and renal outcomes of these agents. An optimized strategy of diuretics remains to be defined for ambulatory diuretics use in patients with chronic heart failure. It might be beneficial to down-titrate or withdraw diuretics in patients with improved cardiac function after medical therapy. Novel approaches such as implantable hemodynamics monitoring provide a promising future for hemodynamic-guided diuretics treatment.

Conclusion (proposition de traduction) : Les diurétiques sont la pierre angulaire de la prise en charge de l'insuffisance cardiaque depuis des décennies et ont sans aucun doute amélioré le pronostic des patients présentant une insuffisance cardiaque. À l'ère de la médecine fondée sur les preuves, d'autres études sont nécessaires pour mieux définir la stratégie diurétique optimisée dans l'insuffisance cardiaque aiguë décompensée, la résistance aux diurétiques et l'insuffisance cardiaque congestive chronique. Il a été prouvé que la stratégie diurétique normalisée et conforme au protocole et la mesure de la décongestion, telles qu'elles ont été démontrées dans des études cliniques récentes, donnent des résultats plus cohérents et permettent une comparaison des résultats cliniques entre les essais cliniques. Son impact sur les bénéfices en termes de survie et sur les résultats à long terme de l'insuffisance cardiaque n'est pas encore clair. L'identification précoce des patients présentant un risque de résistance aux diurétiques et l'implication de soins multidisciplinaires sont cruciales pour les patients présentant une insuffisance cardiaque à haut risque. Alors que de plus en plus de preuves émergent en faveur de nouveaux adjuvants aux diurétiques traditionnels, il est également important d'étudier les résultats cardiovasculaires et rénaux à long terme de ces agents. Une stratégie optimisée de diurétiques reste à définir pour l'utilisation ambulatoire de diurétiques chez les patients souffrant d'insuffisance cardiaque chronique. Il pourrait être bénéfique de diminuer la dose ou d'arrêter les diurétiques chez les patients dont la fonction cardiaque s'est améliorée après un traitement médical. De nouvelles approches telles que la surveillance hémodynamique implantable offrent un avenir prometteur pour le traitement diurétique guidé par l'hémodynamique.

Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations.
Narendren A, Whitehead N, Burrell LM, Yudi MB, Yeoh J, Jones N, Weinberg L, Miles LF, Lim HS, Clark DJ, Al-Fiadh A, Farouque O, Koshy AN. | J Clin Med. 2024 Jul 28;13(15):4416
DOI: https://doi.org/10.3390/jcm13154416  | Télécharger l'article au format  
Keywords: acute coronary syndrome; cardiovascular disease; coronary artery disease; frailty; multimorbidity; octogenarians; older adults.

Review

Editorial : Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.

Conclusion : Managing ACS in older adults presents unique challenges, because of age-related physiological changes, the prevalence of geriatric syndromes, patient goals of care, and frailty, in addition to understanding the risk–benefit ratio of management strategies. Addressing these issues requires further research, as well as the adaptation of guidelines to bridge existing gaps and meet the evolving challenges of this growing demographic. This review describes a comprehensive and integrated approach to managing ACS in older patients, covering the complexities of the diagnostic workup, treatment modalities, pharmacotherapy, and after ACS care, as well as considering PMI in older patients after noncardiac surgery. By addressing the notable gaps in existing guidelines, this guide is aimed at providing clinicians with a concise, yet comprehensive overview of the complexities involved in ACS management in older populations.

Conclusion (proposition de traduction) : La prise en charge des syndromes coronariens aigus chez les personnes âgées présente des défis uniques en raison des changements physiologiques liés à l'âge, de la prévalence des syndromes gériatriques, des objectifs de soins des patients et de la fragilité, ainsi que de la compréhension du rapport risque-bénéfice des stratégies de prise en charge. Pour répondre à ces questions, il faut poursuivre la recherche et adapter les lignes directrices afin de combler les lacunes existantes et de relever les défis en constante évolution de cette population croissante. Cette revue décrit une approche complète et intégrée de la prise en charge des syndromes coronariens aigus chez les patients âgés, couvrant les complexités du bilan diagnostique, les modalités de traitement, la pharmacothérapie et les soins après les syndromes coronariens aigus , ainsi que la prise en compte des lésions myocardiques périopératoires chez les patients âgés après une intervention chirurgicale non cardiaque. En comblant les lacunes notables des lignes directrices existantes, ce guide vise à fournir aux cliniciens une vue d'ensemble concise mais complète des complexités liées à la prise en charge des syndromes coronariens aigus chez les populations âgées.

Temporal Trends in End-Tidal Capnography and Outcomes in Out-of-Hospital Cardiac Arrest: A Secondary Analysis of a Randomized Clinical Trial.
Nassal MMJ, Elola A, Aramendi E, Jaureguibeitia X, Powell JR, Idris A, Raya Krishnamoorthy BP, Daya MR, Aufderheide TP, Carlson JN, Stephens SW, Panchal AR, Wang HE. | JAMA Netw Open. 2024 Jul 1;7(7):e2419274
DOI: https://doi.org/10.1001/jamanetworkopen.2024.19274  | Télécharger l'article au format  
Keywords: Aucun

OriginalInvestigation

Introduction : While widely measured, the time-varying association between exhaled end-tidal carbon dioxide (EtCO₂) and out-of-hospital cardiac arrest (OHCA) outcomes is unclear.

Méthode : To evaluate temporal associations between EtCO₂ and return of spontaneous circulation (ROSC) in the Pragmatic Airway Resuscitation Trial (PART).
Design, setting, and participants: This study was a secondary analysis of a cluster randomized trial performed at multicenter emergency medical services agencies from the Resuscitation Outcomes Consortium. PART enrolled 3004 adults (aged ≥18 years) with nontraumatic OHCA from December 1, 2015, to November 4, 2017. EtCO₂ was available in 1172 cases for this analysis performed in June 2023.
Interventions: PART evaluated the effect of laryngeal tube vs endotracheal intubation on 72-hour survival. Emergency medical services agencies collected continuous EtCO₂ recordings using standard monitors, and this secondary analysis identified maximal EtCO₂ values per ventilation and determined mean EtCO₂ in 1-minute epochs using previously validated automated signal processing. All advanced airway cases with greater than 50% interpretable EtCO₂ signal were included, and the slope of EtCO₂ change over resuscitation was calculated.
Main outcomes and measures: The primary outcome was ROSC determined by prehospital or emergency department palpable pulses. EtCO₂ values were compared at discrete time points using Mann-Whitney test, and temporal trends in EtCO₂ were compared using Cochran-Armitage test of trend. Multivariable logistic regression was performed, adjusting for Utstein criteria and EtCO₂ slope.

Résultats : Among 1113 patients included in the study, 694 (62.4%) were male; 285 (25.6%) were Black or African American, 592 (53.2%) were White, and 236 (21.2%) were another race; and the median (IQR) age was 64 (52-75) years. Cardiac arrest was most commonly unwitnessed (n = 579 [52.0%]), nonshockable (n = 941 [84.6%]), and nonpublic (n = 999 [89.8%]). There were 198 patients (17.8%) with ROSC and 915 (82.2%) without ROSC. Median EtCO₂ values between ROSC and non-ROSC cases were significantly different at 10 minutes (39.8 [IQR, 27.1-56.4] mm Hg vs 26.1 [IQR, 14.9-39.0] mm Hg; P < .001) and 5 minutes (43.0 [IQR, 28.1-55.8] mm Hg vs 25.0 [IQR, 13.3-37.4] mm Hg; P < .001) prior to end of resuscitation. In ROSC cases, median EtCO₂ increased from 30.5 (IQR, 22.4-54.2) mm HG to 43.0 (IQR, 28.1-55.8) mm Hg (P for trend < .001). In non-ROSC cases, EtCO₂ declined from 30.8 (IQR, 18.2-43.8) mm Hg to 22.5 (IQR, 12.8-35.4) mm Hg (P for trend < .001). Using adjusted multivariable logistic regression with slope of EtCO₂, the temporal change in EtCO₂ was associated with ROSC (odds ratio, 1.45 [95% CI, 1.31-1.61]).

Conclusion : In this secondary analysis of the PART trial, temporal increases in EtCO₂ were associated with increased odds of ROSC. These results suggest value in leveraging continuous waveform capnography during OHCA resuscitation.

Conclusion (proposition de traduction) : Dans cette analyse secondaire de l'essai PART, les augmentations dans le temps de l'EtCO₂ ont été associées à des chances accrues de réanimation cardio-vasculaire. Ces résultats suggèrent qu'il est utile de tirer parti de la capnographie à onde continue pendant la réanimation d'un arrêt cardiaque extrahospitalier.

State of the art of sepsis care for the emergency medicine clinician.
Cheng HS, Wong C, Chiu PH, Tong CW, Miu PF. | J Thorac Dis. 2024 Jul 30;16(7):4756-4763
DOI: https://doi.org/10.21037/jtd-24-415  | Télécharger l'article au format  
Keywords: Pneumothorax; persistent air leak; pleurodesis; recurrence; spontaneous

Review Article

Editorial : Spontaneous pneumothorax usually presents as a medical emergency and requires prompt attention and treatment. In patients with underlying lung diseases, it is often associated with prolonged hospitalization, persistent air leak and also a high rate of recurrence. It brings considerable clinical burden to patients and therefore advancement of spontaneous pneumothorax management is eagerly anticipated. In recent years, conservative approach with avoidance of invasive treatment has risen to be a main consideration for primary spontaneous pneumothorax (PSP) patients who are clinically stable with minimal symptoms. The body of evidence in secondary spontaneous pneumothorax (SSP) group is less robust compared with that in PSP group. Non-surgical treatment in SSP is becoming more common due to concerns about morbidity and mortality after surgical pleurodesis as patients are usually older with more underlying medical diseases. Until last year, there have been no updates on the international recommendation of pneumothorax management since the British Thoracic Society (BTS) guideline published in 2010. The latest 2023 BTS guideline on pleural diseases provides us a good opportunity to review the latest development and literature of the care for patients with spontaneous pneumothorax. This article will explore the goals of pneumothorax treatment including air evacuation, cessation of persistent air leak and prevention of recurrence.

Conclusion : There have been major changes in the British Thoracic Society pleural disease guideline published last year on the management of pneumothorax. Management of air evacuation, air leak cessation and recurrence prevention become more evidence-based but ongoing research is still warranted. While conservative and ambulatory treatments are increasingly adopted in clinically stable primary spontaneous pneumothorax patients, their evidence of efficacy and safety in secondary spontaneous pneumothorax group are less robust. Chest drain insertion still remains the most common treatment in secondary spontaneous pneumothorax patients for air evacuation. There are also concerns on morbidity and mortality following surgical approach for secondary spontaneous pneumothorax group. Better categorization of patients’ phenotypes and identification of those who benefit most from intervention are essential for risk stratification. With more upcoming large-scale studies, our understanding on pneumothorax and patient’s outcome could be further enhanced.

Conclusion (proposition de traduction) : Les lignes directrices de la British Thoracic Society sur les pathologies de la plèvre publiées l'année dernière sur la prise en charge du pneumothorax ont connu des changements majeurs. La gestion de l'évacuation de l'air, l'arrêt des fuites d'air et la prévention des récidives reposent désormais davantage sur des données probantes, mais des recherches continues sont toujours nécessaires. Alors que les traitements conservateurs et ambulatoires sont de plus en plus adoptés chez les patients souffrant d'un pneumothorax spontané primaire cliniquement stable, les preuves de leur efficacité et de leur sécurité dans le groupe des pneumothorax spontanés secondaires sont moins solides. L'insertion d'un drain thoracique reste le traitement le plus courant pour l'évacuation de l'air chez les patients souffrant d'un pneumothorax spontané secondaire. La morbidité et la mortalité liées à l'approche chirurgicale dans le groupe des pneumothorax spontanés secondaires sont également préoccupantes. Une meilleure catégorisation des phénotypes des patients et l'identification de ceux qui bénéficient le plus d'une intervention sont essentielles pour la stratification des risques. Grâce à de nouvelles études à grande échelle, notre compréhension du pneumothorax et du devenir des patients pourrait être encore améliorée.

Commentaire : Roberts ME and al; BTS Pleural Guideline Development Group. British Thoracic Society Guideline for pleural disease. Thorax  . 2023 Jul;78(Suppl 3):s1-s42.

Acute liver failure.
Maiwall R, Kulkarni AV, Arab JP, Piano S. | Lancet. 2024 Aug 1:S0140-6736(24)00693-7
DOI: https://doi.org/10.1016/s0140-6736(24)00693-7  | Télécharger l'article au format  
Keywords: Aucun

Seminar

Editorial : Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.

Conclusion : ALF is a rapidly fatal disease and liver transplantation is currently the only definitive therapy. Although survival has improved in the past decade due to better understanding and advancements in intensive care management, most patients with ALF die from multiorgan failure and sepsis. A major challenge is the dearth of emerging data, as additional studies could answer questions faced by clinicians at the bedside when managing this challenging set of patients. The rarity and heterogeneity of the syndrome are major reasons for the absence of large, multicentre, randomised controlled trials. Failure to recognise the clinical signs of advanced ALF and delayed transfer of patients to specialised centres is another factor contributing to increased mortality. There is an increasing burden of ALF of indeterminate cause in adults. Among the most common factors for indeterminate ALF are missing data, insufficient patient medical history, and incomplete or absence of detailed investigation of the causes of patient mortality. It also is unclear whether incorporation of routine metagenomic next-generation sequencing would be prudent as a strategy for identification of novel viruses as a cause of indeterminate ALF. Increasing use of CRRT early in the course of disease has led to reduced incidence of cerebral oedema and improved patient outcomes. Combination of plasma exchange with CRRT might be a more effective strategy in improving patient outcomes compared with CRRT alone; however, it is still not widely used in the management of patients with ALF. Patterns in the use of these therapies vary across the globe based on the dominant cause, expertise, and resource availability. Prospective, multicentre studies identifying prognostic biomarkers that could reflect immune dysregulation, development of dynamic models accounting for changes in biochemical variables, and investigation of haemodynamic alterations in patients on extracorporeal therapies are needed to identify appropriate candidates for liver transplantation. Therapeutic strategies combining detoxification with therapies potentiating liver regeneration are an unmet need, especially in resource- constrained countries where timely liver transplantation is not available to the majority of patients.

Conclusion (proposition de traduction) : L'insuffisance hépatique aiguë est une maladie rapidement mortelle et la transplantation hépatique est actuellement la seule alternative thérapeutique définitive. Bien que la survie se soit améliorée au cours de la dernière décennie grâce à une meilleure compréhension et à des progrès dans la gestion des soins intensifs, la plupart des patients présentant une insuffisance hépatique aiguë meurent d'une défaillance multiviscérale et d'une septicémie. La pénurie de données récentes constitue un défi majeur, car des études supplémentaires permettraient de répondre aux questions auxquelles sont confrontés les cliniciens au chevet de ces patients difficiles. La rareté et l'hétérogénéité du syndrome expliquent en grande partie l'absence d'essais contrôlés randomisés multicentriques de grande envergure. La non-reconnaissance des signes cliniques de l'insuffisance hépatique aiguë avancée et le transfert tardif des patients vers des centres spécialisés constituent un autre facteur contribuant à l'augmentation de la mortalité. L'insuffisance hépatique aiguë de cause indéterminée est de plus en plus fréquente chez les adultes. Parmi les facteurs les plus courants d'insuffisance hépatique aiguë de cause indéterminée figurent les données manquantes, l'insuffisance des antécédents médicaux du patient et l'absence ou l'insuffisance d'investigations détaillées sur les causes de la mortalité du patient. On ne sait pas non plus si l'incorporation d'un séquençage métagénomique de nouvelle génération en routine serait prudente en tant que stratégie d'identification de nouveaux virus comme cause d'une insuffisance hépatique aiguë indéterminée. L'utilisation croissante d'une épuration extra-rénale continue à un stade précoce de la maladie a permis de réduire l'incidence de l'œdème cérébral et d'améliorer les résultats pour les patients. La combinaison des échanges plasmatiques et de l'épuration extra-rénale continue pourrait être une stratégie plus efficace pour améliorer les résultats des patients par rapport à la thérapie continue de remplacement rénal seule ; cependant, elle n'est pas encore largement utilisée dans la prise en charge des patients souffrant d'insuffisance hépatique aiguë. Les schémas d'utilisation de ces traitements varient d'un pays à l'autre en fonction de la cause dominante, de l'expertise et de la disponibilité des ressources. Des études prospectives et multicentriques identifiant des biomarqueurs pronostiques susceptibles de refléter une dysrégulation immunitaire, le développement de modèles dynamiques tenant compte des changements dans les variables biochimiques et l'étude des altérations hémodynamiques chez les patients sous traitements extracorporels sont nécessaires pour identifier les candidats appropriés à une transplantation hépatique. Les stratégies thérapeutiques combinant la détoxication et les traitements potentialisant la régénération du foie constituent un besoin non satisfait, en particulier dans les pays à ressources limitées où la majorité des patients ne peuvent pas bénéficier d'une transplantation hépatique en temps utile.

Long COVID: a clinical update.
Greenhalgh T, Sivan M, Perlowski A, Nikolich JŽ. | Lancet. 2024 Jul 31:S0140-6736(24)01136-X
DOI: https://doi.org/10.1016/s0140-6736(24)01136-x  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : Post-COVID-19 condition (also known as long COVID) is generally defined as symptoms persisting for 3 months or more after acute COVID-19. Long COVID can affect multiple organ systems and lead to severe and protracted impairment of function as a result of organ damage. The burden of this disease, both on the individual and on health systems and national economies, is high. In this interdisciplinary Review, with a coauthor with lived experience of severe long COVID, we sought to bring together multiple streams of literature on the epidemiology, pathophysiology (including the hypothesised mechanisms of organ damage), lived experience and clinical manifestations, and clinical investigation and management of long COVID. Although current approaches to long COVID care are largely symptomatic and supportive, recent advances in clinical phenotyping, deep molecular profiling, and biomarker identification might herald a more mechanism-informed and personally tailored approach to clinical care. We also cover the organisation of services for long COVID, approaches to preventing long COVID, and suggestions for future research.

Conclusion : The evidence outlined in this Review suggests several priority areas for further research.

Conclusion (proposition de traduction) : Les données présentées dans cette étude suggèrent plusieurs domaines prioritaires pour la poursuite de la recherche.

Infective endocarditis.
Li M, Kim JB, Sastry BKS, Chen M. | Lancet. 2024 Jul 27;404(10450):377-392
DOI: https://doi.org/10.1016/s0140-6736(24)01098-5  | Télécharger l'article au format  
Keywords: Aucun

Seminar

Editorial : First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

Conclusion : Infective endocarditis remains a formidable challenge, emphasising the need for a multidisciplinary approach in both management and research. Despite progress, crucial questions persist demanding urgent RCTs to enhance our understanding of infective endocarditis. Advances in microbiological services, imaging technology, and artificial intelligence-driven machine learning offer promising avenues for improved patient outcomes. Only with coordinated and sustained efforts can we effectively confront the evolving nature of infective endocarditis and strive for continued advancements in patient care and outcomes.

Conclusion (proposition de traduction) : L'endocardite infectieuse reste un formidable défi, soulignant la nécessité d'une approche multidisciplinaire tant dans la prise en charge que dans la recherche. Malgré les progrès accomplis, des questions cruciales subsistent et il est urgent de réaliser des essais cliniques randomisés pour améliorer notre compréhension de l'endocardite infectieuse. Les progrès des laboratoires d'analyses microbiologiques, des technologies d'imagerie et de l'apprentissage automatique basé sur l'intelligence artificielle offrent des pistes prometteuses pour améliorer les résultats pour les patients. Ce n'est qu'au prix d'efforts coordonnés et soutenus que nous pourrons faire face efficacement à la nature évolutive de l'endocardite infectieuse et nous efforcer d'obtenir des progrès continus dans les soins et les résultats pour les patients.

Hyponatremia - Treatment standard 2024.
Spasovski G | Nephrol Dial Transplant. 2024 Jul 15:gfae162
DOI: https://doi.org/10.1093/ndt/gfae162
Keywords: diuretics; fluid restriction; hyponatremia; urea; vaptans.

Review

Editorial : Hyponatremia is the most common electrolyte disorder in hospital patients associated with increased morbidity, mortality, hospital stay and financial burden. The speed of a correction with 3% sodium chloride as 100 mL IV bolus or continuous infusion depends on the severity and persistence of the symptoms, and needs frequent biochemical monitoring. The rapid intermittent administration of hypertonic saline is preferred for treatment of symptomatic hyponatremia. In asymptomatic mild hyponatremia, an adequate solute intake with an initial fluid restriction (FR) of 500 mL/d adjusted according to the serum sodium levels is preferred. Almost half of the syndrome of inappropriate diuresis hormone (SIADH) patients do not respond to FR as first-line therapy. At present, urea and tolvaptan are considered as most effective second-line therapies in SIADH. However, the evidence for guidance on the choice of second-line therapy of hypotonic hyponatremia is lacking. Oral urea is considered as very effective and safe treatment. Mild and asymptomatic hyponatremia is treated with adequate solute intake (salt and protein) and an initial FR with adjustments based on serum sodium levels. Specific treatment with vaptans may be considered in either euvolemic or hypervolemic patients with high ADH activity. In order to ensure optimal patient outcome, a close monitoring and readiness for administration of either hypotonic fluids or desmopressin may be crucial in decision making process for specific treatment and eventual overcorrection consequences. According to the guidelines, a gradual correction and clinical evaluation is preferable over the rapid normalization of serum sodium towards the laboratory reference ranges.

Conclusion : Hyponatraemia is the most common electrolyte disorder in hospital patients and is associated with short- and long-term morbidity and mortality. The speed of a correction with 3% NaCl as a 100-ml IV bolus or continuous infusion depends on the severity and persistence of the symptoms and needs frequent biochemical monitoring. The rapid intermittent administration of hypertonic saline is preferred for treatment of symptomatic hyponatraemia.
Almost half of syndrome of inappropriate antidiuretic hormone (SIADH) patients do not respond to fluid restriction as the first-line therapy. At present, urea and tolvaptan are considered the most effective second-line therapies in SIADH. However, the evidence for guidance on the choice of second-line therapy of hypotonic hyponatraemia is lacking, apart from a couple of tolvaptan and empagliflozin randomized con- trolled trials that compare the drugs with placebo. Oral urea is considered to be a very effective and safe treatment. Mild and asymptomatic hyponatraemia is treated with adequate solute intake (salt and protein) and an initial fluid restriction with adjustments based on serum sodium levels. Specific treatment with vaptans may be considered in either euvolaemic or hypervolaemic patients with high ADH activity.
In order to ensure optimal patient outcomes, close mon- itoring and readiness for administration of either hypotonic fluids or desmopressin may be crucial for specific treatment and eventual overcorrection consequences. Although there is an improved awareness of hospital-associated hyponatraemia (hypo-osmotic fluid administration) and the risk of osmotic demyelination syndrome (overaggressive therapeutic correction), close monitoring to avoid iatrogenic morbidity is required. Gradual correction and clinical evaluation according to the guidelines is preferable compared with rapid normalization of serum sodium towards the laboratory reference range.

Conclusion (proposition de traduction) : L'hyponatrémie est le trouble électrolytique le plus fréquent chez les patients hospitalisés et est associée à une morbidité et une mortalité à court et à long terme. La rapidité de la correction avec du NaCl 3 % en bolus IV de 100 ml ou en perfusion continue dépend de la sévérité et de la persistance des symptômes et nécessite une surveillance biochimique fréquente. L'administration rapide et intermittente d'une solution salée hypertonique est préférable pour le traitement de l'hyponatrémie symptomatique.
Près de la moitié des patients présentant un syndrome de l'hormone antidiurétique inappropriée (SIADH) ne répondent pas à la restriction hydrique en tant que traitement de première intention. À l'heure actuelle, l'urée et le tolvaptan sont considérés comme les thérapies de deuxième intention les plus efficaces dans le SIADH. Cependant, les preuves pour guider le choix du traitement de seconde ligne de l'hyponatrémie hypotonique manquent, à part quelques essais randomisés contrôlés sur le tolvaptan et l'empagliflozine qui comparent les médicaments avec un placebo. L'urée orale est considérée comme un traitement très efficace et sûr. L'hyponatrémie légère et asymptomatique est traitée par un apport adéquat en solutés (sel et protéines) et une restriction hydrique initiale avec des ajustements basés sur le taux de sodium sérique sérique. Un traitement spécifique par vaptans peut être envisagé chez les patients euvolémiques ou hypervolémiques présentant une activité ADH élevée.
Afin d'assurer des résultats optimaux pour le patient, une surveillance étroite et la préparation à l'administration de solutés hypotoniques ou de desmopressine peuvent être cruciales pour un traitement spécifique et les conséquences éventuelles d'une surcorrection. Bien qu'il y ait une meilleure prise de conscience de l'hyponatrémie induit par l'hospitalisation (administration de solutés hypo-osmotiques) et du risque de syndrome de démyélinisation osmotique (correction thérapeutique trop agressive), une surveillance étroite est nécessaire pour éviter la morbidité iatrogène. Une correction progressive et une évaluation clinique conformément aux lignes directrices sont préférables à une normalisation rapide du sodium sanguin vers l'intervalle de référence du laboratoire.

Commentaire :  Algorithme de traitement de l'hyponatrémie sévère

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.
Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ; AMERICAN ACADEMY OF PEDIATRICS Committee on Pediatric Emergency Medicine, Section on Radiology; AMERICAN COLLEGE OF RADIOLOGY; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS Pediatric Emergency Medicine Committee. | Pediatrics. 2024 Jul 1;154(1):e2024066854
DOI: https://doi.org/10.1542/peds.2024-066854  | Télécharger l'article au format  
Keywords: Aucun

POLICY STATEMENT

Editorial : Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Conclusion : Important advances in imaging technology have resulted in increased use of advanced imaging to diagnose and manage pediatric patients in the ED. To optimize imaging, there are important considerations for the institution and for physicians, physician assistants, and nurse practitioners who care for patients. These include adherence to the ALARA principle, using ultrasonography when appropriate and feasible as an alternative to CT, ensuring there are policies to facilitate consultation with pediatric subspecialists, including pediatric radiologists, and ensuring appropriate transfer to a pediatric center when necessary. For patients who will be transferred and for whom the imaging will not alter management prior to or during transport, it is optimal for imaging to be deferred to the receiving institution. Physicians, physician assistants, and nurse practitioners should always weigh the benefits and risks of imaging and incorporate the recommendations, resources, and strategies in this policy statement and data in the accompanying technical report to optimize imaging in children.

Conclusion (proposition de traduction) : Les progrès importants de la technique d'imagerie ont entraîné un recours accru à l'imagerie spécialisée pour diagnostiquer et prendre en charge les patients pédiatriques dans les services d'urgence. Pour optimiser l'imagerie, il y a des considérations importantes pour l'établissement et pour les médecins, les assistants médicaux et les infirmières praticiennes qui s'occupent des patients. Il s'agit notamment de respecter le principe ALARA, d'utiliser l'échographie lorsque cela est approprié et possible comme alternative à la tomodensitométrie, de s'assurer qu'il existe des politiques facilitant la consultation avec des pédiatres sous-spécialisés, y compris des radiologues pédiatriques, et d'assurer un transfert approprié vers un centre pédiatrique lorsque cela est nécessaire. Pour les patients qui seront transférés et pour lesquels l'imagerie ne modifiera pas la prise en charge avant ou pendant le transport, il est préférable que l'imagerie soit reportée dans l'établissement d'accueil. Les médecins, les auxiliaires médicaux et les infirmières praticiennes doivent toujours peser les avantages et les risques de l'imagerie et intégrer les recommandations, les ressources et les stratégies de cette déclaration de principe et les données du rapport technique qui l'accompagne afin d'optimiser l'imagerie chez les enfants.

Neurological prognosis prediction upon arrival at the hospital after out-of-hospital cardiac arrest: R-EDByUS score.
Shimada T, Kawai R, Shintani A, Shibata A, Otsuka K, Ito A, Yamazaki T, Izumiya Y, Fukuda D, Yonemoto N, Tahara Y, Ikeda T; Japanese Circulation Society Resuscitation Science Study JCS-ReSS Group. | Resuscitation. 2024 Jul;200:110257
DOI: https://doi.org/10.1016/j.resuscitation.2024.110257  | Télécharger l'article au format  
Keywords: Arrhythmia; Cardiogenic; Mechanical circulatory support; Risk score; Sudden cardiac death; Termination of resuscitation.

Clinical paper

Introduction : To develop a new scoring model for patients with cardiogenic out-of-hospital cardiac arrest (OHCA) to facilitate neurological prognosis prediction upon hospital arrival by using prehospital resuscitation features alone.

Méthode : Between 2005 and 2019, we enrolled 942,891 adult patients with OHCA of presumed cardiac aetiology from the All-Japan Utstein Registry. Scoring models applied prehospital resuscitation features a priori from the variables the American College of Cardiology algorithm including age, duration to return of spontaneous circulation (ROSC) or hospital arrival, no bystander cardiopulmonary resuscitation (CPR), unwitnessed arrest, and nonshockable rhythm (R-EDByUS score) to predict unfavorable neurological outcomes defined as Cerebral Performance Category 3, 4, or 5 at 1 month. We created nomograms as a "Regression-based model," and created a "Simplified model" in which points were assigned by category for predicting unfavorable neurological outcomes for both the prehospital ROSC cohort (67,064 patients) and the ongoing CPR cohort (875,827 patients). For internal validation, bootstrap optimism-corrected estimates of predictive performance were calculated.

Résultats : A total of 46,971 (70.0%) and 870,991 (99.4%) patients in the prehospital ROSC and ongoing CPR cohorts, respectively, had unfavorable neurological outcomes. In the prehospital ROSC cohort, the C-statistics of the Regression-based and Simplified models were 0.851 and 0.842, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively. In the ongoing CPR cohort, the C-statistics of the Regression-based and Simplified models were 0.872 and 0.865, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively.

Conclusion : The R-EDByUS score accurately predicted the neurological prognosis of cardiogenic OHCA upon hospital arrival.

Conclusion (proposition de traduction) : Le score R-EDByUS permet de prédire avec précision le pronostic neurologique d'un arrêt cardiaque cardiaque extrahospitalier à l'arrivée à l'hôpital.

Inflammatory response after prehospital high-dose glucocorticoid to patients resuscitated from out-of-hospital cardiac arrest: A sub-study of the STEROHCA trial.
Obling LER, , Beske RP, Meyer MAS, Grand J, Wiberg S, Damm-Hejmdal A, Bjerre M, Frikke-Schmidt R, Folke F, Møller JE, Kjaergaard J, Hassager C. | Resuscitation. 2024 Jul 31:110340
DOI: https://doi.org/10.1016/j.resuscitation.2024.110340  | Télécharger l'article au format  
Keywords: Cytokines; Glucocorticoid; Inflammation; Out-of-Hospital Cardiac Arrest; Post-Cardiac Arrest Syndrome; Prehospital Intervention.

CLINICAL PAPER

Introduction : The post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA) is characterized by a series of pathological events, including inflammation. In the randomized "STERoid for OHCA" (STEROHCA) trial, prehospital high-dose glucocorticoid decreased interleukin (IL) 6 and C-reactive protein levels following resuscitated OHCA. The aim of this predefined sub-study was to assess the inflammatory response the first three days of admission.

Méthode : The STEROHCA trial enrolled 137 OHCA patients randomized to either a single prehospital injection of methylprednisolone 250 mg or placebo. Inflammatory markers, including pro- and anti-inflammatory cytokines, were analyzed in plasma samples, from 0-, 24-, 48-, and 72 h post-admission. Mixed-model analyses were applied using log-transformed data to assess group differences.

Résultats : The 137 patients included in this sub-study had a median age of 67 years (57 to 74), and the 180-day survival rates were 75% (n = 51/68) and 64% (n = 44/69) in the glucocorticoid and placebo group, respectively. A total of 130 (95%) patients had at least one plasma sample available. The anti-inflammatory cytokine IL-10 was increased at hospital admission in the glucocorticoid group (ratio 2.74 (1.49-5.05), p = 0.006), but the intervention showed the strongest effect after 24 h, decreasing pro-inflammatory levels of IL-6 (ratio 0.06 (0.03-0.10), p < 0.001), IL-8 (ratio 0.53 (0.38-0.75), p < 0.001), macrophage chemokine protein-1 (MCP-1, ratio 0.02 (0.13-0.31), p < 0.001), macrophage inflammatory protein-1-beta (MIP-1b, ratio 0.28 (0.18-0.45), p < 0.001), and tumor necrosis factor-α (TNF-α, ratio 0.6 (0.4-0.8), p = 0.01).

Conclusion : Administering high-dose glucocorticoid treatment promptly after resuscitation from OHCA influenced the inflammatory response with a reduction in several systemic proinflammatory cytokines after 24 h.

Conclusion (proposition de traduction) : L'administration d'une forte dose de glucocorticoïdes rapidement après la réanimation d'un arrêt cardiaque extrahospitalier a influencé la réponse inflammatoire avec une réduction de plusieurs cytokines pro-inflammatoires systémiques après 24 heures.

Commentaire : De la même équipe :
Obling LER, Beske RP, Meyer MAS, Grand J, Wiberg S, Mohr T, et al. Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial. Crit Care [Internet]. 2024 Jan 22;28(1):28.
Le traitement préhospitalier par glucocorticoïdes à forte dose a été associé à une réduction de la consommation de norépinéphrine chez les patients réanimés victimes d'un accident vasculaire cérébral.

The accuracy of Gemini, GPT-4, and GPT-4o in ECG analysis: A comparison with cardiologists and emergency medicine specialists.
Günay S, Öztürk A, Yiğit Y. | Am J Emerg Med. 2024 Jul 30;84:68-73
DOI: https://doi.org/10.1016/j.ajem.2024.07.043  | Télécharger l'article au format  
Keywords: Artificial intelligence; ChatGPT; Electrocardiography; GPT-4; GPT-4o; Gemini.

Article

Introduction : GPT-4, GPT-4o and Gemini advanced, which are among the well-known large language models (LLMs), have the capability to recognize and interpret visual data. When the literature is examined, there are a very limited number of studies examining the ECG performance of GPT-4. However, there is no study in the literature examining the success of Gemini and GPT-4o in ECG evaluation. The aim of our study is to evaluate the performance of GPT-4, GPT-4o, and Gemini in ECG evaluation, assess their usability in the medical field, and compare their accuracy rates in ECG interpretation with those of cardiologists and emergency medicine specialists.

Méthode : The study was conducted from May 14, 2024, to June 3, 2024. The book "150 ECG Cases" served as a reference, containing two sections: daily routine ECGs and more challenging ECGs. For this study, two emergency medicine specialists selected 20 ECG cases from each section, totaling 40 cases. In the next stage, the questions were evaluated by emergency medicine specialists and cardiologists. In the subsequent phase, a diagnostic question was entered daily into GPT-4, GPT-4o, and Gemini Advanced on separate chat interfaces. In the final phase, the responses provided by cardiologists, emergency medicine specialists, GPT-4, GPT-4o, and Gemini Advanced were statistically evaluated across three categories: routine daily ECGs, more challenging ECGs, and the total number of ECGs.

Résultats : Cardiologists outperformed GPT-4, GPT-4o, and Gemini Advanced in all three groups. Emergency medicine specialists performed better than GPT-4o in routine daily ECG questions and total ECG questions (p = 0.003 and p = 0.042, respectively). When comparing GPT-4o with Gemini Advanced and GPT-4, GPT-4o performed better in total ECG questions (p = 0.027 and p < 0.001, respectively). In routine daily ECG questions, GPT-4o also outperformed Gemini Advanced (p = 0.004). Weak agreement was observed in the responses given by GPT-4 (p < 0.001, Fleiss Kappa = 0.265) and Gemini Advanced (p < 0.001, Fleiss Kappa = 0.347), while moderate agreement was observed in the responses given by GPT-4o (p < 0.001, Fleiss Kappa = 0.514).

Conclusion : While GPT-4o shows promise, especially in more challenging ECG questions, and may have potential as an assistant for ECG evaluation, its performance in routine and overall assessments still lags behind human specialists. The limited accuracy and consistency of GPT-4 and Gemini suggest that their current use in clinical ECG interpretation is risky.

Conclusion (proposition de traduction) : Bien que le GPT-4o soit prometteur, en particulier sur la question des ECG les plus difficiles, et qu'il puisse avoir un potentiel en tant qu'assistant pour l'évaluation de l'ECG, ses performances dans les évaluations de routine et les évaluations globales sont encore inférieures à celles des spécialistes humains. La précision et la cohérence limitées du GPT-4 et de Gemini suggèrent que leur utilisation actuelle dans l'interprétation clinique de l'ECG est risquée.

Propofol administration for induction is associated with peri-intubation instability in trauma critical care unit patients.
Snyder KB, Gushing J, Quang C, Stewart K, Sarwar Z, Albrecht R, Blair SG. | Am J Surg. 2024 Jul 23;238:115858
DOI: https://doi.org/10.1016/j.amjsurg.2024.115858  | Télécharger l'article au format  
Keywords: Hemodynamics; Intubation; Propofol; Trauma

Original Research Article

Introduction : Peri-intubation hypotension is associated with increased hospital length of stay and morbidity. Propofol is associated with alterations in hemodynamics. We hypothesize that using propofol for induction leads to peri-intubation hypotension in trauma critical care patients.

Méthode : Patients that underwent unplanned intubation in the trauma intensive care unit (TICU) were prospectively enrolled. Peri-intubation vitals and medications were recorded to assess hypotension within 10 ​min of intubation. Patients were divided into propofol (PROP) or other medication (OTR) groups.

Résultats : Data was complete for 69 patients; 31 PROP and 38 OTR. In OTR there was an 8.8-point (-21.1, 3.6) SBP decrease (p ​= ​0.159) and in PROP there was a 30.8-point (-45.6, -16.0) SBP decrease (p ​= ​0.0002) with significant increases in heart rate (HR) and shock index (SI) (HR p ​= ​0.001, SI p ​< ​0.0001).

Conclusion : In patients without hypotension prior to intubation, we observed a statistically significant drop in the patients' SBP with use of propofol. In trauma critical care unit patients, we recommend considering an induction medication for unplanned intubation other than propofol.

Conclusion (proposition de traduction) : Chez les patients ne présentant pas d'hypotension avant l'intubation, nous avons observé une baisse statistiquement significative de la tension artérielle des patients avec l'utilisation du propofol. Chez les patients des unités de soins intensifs en traumatologie, nous recommandons d'envisager un autre médicament d'induction que le propofol en cas d'intubation non programmée.

Contemporary management of open extremity fractures: What you need to know.
Stahel PF, Kaufman AM. | J Trauma Acute Care Surg. 2024 Jul 1;97(1):11-22
DOI: https://doi.org/10.1097/ta.0000000000004288  | Télécharger l'article au format  
Keywords: Aucun

WHAT YOU NEED TO KNOW SERIES – REVIEWS

Editorial : Open extremity fractures are high-risk injuries prone to significant complications, including soft tissue loss, bone defects, infection, infected nonunion, and the necessity for limb amputation. Large-scale multicenter prospective studies from the Lower Extremity Assessment Project and the Major Extremity Trauma Research Consortium have provided novel scientific insights pertinent to the timeliness and appropriateness of specific treatment modalities aimed at improving outcomes of patients with open extremity injuries. These include the imperative for early administration of intravenous antibiotics within 3 hours of injury, preferably within 1 hour of hospital admission. Unlike the proven value of early antibiotics, the time to initial surgical debridement does not appear to affect infection rates and patient outcomes. Recent evidence-based consensus guidelines from the American Academy of Orthopedic Surgeons provide scientific guidance for preventing surgical site infections in patients with open extremity fractures and support the decision making of limb salvage versus amputation in critical open extremity injuries. Patient survival represents the overarching priority in the management of any trauma patient with associated orthopedic injuries. Therefore, the timing and modality of managing open fractures must take into account the patient's physiology, response to resuscitation, and overall injury burden. The present review was designed to provide a state-of-the-art overview on the recommended diagnostic workup and management strategies for patients with open extremity fractures, based on the current scientific evidence.

Conclusion : The historic Gustilo-Anderson classification remains pre-eminent in the vast body ofcurrent literature despite published validation studies in support ofthe more recent and encompassing OTA-OFC. Large-scale multicenter prospective studies from national registries (LEAP, METRC) and the new AAOS evidence-based consensus guidelines have provided novel scientific insights pertinent to the timeliness and appropriateness ofspecific treatment modalities (antibiotics, debridement,wound closure, surgical fracture fixation, etc.) and for the decision making for limb salvage versus early limb amputation in critical open extremity in- juries. These studies have debunked several dogmatic myths in the management of open fractures, including the anecdotal “6-hour rule” to debridement and the erroneous assumption that a mangled lower extremity should be amputated in absence of plantar sensation (“insensate foot”). Furthermore, widely disseminated objective scoring systems from the 1990s, such as the MESS, have been abandoned in the modern literature because ofthe lack ofa predictive value in the decision making for amputation versus limb salvage. Patient survival represents the overarching priority in the management ofany trauma patient with associated critical extremity injuries (“limb for life”). Therefore, the timing and modality of managing open extremity fractures must take into account.

Conclusion (proposition de traduction) : La classification historique de Gustilo-Anderson reste prépondérante dans la vaste littérature actuelle malgré les études de validation publiées en faveur de la classification OTA-OFC, plus récente et plus complète. Des études prospectives multicentriques à grande échelle réalisées à partir de registres nationaux (LEAP, METRC) et les nouvelles directives consensuelles de l'AAOS fondées sur des données probantes ont apporté de nouvelles connaissances scientifiques sur l'opportunité et l'adéquation de modalités de traitement spécifiques (antibiotiques, débridement, fermeture de la plaie, fixation chirurgicale de la fracture, etc) et sur la prise de décision concernant le sauvetage du membre par rapport à l'amputation précoce du membre dans les cas critiques d'accidents ouverts des extrémités. Ces études ont mis fin à plusieurs mythes dogmatiques dans la prise en charge des fractures ouvertes, notamment la règle anecdotique des « 6 heures » pour le débridement et l'hypothèse erronée selon laquelle un membre inférieur mutilé doit être amputé en l'absence de sensation plantaire (« pied insensible »). En outre, les systèmes de scores objectifs largement diffusés dans les années 1990, tels que le MESS, ont été abandonnés dans la littérature moderne en raison de l'absence de valeur prédictive dans la prise de décision concernant l'amputation par rapport au sauvetage du membre. La survie du patient représente la priorité absolue dans la prise en charge de tout patient victime d'un traumatisme et présentant des lésions critiques aux extrémités (« amputation pour sauver une vie »). Par conséquent, le moment et les modalités de la prise en charge des fractures ouvertes des extrémités doivent tenir compte.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.
Leonard JC, Harding M, Cook LJ, Leonard JR, Adelgais KM, Ahmad FA, Browne LR, Burger RK, Chaudhari PP, Corwin DJ, Glomb NW, Lee LK, Owusu-Ansah S, Riney LC, Rogers AJ, Rubalcava DM, Sapien RE, Szadkowski MA, Tzimenatos L, Ward CE, Yen K, Kuppermann N. | Lancet Child Adolesc Health. 2024 Jul;8(7):482-490
DOI: https://doi.org/10.1016/s2352-4642(24)00104-4
Keywords: Aucun

https://doi.org/10.1016/s2352-4642(24)00104-4

Introduction : Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department.

Méthode : In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray u

Résultats : Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays.

Conclusion : Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments.

Conclusion (proposition de traduction) : Intégrée dans un algorithme clinique, la règle de prédiction des lésions du rachis cervical a montré un fort potentiel pour aider les cliniciens à déterminer quels enfants arrivant aux urgences après un traumatisme contondant devraient subir une imagerie radiographique du cou à la recherche d'une éventuelle lésion du rachis cervical. La mise en œuvre de l'algorithme clinique pourrait réduire le recours à des examens radiographiques inutiles dans les services d'urgence et éliminer l'exposition à des radiations à haut risque. Les travaux futurs devraient valider la règle de prédiction et l'algorithme de soins dans des contextes plus généraux tels que les services d'urgence communautaires.

Deep venous thrombosis (DVT) diagnostics: gleaning insights from point-of-care ultrasound (PoCUS) techniques in emergencies: a systematic review and meta-analysis.
Zaki HA, Albaroudi B, Shaban EE, Elgassim M, Almarri ND, Basharat K, Shaban A. | Ultrasound J. 2024 Jul 30;16(1):37. doi: 10.1186/s13089-024-00378-1
DOI: https://doi.org/10.1186/s13089-024-00378-1  | Télécharger l'article au format  
Keywords: Deep vein thrombosis; Deep venous thrombosis; Emergency medicine; Meta-analysis; Point-of-care systems; Sensitivity; Specificity; Systematic review; Ultrasound.

Review

Introduction : The assessment of deep venous thrombosis (DVT) is clinically difficult diagnosis. The "gold standard test" for DVT diagnosis is venography; however, various point-of-care ultrasound (POCUS) protocols have been suggested for DVT evaluation in the emergency department.

Méthode : This review evaluated the role of different POCUS protocols in diagnosing DVT in the emergency department.
Methods: A systematic review and meta-analysis was conducted based of PRISMA guideline and registered on PROSEPRO (CRD42023398871). An electronic database search in Embase, PubMed, ScienceDirect, and Google scholar and a manual search were performed to identify eligible studies till February 2023. Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was used to assess the risk of bias in included studies. Quantitative analysis was carried out using STATA 16 and Review Manager software (RevMan 5.4.1). Sensitivity, specificit

Résultats : Heterogeneity was identified between 26 included studies for review. The pooled sensitivity, specificity, PPV, and NPV for the 2-point POCUS protocol were 92.32% (95% CI: 87.58-97.06), 96.86% (95% CI: 95.09-98.64), 88.41% (95% CI: 82.24-94.58) and 97.25% (95% CI: 95.51-98.99), respectively. Similarly, the pooled sensitivity, specificity, PPV, and NPV for 3-point POCUS were 89.15% (95% CI: 83.24-95.07), 92.71% (95% CI: 89.59-95.83), 81.27% (95% CI: 73.79-88.75), and 95.47% (95% CI: 92.93-98). The data pooled for complete compression ultrasound, and whole-leg duplex ultrasound also resulted in a sensitivity and specificity of 100% (95% CI: 98.21-100) and 97.05% (95% CI: 92.25-100), respectively. On the other hand, the time from triage to DVT diagnosis was significantly shorter for emergency physician-performed POCUS than diagnostic tests performed by radiologists.

Conclusion : The diagnostic performance of POCUS protocols performed by emergency physicians was excellent. Combined with the significant reduction in time to diagnosis. POCUS can be used as the first-line imaging tool for DVT diagnosis in the emergency department. We also recommended that attending emergency physicians with POCUS training are present during DVT diagnosis to improve diagnostic performance even though high diagnostic performance is observed even with the minimum training.

Conclusion (proposition de traduction) : Les performances diagnostiques des protocoles d'échographie au point d'intervention réalisés par les médecins urgentistes sont excellentes. Combinée à la réduction significative du temps nécessaire au diagnostic, l'échographie au point d'intervention peut être considérée comme un outil de diagnostic efficace. L'échographie au point de service peut être utilisée comme outil d'imagerie de première ligne pour le diagnostic de la thrombose veineuse profonde dans les services d'urgence. Nous avons également recommandé que des médecins urgentistes titulaires d'une formation à l'échographie soient présents lors du diagnostic de la thrombose veineuse profonde afin d'améliorer les performances diagnostiques, même si des performances diagnostiques élevées sont observées même avec une formation minimale.