Defibrillation strategies for patients with refractory ventricular fibrillation: A systematic review and meta-analysis.
Yu J, Yu Y, Liang H, Zhang Y, Yuan D, Sun T, Li Y, Gao Y. | Am J Emerg Med. 2024 Aug 5;84:149-157
DOI: https://doi.org/10.1016/j.ajem.2024.07.059  | Télécharger l'article au format  
Keywords: Double defibrillation; Double sequential external defibrillation; Double simultaneous defibrillation; Meta-analysis; Refractory ventricular fibrillation.

Article

Introduction : The aim of this study was to summarize the existing evidence about the effectiveness of double defibrillation (DD) in comparison to standard defibrillation for patients with refractory ventricular fibrillation (RVF). DD encompasses double "sequential" external defibrillation (DSeq-D) and double "simultaneous" defibrillation (DSim-D), with the study also shedding light on the respective effects of DSeq-D and DSim-D.

Méthode : Investigators systematically searched PubMed, EMBASE and Cochrane Central databases for randomized controlled trials (RCTs) and cohort studies from their inception until June 06, 2024. The rate of survival to hospital discharge was the primary outcome, while the incidence of return of spontaneous circulation (ROSC), termination of ventricular fibrillation (VF), survival to hospital admission and good neurologic outcome were secondary outcomes. Relative ratios (RR) and 95% confidence intervals (CIs) were calculated for each outcome. Heterogeneity was assessed using I square value.

Résultats : A total of 6 trials, comprising 1360 patients, were included. One was an RCT, and five were observational cohort studies. The RCT showed that, compared to standard defibrillation, DSeq-D was associated with higher incidences of survival to hospital discharge, termination of VF, ROSC and good neurologic outcome. However, the pooled results of cohort studies found no benefit of DD over standard defibrillation in survival to hospital discharge (RR, 0.91; 95% CI, 0.46-1.78), nor in secondary outcomes. Furthermore, subgroup analysis suggested DSim-D was linked with lower ROSC rate compared to standard defibrillation (RR, 0.65; 95% CI, 0.49-0.86), while there was no significance between DSeq-D and standard defibrillation (RR, 1.00; 95% CI, 0.70-1.42).

Conclusion : The benefit of DSeq-D in survival to hospital discharge for RVF patients was found in the RCT, but not in cohort studies. Additionally, DSim-D should be applied with greater caution for RVF patients. Further validation is needed through larger-scale and higher-quality trials.

Conclusion (proposition de traduction) : L'avantage de la double défibrillation externe « séquentielle » en termes de survie jusqu'à la sortie de l'hôpital pour les patients présentant une fibrillation ventriculaire réfractaire a été constaté dans l'essai contrôlé randomisé, mais pas dans les études de cohorte. En outre, la double défibrillation « simultanée » devrait être appliquée avec une plus grande prudence chez les patients présentant une fibrillation ventriculaire réfractaire. Une validation supplémentaire est nécessaire par le biais d'essais à plus grande échelle et de meilleure qualité.

Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine Among Critically Ill Patients.
Wunsch H, Bosch NA, Law AC, Vail EA, Hua M, Shen BH, Lindenauer PK, Juurlink DN, Walkey AJ, Gershengorn HB. | Am J Respir Crit Care Med. 2024 Aug 22
DOI: https://doi.org/10.1164/rccm.202404-0813OC
Keywords: etomidate; intensive care unit; intubation; ketamine; mechanical ventilation.

Article

Introduction : Uncertainty remains regarding the risks associated with single dose use of etomidate.
Objectives: To assess use of etomidate in critically ill patients and compare outcomes for patients who received etomidate versus ketamine.

Méthode : We assessed patients who received invasive mechanical ventilation (IMV), admitted to an ICU in the Premier Healthcare Database, 2008-2021. The exposure was receipt of etomidate on the day of IMV initiation and the main outcome was hospital mortality. Using multivariable regression we compared patients who received IMV within the first two days of hospitalization who received etomidate with propensity-score matched patients who received ketamine. We also assessed whether receipt of corticosteroids in the days after intubation modified the association between etomidate and mortality.

Résultats : Of 1,689,945 patients who received IMV, nearly half (738,855; 43.7%) received etomidate. Among those who received IMV in the first two days of hospitalization, we established 22,273 matched pairs given either etomidate or ketamine. In the primary analysis, receipt of etomidate was associated with greater hospital mortality relative to ketamine (21.6% vs 18.7%; absolute risk difference: 2.8%, 95% CI 2.1%, 3.6%; adjusted odds ratio: 1.28, 95% CI 1.21,1.34). This was consistent across subgroups and sensitivity analyses. We found no attenuation of the association with mortality with receipt of corticosteroids in the days following etomidate use.

Conclusion : Use of etomidate on the day of IMV initiation is common and associated with a higher odds of hospital mortality compared with ketamine. This finding is independent of subsequent treatment with corticosteroids.

Conclusion (proposition de traduction) : L'utilisation de l'étomidate le jour de l'instauration de la ventilation mécanique invasive est courante et associée à un risque plus élevé de mortalité hospitalière par rapport à la kétamine. Cette constatation est indépendante du traitement ultérieur par corticostéroïdes.

Interpreting the chest radiograph.
Rigby DM, Hacking L. | Anaesth Intens Care Med. 2024 August 21
DOI: https://doi.org/10.1016/j.resuscitation.2024.110366  | Télécharger l'article au format  
Keywords: Alveolar; chest X-ray; interstitial; lines; pleural

Thoracic anaesthesia

Editorial : Presented is an approach to a chest radiograph, paying particular attention to features commonly seen in the intensive care unit (ICU) with regards to iatrogenic lines and tubes, together with common pathologies that may be encountered. This is accompanied by helpful images to use as an aide memoire when reviewing ICU chest X-rays. Pitfalls in interpreting these often complex X-rays are also discussed.

Conclusion : After reading this article, you should be able to:
&bull: systematically review a chest X-ray
&bull: evaluate chest X-ray lines and tube in patients on the intensive care unit (ICU)
&bull: categorize interstitial, alveolar and pleural disease based on their appearance
&bull: be aware of pitfalls when interpreting X-rays in the ICU setting

Conclusion (proposition de traduction) : Après avoir lu cet article, vous devriez être en mesure de :
&bull: examiner systématiquement une radiographie thoracique
&bull: évaluer les lignes et les dispositifs médicaux sur la radiographie thoracique chez les patients de l'unité de soins intensifs (USI)
. &bull: catégoriser les maladies interstitielles, alvéolaires et pleurales en fonction de leur apparence
. &bull: être conscient des pièges lors de l'interprétation des radiographies en unité de soins intensifs

Sepsis in 2024: A Review.
Wayland J, Teixeira JP, Nielsen ND. | Anaesth Intens Care Med. 2024 August 20
DOI: https://doi.org/10.1016/j.mpaic.2024.06.010  | Télécharger l'article au format  
Keywords: Critical care; intensive care; sepsis; septic shock

INTENSIVE CARE

Editorial : Sepsis is responsible for tremendous morbidity, mortality, and healthcare expenditure worldwide. Over the past decade, the conceptualization of sepsis has shifted from one based upon an inflammatory response to one defined by a dysregulated immune response to infection and resulting organ dysfunction. The definitions of sepsis and septic shock were revised to improve their diagnostic specificity and facilitate accurate and timely diagnoses at the bedside. The core of sepsis management remains early identification and diagnostic testing, early antimicrobial therapy, and early haemodynamic resuscitation. Recently, there has been additional movement towards classifying and treating sepsis based on genotype, phenotype, and endotype, though these methods are not yet widely accessible or adopted. Current guidelines recommend that the first steps in treatment and resuscitation take place within 1 hour from when septic shock is suspected. Additional essential elements in the current sepsis management guidelines include using dynamic parameters to assess fluid responsiveness, a conservative fluid strategy following initial resuscitation (with subsequent de-resuscitation when possible), serial reassessments of haemodynamic status, and adaptable treatment plans. This review provides a summary of the most recent clinical trials and practice guidelines for the diagnosis and treatment of sepsis in the critical care setting.

Conclusion : Sepsis and septic shock are leading contributors to worldwide morbidity and mortality. The current definitions of sepsis and septic shock are based upon an expanded understanding of sepsis as a dysregulated immune response as opposed to solely an inflammatory process. Early recognition and prompt management, such as the implementation of the 1-Hour Bundle for septic shock, are essential to improving patient outcomes. The core elements of any treatment algorithm remain the same: antibiotics, source control, intravenous fluid resuscitation, and vasopressors, tempered with the recognition that sepsis is not a static process and that frequent reassessment and revision of the treatment plan are essential. A number of potential targeted adjunctive therapies and novel diagnostic techniques are on the horizon, though none yet have a role in routine clinical practice.

Conclusion (proposition de traduction) : Le sepsis et le choc septique sont les principaux facteurs de morbidité et de mortalité dans le monde. Les définitions actuelles du sepsis et du choc septique sont basées sur une compréhension élargie du sepsis en tant que réponse immunitaire déréglée par opposition au seul processus inflammatoire. Une reconnaissance précoce et une prise en charge rapide, comme la mise en œuvre de l'ensemble de mesures en une heure pour le choc septique, sont essentielles pour améliorer les résultats pour les patients. Les éléments de base de tout algorithme de traitement restent les mêmes : Les éléments de base de tout algorithme de traitement restent les mêmes : antibiotiques, contrôle de la source, réanimation par voie intraveineuse et vasopresseurs, tout en reconnaissant que le sepsis n'est pas un processus statique et qu'il est essentiel de réévaluer et de réviser fréquemment le plan de traitement. Un certain nombre de thérapies complémentaires ciblées potentielles et de nouvelles techniques de diagnostic se profilent à l'horizon, bien qu'aucune n'ait encore un rôle à jouer dans la pratique clinique de routine.

Tube Thoracostomy Should Remain the Preferred Intervention for Traumatic Hemothorax.
Saint Louis LS, Klein EN, Jafari D. | Ann Emerg Med. 2024 Aug 31:S0196-0644(24)00412-8
DOI: https://doi.org/10.1016/j.annemergmed.2024.07.018
Keywords: Aucun

CLINICAL CONTROVERSIES

Editorial : Tube thoracostomy is a critical intervention for managing thoracic conditions that threaten respiratory and circulatory function, thereby preventing potentially fatal outcomes. Drainage of the pleural space is a concept that dates back to the time of Hippocrates.1 Chest tubes became widely used in 1917 for a variety of pleural conditions; however, it was not until the Korean war that emergency tube thoracostomy became a common occurrence in acute trauma.1 In recent years, small-bore percutaneous thoracostomy tubes (14 French and smaller) were proposed as an alternative to large-bore chest tubes (28-40 French). The purpose of this article is to review the current literature on the use of percutaneous thoracostomy tube drainage catheters and refute the notion that the existing literature strongly supports replacing larger thoracostomy tubes with small-bore percutaneous tubes in the management of traumatic hemothorax.

Conclusion : In conclusion, the data supporting percutaneous thoracostomy tubes as an alternative for thoracostomy tubes in the management of traumatic hemothorax only exist for select groups of patients, namely hemodynamically stable patients in whom immediate tube insertion is not necessary. The Eastern Association for Surgery of Trauma and the Western Trauma Association only recommend percutaneous thoracostomy tubes in stable patients with traumatic hemothorax, and clinicians seem to prefer thoracostomy tubes in more emergent situations. We know tube thoracostomy is an effective treatment for all traumatic pneumothoraces, but more robust data are needed before conventional thoracostomy tubes can be replaced by percutaneous thoracostomy tubes.

Conclusion (proposition de traduction) : En conclusion, les données en faveur des drains souples perforés de thoracostomie comme alternative aux drains à trocart interne de thoracostomie dans la prise en charge de l'hémothorax traumatique n'existent que pour des groupes de patients sélectionnés, à savoir les patients hémodynamiquement stables chez qui l'insertion immédiate du tube n'est pas nécessaire. L'Eastern Association for Surgery of Trauma et la Western Trauma Association ne recommandent les drains souples perforés de thoracostomie que chez les patients stables présentant un hémothorax traumatique, et les cliniciens semblent préférer les drains à trocart interne de thoracostomie dans les situations plus urgentes. Nous savions que le drains à trocart interne était le traitement efficace pour tous les pneumothorax traumatiques, mais des données plus solides sont nécessaires avant de pouvoir remplacer les drains à trocart interne de thoracostomie conventionnels par des drains souples perforés de thoracostomie percutanée.

Commentaire : Les drains souples perforés de thoracostomie sont de petit calibre (14 French et moins : Pleurocath, drain de Fuhrman... introduits selon la technique de Seldinge) et sont moins pourvoyeurs de lésions pulmonaires. C'est pour cela qu'en cas de pneumothorax spontané, sans signe de gravité et chez un patient sans pathologie pulmonaire chronique sous-jacente (pathologie interstitielle, connectivite…) ils sont préférés.
Les drains à trocart interne de thoracostomie conventionnels sont de gros calibre (28-40 French), ces derniers exposent, par leur mandrin inclus dans le drain, au risque de lésion endothoracique si celui-ci n’est pas immobilisé dès le passage de la plèvre pariétale. Ils sont préférés dans les hémothorax traumatiques afin d’éviter qu’ils ne se bouchent avec des caillots et de drainer incomplètement la plèvre.

Severe hyperlactatemia in the emergency department: clinical characteristics, etiology and mortality.
Tangpaisarn T, Drumheller BC, Daungjunchot R, Kotruchin P, Daorattanachai K, Phungoen P. | BMC Emerg Med. 2024 Aug 20;24(1):150
DOI: https://doi.org/10.1186/s12873-024-01071-1  | Télécharger l'article au format  
Keywords: Emergency department; Lactate; Severe hyperlactatemia.

Research

Introduction : Severe hyperlactatemia (lactate level ≥ 10 mmol/L) is associated with high mortality rates in critically ill patients. However, there is limited data on emergency department (ED) patients. We aimed to investigate the clinical characteristics, etiology and outcomes of patients with severe hyperlactatemia in the ED setting.

Méthode : A retrospective cohort study was conducted at a tertiary care hospital in Thailand. We included adult patients with a venous lactate sample taken in the ED within one hour. We excluded patients after out-of-hospital cardiac arrest, transferred to/from another hospital or those with missing clinical data. Mortality rates were evaluated among patients with increasing degrees of lactate elevation and among patients with severe hyperlactatemia, stratified by causative etiology.

Résultats : We analyzed venous lactate levels in 40,047 patients, with 26,680 included in the analysis. Among these, 1.7% had severe hyperlactatemia (lactate ≥ 10 mmol/L), 10.5% moderate (4-9.99 mmol/L), 28.8% mild (2-3.99 mmol/L), and 59.0% normal levels (< 2 mmol/L). Severe hyperlactatemia was associated with high mortality rates of 29%, 37%, and 38% at 7, 28, and 60 days respectively, significant ICU admissions and mechanical ventilation rates. Patients with severe hyperlactatemia were stratified into high (> 50% mortality), moderate (21-50%), and low (< 20%) 28-day mortality risk groups. High-risk conditions included non-septic shock, traumatic injuries/burns, and neurological issues, with mortality rates of 51.1%, 61.8%, and 57.1%, respectively. In the moderate risk group, namely infection without shock showed a high prevalence, with a mortality rate of 36%. In the low-risk group, seizures and fainting were associated with lower mortality, exhibiting mortality rates of 0%.

Conclusion : Severe hyperlactatemia is associated with higher rates of ICU admission and mortality compared to other degrees of lactate elevation in a general ED population. However, mortality rates can vary considerably, depending on the underlying etiology associated with different primary diagnoses.

Conclusion (proposition de traduction) : L'hyperlactatémie sévère est associée à des taux plus élevés d'admission en USI et de mortalité par rapport à d'autres degrés d'élévation du lactate dans une population générale de services d'urgence. Cependant, les taux de mortalité peuvent varier considérablement en fonction de l'étiologie sous-jacente associée à différents diagnostics primaires.

Commentaire : Les conditions à haut risque comprenaient le choc non septique, les lésions traumatiques/brûlures et les problèmes neurologiques, avec des taux de mortalité de 51,1 %, 61,8 % et 57,1 %, respectivement.
Dans le groupe à risque modéré, la prévalence de l'infection sans choc était élevée, avec un taux de mortalité de 36 %.
Dans le groupe à faible risque, les convulsions et les évanouissements ont été associés à une mortalité plus faible, avec un taux de mortalité de 0 %.

Oxygen accumulation and associated dangers in rescue helicopters.
Kohler LM, Köhler A, Perschinka F, Benda BM, Joannidis M, Hartig F. | BMC Emerg Med. 2024 Aug 13;24(1):146
DOI: https://doi.org/10.1186/s12873-024-01066-y  | Télécharger l'article au format  
Keywords: Explosion; Fire hazard; Oxygen accumulation; Oxygen administration; Oxygen clouds; Oxygen enrichment; Prevention; Rescue helicopter.

Research

Introduction : At the time of the COVID-19 pandemic, devastating incidents increased due to frequent oxygen administration to patients. The dangers associated with the use of oxygen, especially through local enrichments and formation of "oxygen clouds", have been well understood for years. Nevertheless, dramatic incidents continue to occur, since fire hazard increases exponentially with oxygen concentrations above 23%. Rescue helicopters are at a particular high risk, because of technical reasons such as oxygen use in a very small space, surrounded by kerosene lines, electronic relays and extremely hot surfaces.

Méthode : In this study three different sized rescue helicopter models (Airbus H135, H145 and MD902) were examined. Oxygen enrichment in the cabin was measured with an oxymeter during a delivery rate of 15 l/min constant flow for 60 min. Furthermore, the clearance of the enriched atmosphere was tested in different situations and with different ventilation methods. To make the airflow visible, a fog machine was used to fill the helicopter cabin.

Résultats : Oxygen accumulation above 21% was detected in every helicopter. After 10-15 min, the critical 23% threshold was exceeded in all three aircrafts. The highest concentration was detected in the smallest machine (MD902) after 60 min with 27.4%. Moreover, oxygen clouds persisted in the rear and the bottom of the aircrafts, even when the front doors were opened. This was most pronounced in the largest aircraft, the H145 from Airbus Helicopters. Complete and rapid removal of elevated oxygen concentrations was achieved only by cross-ventilation within 1 min.

Conclusion : Oxygen should be handled with particular care in rescue helicopters. Adapted checklists and precautions can help to prevent oxygen accumulation, and thus, fatal incidents. To our knowledge, this is the first study, which analyzed oxygen concentrations in different settings in rescue helicopters.

Conclusion (proposition de traduction) : L'oxygène doit être manipulé avec une attention particulière dans les hélicoptères de secours. Des listes de contrôle et des précautions adaptées peuvent aider à prévenir l'accumulation d'oxygène et, par conséquent, les incidents mortels. À notre connaissance, il s'agit de la première étude qui a analysé les concentrations d'oxygène dans différents contextes au sein d'hélicoptères de secours.

Blood pressure variability and prognostic significance in traumatic brain injury: analysis of the eICU-CRD database.
Zhang SY, Li CL, Yin J, Jiang M, Yang XF. | BMC Emerg Med. 2024 Aug 7;24(1):141
DOI: https://doi.org/10.1186/s12873-024-01054-2  | Télécharger l'article au format  
Keywords: Blood pressure variability; Discharge-home rate; Mortality; Traumatic brain injury.

Research

Introduction : Preliminary evidence demonstrates that visit-to-visit systolic blood pressure (SBP) variability is a prognostic factor of TBI. However, literature regarding the impact of initial blood pressure management on the outcomes of TBI patients is limited. We aimed to further validate the clinical significance of BPV on the prognostic outcomes of patients with TBI.

Méthode : We performed the analysis by using individual patient-level data acquired from the eICU-CRD, which collected 200,859 ICU admissions of 139,367 patients in 2014 and 2015 from 208 US hospitals. Adult patients with traumatic intraparenchymal hemorrhage or contusion were included. The primary outcome was in-hospital mortality and the secondary outcome was discharge-home rate. Blood pressure variability (BPV) was calculated according to standard criteria: at least six measurements were taken in the first 24 h (hyperacute group) and 36 over days 2-7 (acute group). We estimated the associations between BPV and outcomes with logistic and proportional odds regression models. The key parameter for BPV was standard deviation (SD) of SBP, categorized into quintiles. We also calculated the average real variability (ARV), as well as maximum, minimum, and mean SBP for comparison in our analysis.

Résultats : We studied 1486 patients in the hyperacute group and 857 in the acute group. SD of SBP had a significant association with the in-hospital mortality for both the hyperacute group (highest quintile adjusted OR 2.28 95% CI 1.18-4.42; p_trend<0.001) and the acute group (highest quintile adjusted OR 2.17, 95% CI 1.08-4.36; p_trend<0.001). The strongest predictors of primary outcome were SD of SBP in the hyperacute phase and minimum SBP in the acute phase. Associations were similar for the discharge-home rate (for the hyperacute group, highest quintile adjusted OR 0.58, 95% CI 0.37-0.89; p_trend<0.001; for the acute group OR 0.55, 95% CI 0.32-0.95; p_trend<0.001).

Conclusion : Systolic BPV seems to predict a poor outcome in patients with TBI. The benefits of early treatment to maintain appropriate SBP level might be enhanced by smooth and sustained control.

Conclusion (proposition de traduction) : La variabilité de la pression artérielle systolique semble prédire un mauvais résultat chez les patients souffrant de lésions cérébrales traumatiques . Les avantages d'un traitement précoce visant à maintenir un niveau approprié de pression artérielle systolique pourraient être renforcés par un contrôle régulier et continu.

A systematic review and meta-analysis comparing outcomes between using subcutaneous insulin and continuous insulin infusion in managing adult patients with diabetic ketoacidosis.
Alnuaimi A, Mach T, Reynier P, Filion KB, Lipes J, Yu OHY. | BMC Endocr Disord. 2024 Aug 1;24(1):133
DOI: https://doi.org/10.1186/s12902-024-01666-6  | Télécharger l'article au format  
Keywords: Diabetes; Diabetic ketoacidosis; Subcutaneous insulin; Systematic review.

Systematic Review

Introduction : The purpose of this systematic review and meta-analysis was to synthesize the current literature to determine the safety and efficacy of using subcutaneous insulin compared to an intravenous (IV) insulin infusion in managing diabetic ketoacidosis (DKA).

Méthode : We searched Ovid-Medline, EMBASE, SCOPUS, BIOSIS and CENTRAL from inception to April 26, 2024. Randomized controlled trials (RCTs) and observational studies that assessed the use of subcutaneous compared to intravenous insulin for the treatment of mild to moderate DKA were included. Data extraction and quality assessment were performed by two independent reviewers and disagreements were resolved through further discussion or by a third reviewer. The Cochrane Risk of Bias tool version 2.0 was used to evaluate the RCTs and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS)-I tool was used to evaluate the observational studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Meta-analyses were conducted using random-effects models. We followed the PRISMA guidelines for reporting our findings.

Résultats : Six RCTs (245 participants) and four observational studies (8444 patients) met our inclusion criteria. Some studies showed a decreased length of stay (Mean Difference [MD] in days: -0.39; 95% CI: -2.83 to 2.08; I²: 0%) among individuals treated with subcutaneous insulin compared to intravenous insulin. There was no difference in the risk of all-cause mortality, time to resolution of DKA (MD in hours: 0.17; 95% confidence interval [CI]: -3.45 to 3.79; I²: 0%) and hypoglycemia (Risk Ratio [RR]: 1.02; 95% CI: 0.88 to 1.19; I²: 0%) between the two groups.

Conclusion : Treatment of DKA with subcutaneous insulin may be a safe and effective alternative to IV insulin in selected patients. The limited available evidence underscores the need for further studies to explore optimal dosing, patient selection criteria and long-term outcomes.

Conclusion (proposition de traduction) : Le traitement de l'acidocétose diabétique par l'insuline sous-cutanée peut être une alternative sûre et efficace à l'insuline IV chez certains patients. Le peu de données disponibles souligne la nécessité de mener d'autres études pour déterminer le dosage optimal, les critères de sélection des patients et les résultats à long terme.

Severe acute pancreatitis.
Søreide K, Barreto SG, Pandanaboyana S. | Br J Surg. 2024 Aug 2;111(8):znae170
DOI: https://doi.org/10.1093/bjs/znae170  | Télécharger l'article au format  
Keywords: Aucun

JOURNAL ARTICLE

Editorial : The incidence of acute pancreatitis worldwide is increasing, with an over 3% increase in incidence per year in North America, Australia, the UK, and Northern Europe. In 2019, some 2.8 million episodes of acute pancreatitis occurred globally, leading to an estimated 115 000 deaths. Diagnosis of acute pancreatitis is usually made by clinical evaluation of signs and symptoms, blood tests (greater than 3 times upper normal cut-off value of serum amylase and/or lipase elevation), and the use of imaging when diagnostic uncertainty exists

Conclusion : In summary, acute pancreatitis is a common disease encountered in surgical practice globally. Early initiation of supportive treatment, determination of severity to identify patients in, or at risk of, organ failure to provide them with timely critical care support aimed at reversing organ failure, an emphasis on nutrition, a step-up approach to managing infected (peri)pancreatic necrosis, and the judicious use of ERCP in patients with concomitant cholangitis are critical for delivering optimal care to patients. Ongoing efforts to identify a specific treatment for acute pancreatitis are warranted.

Conclusion (proposition de traduction) : En résumé, la pancréatite aiguë est une maladie fréquente dans la pratique chirurgicale au niveau mondial. L'instauration précoce d'un traitement de support, la recherche de la gravité pour identifier les patients présentant une défaillance d'organe ou un risque de défaillance d'organe afin de leur apporter en temps utile un traitement de soins intensifs visant à corriger la défaillance d'organe, l'accent mis sur la nutrition, une approche progressive de la gestion de la nécrose (péri)pancréatique infectée et l'utilisation judicieuse de la cholangiopancréatographie rétrograde endoscopique chez les patients présentant une angiocholite concomitante sont des éléments essentiels pour fournir des soins optimaux aux patients. Des efforts continus pour identifier un traitement spécifique de la pancréatite aiguë sont justifiés.

Utility of serial troponin testing for emergency department patients with syncope.
Mukarram M, Rowe BH, Ishimwe AC, Hegdekar M, Sivilotti MLA, Taljaard M, Nemnom MJ, Thiruganasambandamoorthy V. | CJEM. 2024 Aug 2
DOI: https://doi.org/10.1007/s43678-024-00740-1  | Télécharger l'article au format  
Keywords: Emergency department; Serial troponin testing; Short-term serious adverse events; Syncope.

Article

Introduction : For emergency department (ED) patients with syncope, cardiac troponin can identify acute coronary syndrome (ACS) and prognosticate for 30-day serious adverse events. However, it is unclear if serial testing improves diagnostic yield and prognostication.

Méthode : This was a secondary analysis of data from two prospective studies conducted to develop the Canadian Syncope Risk Score. Adults (age ≥ 16 years) with syncope were enrolled, and patient characteristics, vital signs, physician diagnostic impression, electrocardiogram and troponin results, and adjudicated 30-day serious adverse event were collected. The primary outcome was the detection of a serious adverse event within 30 days of ED disposition. The secondary outcome was comparison of ED length of stay among patients with single versus serial troponin measurements.

Résultats : 4996 patients [mean age 64.5 (SD 18.8) years, 52.2% male] were included: 4397 (89.8%) with single troponin [232 (5.3%) with serious adverse event in the ED and 203 (4.6%) after ED disposition]; 499 (10.2%) patients with > 1 troponin measurement [39 (7.8%) with serious adverse event in ED and 60 (12.0%) after ED disposition]. Among those with serial measurements, 10 patients (2.0%) had a rise from below to above the 99th percentile threshold, of whom 4 patients (0.8%) suffered serious adverse event: two with arrhythmias diagnosed on electrocardiogram, one with ACS and one suffered respiratory failure. Nine patients (1.8%) had Canadian Syncope Risk Score risk reclassification based on serial measurement, and none suffered 30-day serious adverse event. Median ED length of stay was significantly longer for patients with serial testing (5.6 vs. 3.8 h, p < 0.001).

Conclusion : The initial troponin measurement was sufficient for serious adverse event detection and in-ED risk stratification. Serial troponin testing does not improve the diagnostic yield or prognostication and should be reserved for patients with ongoing symptoms or electrocardiogram findings suggestive of cardiac ischemia.

Conclusion (proposition de traduction) : Le dosage initial de la troponine est suffisant pour la détection des événements indésirables graves et la stratification du risque au sein du service des urgences. Le dosage en série de la troponine n'améliore pas le rendement diagnostique ou le pronostic et doit être réservé aux patients présentant des symptômes persistants ou des résultats d'électrocardiogramme évocateurs d'une ischémie cardiaque.

Commentaire : Reyes J, Becker BA, D'Angelo J, Golden B, Stahlman BA, Miraoui M, Atwood J. Utility of serial conventional troponin testing for emergency department patients stratified by HEART score and symptom timing. Am J Emerg Med. 2023 Jul;69:173-179  .
Nos données suggèrent que la mesure en série de la troponine conventionnelle n'apporte qu'un bénéfice supplémentaire limité chez les patients à faible risque du score HEART, indépendamment de la durée et du moment de l'apparition des symptômes. Inversement, la mesure en série de la troponine peut s'avérer utile chez les patients à risque modéré/élevé selon le score HEART, en particulier ceux qui se présentent dans les 3 heures suivant les symptômes.

Brief report: incidence and outcomes of pediatric tracheal intubation-associated cardiac arrests in the ICU-RESUS clinical trial.
Graham K, Nishisaki A, Reeder RW, McGovern EL, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Diddle W, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen P, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Berg RA. | Crit Care. 2024 Aug 30;28(1):286
DOI: https://doi.org/10.1186/s13054-024-05065-0  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Infant; Intubation; Outcome; Pediatric.

RESEARCH

Introduction : Tracheal intubation (TI)-associated cardiac arrest (TI-CA) occurs in 1.7% of pediatric ICU TIs. Our objective was to evaluate resuscitation characteristics and outcomes between cardiac arrest patients with and without TI-CA.

Méthode : Secondary analysis of cardiac arrest patients in both ICU-RESUS trial and ancillary CPR-NOVA study. The primary exposure was TI-CA, defined as cardiac arrest occurred during TI procedure or within 20 min after endotracheal tube placement. The primary outcome was survival to hospital discharge with favorable neurological outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged).

Résultats : Among 315 children with cardiac arrests, 48 (15.2%) met criteria for TI-CA. Pre-existing medical conditions were similar between groups. Pre-arrest non-invasive mechanical ventilation was more common among TI-CA patients (18/48, 37.5%) compared to non-TI-CA patients (35/267, 13.1%). In 48% (23/48), the TI-CA occurred within 20 min after intubation (i.e., not during intubation). Duration of CPR was longer in TI-CA patients (median 11.0 min, interquartile range [IQR]: 2.5, 35.5) than non-TI-CA patients (median 5.0 min, IQR 2.0, 21.0), p = 0.03. Return of spontaneous circulation occurred in 32/48 (66.7%) TI-CA versus 186/267 (69.7%) non-TI-CA, p = 0.73. Survival to hospital discharge with favorable neurological outcome occurred in 29/48 (60.4%) TI-CA versus 146/267 (54.7%) non-TI-CA, p = 0.53.

Conclusion : Fifteen percent of these pediatric ICU cardiac arrests were associated with TI. Half of TI-CA occurred after endotracheal tube placement. While duration of CPR was longer in TI-CA patients, there were no differences in unadjusted outcomes following TI-CA versus non-TI-CA.

Conclusion (proposition de traduction) : Quinze pour cent de ces arrêts cardiaques en USI pédiatrique étaient associés à une intubation trachéale. La moitié des arrêts cardiaques associés à l'intubation trachéale se sont produits après la mise en place de la sonde endotrachéale. Bien que la durée de la RCP ait été plus longue chez les patients ayant subi un arrêt cardiaque associé à une intubation trachéale, il n'y avait pas de différence dans les résultats non ajustés après un arrêt cardiaque associé à une intubation trachéale par rapport à un arrêt cardiaque non associé à une intubation trachéale.

STAB-5: an aide-mémoire for the efficient prehospital management of penetrating trauma by emergency medical services.
Robinson M, Rath F, Sutton C, Kinsella M, Ter Avest E, Carenzo L. | Crit Care. 2024 Aug 5;28(1):261
DOI: https://doi.org/10.1186/s13054-024-05048-1  | Télécharger l'article au format  
Keywords: Aucun

Correspondence

Introduction : Penetrating trauma represents a significant percentage of the overall trauma case load in many trauma systems.For patients with penetrating injuries, a longer time to hospital is associated with an increase in risk-adjusted odds of death [1, 2]. Therefore, expedited treatment and transport of by Emergency Medical Services (EMS) crews, who are usually the first healthcare practitioners to attend these patients on scene, is warranted.

Méthode : To expedite decision-making by EMS crews and to improve immediate care for patients withpenetrating torso injuries, a 5-step aide-mémoire was developed based on available literature and expert opinion.

Résultats : 5 key-points are essential in the EMS treatment of patients with (central) stab wounds.

Conclusion : The STAB-5 mnemonic is a standard simple approach for treatment of patients with penetrating injuries by EMS crews, focusing on early haemorrhage control and short on-scene times, which may contribute to better patient outcomes in systems where providers have limited exposure to penetrating injuries.

Conclusion (proposition de traduction) : Le moyen mnémotechnique STAB-5 est une approche standard simple pour le traitement des patients présentant des lésions pénétrantes par les équipes des services médicaux d'urgence, qui se concentre sur le contrôle précoce des hémorragies et des délais courts sur place, ce qui peut contribuer à de meilleurs résultats pour les patients dans les systèmes où les prestataires ont une exposition limitée aux lésions pénétrantes.

Commentaire : 

Black and white: how good are clinicians at diagnosing elbow injuries from paediatric elbow radiographs alone?.
Dann L, Edwards S, Hall D, Davis T, Roland D, Barrett M. | Emerg Med J. 2024 Aug 24:emermed-2024-214047
DOI: https://doi.org/10.1136/emermed-2024-214047
Keywords: pediatric emergency medicine; pediatric injury; trauma; x-ray.

Original research

Introduction : Paediatric trauma elbow radiographs are difficult to interpret and there is a potential for harm if misdiagnosed. The primary goal of this study was to assess the ability of healthcare professionals internationally to interpret paediatric trauma elbow radiographs from the radiograph alone by formulating the correct diagnosis.

Méthode : This prospective international study was conducted online via the Free Open Access Medical Education platform, Don't Forget the Bubbles (DFTB, ISSN 2754-5407). Participants were recruited via the DFTB social media accounts between 17 August and 14 September 2021. Submissions that were incomplete or from participants who do not interpret paediatric elbow radiographs in their clinical practice were excluded. Participants completed an online survey of demographic data followed by interpreting 10 trauma-indicated elbow radiographs, by selecting multiple-choice options. The primary outcome was correct diagnosis.

Résultats : Participant responses from 18 countries were analysed, with most responses from the UK, Australia and Ireland. Participants had backgrounds in emergency medicine (EM), paediatric emergency medicine (PEM), general practice (GP) and paediatrics, with over 70% having 6+ years of postgraduate experience. 3180 radiographs were interpreted by 318 healthcare professionals. Only nine (2.8%) participants correctly diagnosed all 10. The mean number of radiographs correctly interpreted was 5.44 (SD 2.3). The mean number for those with 6+ years of experience was 6.02 (SD 2.2). On reviewing the normal radiograph, 158 (49.7%) overcalled injuries. Participants with EM or PEM background were equally likely to have more correct answers than those from paediatric or GP backgrounds.

Conclusion : Globally, healthcare professional's success in correctly diagnosing paediatric elbow injuries from radiographs was suboptimal in this non-clinical exercise, despite capturing quite an experienced cohort of clinicians. This study has provided us with detailed baseline data to accurately assess the impact of interventions aimed at improving clinicians' interpretation of paediatric elbow radiographs in future studies.

Conclusion (proposition de traduction) : Globalement, la capacité des professionnels de santé à diagnostiquer correctement les lésions pédiatriques du coude à partir de radiographies était sous-optimale dans cet exercice non clinique, malgré la présence d'une cohorte de cliniciens expérimentés. Cette étude nous a fourni des données de base détaillées pour évaluer avec précision l'impact des interventions visant à améliorer l'interprétation des radiographies pédiatriques du coude par les cliniciens dans de futures études.

Increased mortality in elderly patients who spent the night in the emergency department: lessons from the ‘No Bed Night’ study?.
Roussel M | Eur J Emerg Med. 2024 Aug 1;31(4):234-235
DOI: https://doi.org/10.1097/mej.0000000000001139
Keywords: Aucun

VIEWPOINT

Editorial : In media outlets worldwide, images and stories depict- ing emergency departments (EDs) overwhelmed with patients lying on stretchers in corridors have become increasingly common. This issue of overcrowding in EDs has escalated to unprecedented levels during the triple epidemic of the 2022 winter in Europe with the coexistence of respiratory syncytial virus, influenzae, and COVID-19 surge, highlighting a pressing challenge. Boarding delays are recognized as the major explanatory factor for ED overcrowding.

Conclusion : Patients visiting our EDs, especially the most fragile, are seeking care and help from our institutions. As emergency physicians, it is a terrible concept to accept that patients are put at risk just by visiting us. It has been widely described that emergency physicians may suffer from an increased risk of burnout. The idea that, despite our care and effort, our patients may encounter avoidable death is impossible to accept. But indeed, this is the case. If we roughly transpose our results to our daily practice, among the next 25 patients that will stay overnight in the EDs, we will have to deal with the fact that one of them will die because of the lack of available ward bed.
We will have to deal with the fact that there is a treatment that is associated with a 4% absolute mortality reduction and that this treatment is too often denied to our patients, for whom we have a duty.

Conclusion (proposition de traduction) : Les patients qui se rendent dans nos services d'urgence, en particulier les plus fragiles, recherchent des soins et de l'aide auprès de nos institutions. En tant que médecins urgentistes, c'est un concept terrible que d'accepter que les patients soient mis en danger par le simple fait de nous rendre visite. Il a été largement décrit que les médecins urgentistes peuvent souffrir d'un risque accru d'épuisement professionnel. Il est impossible d'accepter l'idée que, malgré nos soins et nos efforts, nos patients puissent être confrontés à une mort évitable. Pourtant, c'est bien le cas. Si nous transposons grossièrement nos résultats à notre pratique quotidienne, parmi les 25 prochains patients qui passeront la nuit aux urgences, nous devrons faire face au fait que l'un d'entre eux mourra en raison du manque de lits disponibles dans le service.
Nous devrons faire face au fait qu'il existe un traitement associé à une réduction absolue de la mortalité de 4 % et que ce traitement est trop souvent refusé à nos patients, pour lesquels nous avons un devoir.

Consensus paper on the assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13–15 at the emergency department: A multidisciplinary overview.
Backus BE, Moustafa F, Skogen K, Sapin V, Rane N, Moya-Torrecilla F, Biberthaler P, Tenovuo O. | Eur J Emerg Med. 2024 Aug 1;31(4):240-249
DOI: https://doi.org/10.1097/mej.0000000000001140
Keywords: Aucun

REVIEWS

Editorial : Traumatic brain injury (TBI) is a common reason for presenting to emergency departments (EDs). The assessment of these patients is frequently hampered by various confounders, and diagnostics is still often based on nonspecific clinical signs. Throughout Europe, there is wide variation in clinical practices, including the follow-up of those discharged from the ED. The objective is to present a practical recommendation for the assessment of adult patients with an acute TBI, focusing on milder cases not requiring in-hospital care. The aim is to advise on and harmonize practices for European settings. A multiprofessional expert panel, giving consensus recommendations based on recent scientific literature and clinical practices, is employed. The focus is on patients with a preserved consciousness (Glasgow Coma Scale 13–15) not requiring in-hospital care after ED assessment. The main results of this paper contain practical, clinically usable recommendations for acute clinical assessment, decision-making on acute head computerized tomography (CT), use of biomarkers, discharge options, and needs for follow-up, as well as a discussion of the main features and risk factors for prolonged recovery. In conclusion, this consensus paper provides a practical stepwise approach for the clinical assessment of patients with an acute TBI at the ED. Recommendations are given for the performance of acute head CT, use of brain biomarkers and disposition after ED care including careful patient information and organization of follow-up for those discharged.

Conclusion : In this paper, we present a concise recommendation for the workflow needed when facing patients with a TBI of 13–15 at the ED, based on accumulated research and multiprofessional clinical experience. Some aspects of this paper, such as features of history taking and clinical examination, decisions of discharge, as well as a list of various risk factors for incomplete recovery, are hard to find in the existing scientific literature. We also provide a practical update on the use of currently available blood biomarkers for TBI. We do hope that this paper helps to harmonize the assessment of these patients and avoid deleterious consequences these patients may face if important aspects in their acute clinical evaluation have been missed.

Conclusion (proposition de traduction) : Dans cet article, nous présentons une recommandation concise concernant le processus de gestion des patients souffrant d'une lésion cérébrale traumatique de 13 à 15 ans aux urgences, sur la base des recherches accumulées et de l'expérience clinique multiprofessionnelle. Certains aspects de cet article, tels que les caractéristiques de l'anamnèse et de l'examen clinique, les décisions de sortie, ainsi qu'une liste de divers facteurs de risque de récupération incomplète, sont difficiles à trouver dans la littérature scientifique existante. Nous fournissons également une mise à jour pratique sur l'utilisation des biomarqueurs sanguins actuellement disponibles pour les lésions cérébrales traumatiques. Nous espérons que cet article contribuera à harmoniser l'évaluation de ces patients et à éviter les conséquences délétères auxquelles ils pourraient être confrontés si des aspects importants de leur évaluation clinique aiguë n'ont pas été pris en compte.

The syncope core management process in the emergency department: a consensus statement of the EUSEM syncope group.
Möckel M, Catherine Janssens KA, Pudasaini S, Garcia-Castrillo Riesgo L, Moya Torrecilla F, Golea A, Reed MJ, Karamercan M, Fernández Cejas JA, Laribi S; EUSEM syncope group. | Eur J Emerg Med. 2024 Aug 1;31(4):250-259
DOI: https://doi.org/10.1097/mej.0000000000001146  | Télécharger l'article au format  
Keywords: Aucun

Reviews

Introduction : The European Society of Cardiology issued updated syncope guidelines in 2018 which included recommendations for managing syncope in the emergency department (ED) setting. However, these guidelines lack detailed process-oriented instructions regarding the fact that ED syncope patients initially present with a transient loss of consciousness (TLOC), which can have a broad spectrum of causes. This study aims to establish a European consensus on the general process of the workup and care for patients with suspected syncope and provides rules for sufficient and systematic management of the broad group of syncope (initially presenting as TLOC) patients in the ED. A variety of European diagnostic and therapeutic standards for syncope patients were reviewed and summarized in three rounds of a modified Delphi process by the European Society for Emergency Medicine syncope group. Based on a consensus statement, a detailed process pathway is created. The primary outcome of this work is the presentation of a universal process pathway for the structured management of syncope patients in European EDs. The here presented extended event process chain (eEPC) summarizes and homogenizes the process management of European ED syncope patients. Additionally, an exemplary translation of the eEPC into a practice-based flowchart algorithm, which can be used as an example for practical use in the ED, is provided in this work. Syncope patients, initially presenting with TLOC, are common and pose challenges in the ED. Despite variations in process management across Europe, the development of a universally applicable syncope eEPC in the ED was successfully achieved. Key features of the consensus and eEPC include ruling out life-threatening causes, distinguishing syncope from nonsyncopal TLOCs, employing syncope risk stratification categories and based on this, making informed decisions regarding admission or discharge.

Conclusion : The spectrum of syncope patients in European EDs as well as their management strategies are broad but were possible to understand and summarized into a comprehensive eEPC. The focus and challenges are especially on (a) filtering syncopal TLOCs and (b) stratifying them via risk category. Etiology-wise, unrecognized trauma (TLOC), early identification of sepsis and shock as well as syncope as a symptom of an underlying disease correspond to common ED challenges. Additional studies are needed to gain more detailed primary data on patients with syncope in the ED on the basis of which this syncope eEPC can be further adapted. Whether the use of this eEPC for digital tools and the construction of location-specific algorithms may improve syncope ED care, should be of interest for future research, too.

Conclusion (proposition de traduction) : Le profil des patients victimes de syncope dans les services d'urgence européens ainsi que leurs stratégies de prise en charge sont très variés, mais il a été possible de les comprendre et de les résumer dans une chaîne de processus d'événements étendue et complète. Les objectifs et les problèmes concernent en particulier (a) le filtrage des pertes de conscience syncopales transitoires et (b) la stratification des patients par catégorie de risque. Du point de vue étiologique, les traumatismes non reconnus, l'identification précoce du sepsis et du choc, ainsi que la syncope comme symptôme d'une maladie sous-jacente, correspondent à des difficultés communes aux services d'urgence. Des études supplémentaires sont nécessaires pour obtenir des données de base plus détaillées sur les patients souffrant de syncope aux urgences, sur la base desquelles cette chaîne de processus d'événement élargi de syncope peut être adaptée. La question de savoir si l'utilisation de cette chaîne de processus étendue pour les outils numériques et la construction d'algorithmes spécifiques à un lieu peuvent améliorer les soins aux urgences en cas de syncope devrait également faire l'objet d'une recherche future.

High-flow nasal cannula oxygen versus noninvasive ventilation for the management of acute cardiogenic pulmonary edema: a randomized controlled pilot study.
Marjanovic N, Piton M, Lamarre J, Alleyrat C, Couvreur R, Guenezan J, Mimoz O, Frat JP. | Eur J Emerg Med. 2024 Aug 1;31(4):267-275
DOI: https://doi.org/10.1097/mej.0000000000001128
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Whether high-flow nasal oxygen can improve clinical signs of acute respiratory failure in acute heart failure (AHF) is uncertain.

Méthode : To compare the effect of high-flow oxygen with noninvasive ventilation (NIV) on respiratory rate in patients admitted to an emergency department (ED) for AHF-related acute respiratory failure.
Design, settings and participants: Multicenter, randomized pilot study in three French EDs. Adult patients with acute respiratory failure due to suspected AHF were included. Key exclusion criteria were urgent need for intubation, Glasgow Coma Scale <13 points or hemodynamic instability.
Intervention: Patients were randomly assigned to receive high-flow oxygen (minimum 50 l/min) or noninvasive bilevel positive pressure ventilation.
Outcomes measure: The primary outcome was change in respiratory rate within the first hour of treatment and was analyzed with a linear mixed model. Secondary outcomes included changes in pulse oximetry, heart rate, blood pressure, blood gas samples, comfort, treatment failure and mortality.

Résultats : Among the 145 eligible patients in the three participating centers, 60 patients were included in the analysis [median age 86 (interquartile range (IQR), 90; 92) years]. There was a median respiratory rate of 30.5 (IQR, 28; 33) and 29.5 (IQR, 27; 35) breaths/min in the high-flow oxygen and NIV groups respectively, with a median change of -10 (IQR, -12; -8) with high-flow nasal oxygen and -7 (IQR, -11; -5) breaths/min with NIV [estimated difference -2.6 breaths/min (95% confidence interval (CI), -0.5-5.7), P = 0.052] at 60 min. There was a median SpO 2 of 95 (IQR, 92; 97) and 96 (IQR, 93; 97) in the high-flow oxygen and NIV groups respectively, with a median change at 60 min of 2 (IQR, 0; 5) with high-flow nasal oxygen and 2 (IQR, -1; 5) % with NIV [estimated difference 0.8% (95% CI, -1.1-2.8), P = 0.60]. PaO 2 , PaCO 2 and pH did not differ at 1 h between groups, nor did treatment failure, intubation and mortality rates.

Conclusion : In this pilot study, we did not observe a statistically significant difference in changes in respiratory rate among patients with acute respiratory failure due to AHF and managed with high-flow oxygen or NIV. However, the point estimate and its large confidence interval may suggest a benefit of high-flow oxygen.

Conclusion (proposition de traduction) : Dans cette étude pilote, nous n'avons pas observé de différence statistiquement significative dans les changements de la fréquence respiratoire chez les patients souffrant d'insuffisance respiratoire aiguë due à l'OAP et pris en charge avec de l'oxygène à haut débit ou de la VNI. Cependant, les estimations ponctuelles et l'importance de l'intervalle de confiance peuvent suggérer un bénéfice de l'oxygène à haut débit.

Risk factors and effect of dyspnea inappropriate treatment in adults' emergency department: a retrospective cohort study.
Balen F, Lamy S, Froissart L, Mesnard T, Sanchez B, Dubucs X, Charpentier S. | Eur J Emerg Med. 2024 Aug 1;31(4):276-280
DOI: https://doi.org/10.1097/mej.0000000000001129
Keywords: Aucun

Original article

Editorial : Dyspnea is a frequent symptom in adults' emergency departments (EDs). Misdiagnosis at initial clinical examination is common, leading to early inappropriate treatment and increased in-hospital mortality. Risk factors of inappropriate treatment assessable at early examination remain undescribed herein. The objective of this study was to identify clinical risk factors of dyspnea and inappropriate treatment in patients admitted to ED. This is an observational retrospective cohort study. Patients over the age of 15 who were admitted to adult EDs of the University Hospital of Toulouse (France) with dyspnea were included from 1 July to 31 December 2019. The primary end-point was dyspnea and inappropriate treatment was initiated at ED. Inappropriate treatment was defined by looking at the final diagnosis of dyspnea at hospital discharge and early treatment provided. Afterward, this early treatment at ED was compared to the recommended treatment defined by the International Guidelines for Acute Heart Failure, bacterial pneumonia, chronic obstructive pulmonary disease, asthma or pulmonary embolism. A total of 2123 patients were analyzed. Of these, 809 (38%) had inappropriate treatment in ED. Independent risk factors of inappropriate treatment were: age over 75 years (OR, 1.46; 95% CI, 1.18-1.81), history of heart disease (OR, 1.32; 95% CI, 1.07-1.62) and lung disease (OR, 1.47; 95% CI, 1.21-1.78), SpO 2 <90% (OR, 1.64; 95% CI, 1.37-2.02), bilateral rale (OR, 1.25; 95% CI, 1.01-1.66), focal cracklings (OR, 1.32; 95% CI, 1.05-1.66) and wheezing (OR, 1.62; 95% CI, 1.31-2.03). In multivariate analysis, under-treatment significantly increased in-hospital mortality (OR, 2.13; 95% CI, 1.29-3.52) compared to appropriate treatment. Over-treatment nonsignificantly increased in-hospital mortality (OR, 1.43; 95% CI, 0.99-2.06). Inappropriate treatment is frequent in patients admitted to ED for dyspnea. Patients older than 75 years, with comorbidities (heart or lung disease), hypoxemia (SpO 2 <90%) or abnormal pulmonary auscultation (especially wheezing) are at risk of inappropriate treatment.

Conclusion : Inappropriate treatment is frequent in patients admitted to the ED for dyspnea. Patients older than 75 years with comorbidities (heart or lung disease), hypoxemia (SpO₂ <90%) or abnormal pulmonary auscultation (especially wheezing) are at risk of inappropriate treatment. Undertreatment is associated with in-hospital mortality, while the impact of over-treatment remains unclear.

Conclusion (proposition de traduction) : Les traitements inappropriés sont fréquents chez les patients admis aux urgences pour dyspnée. Les patients âgés de plus de 75 ans présentant des comorbidités (maladies cardiaques ou pulmonaires), une hypoxémie (SpO₂ < 90 %) ou une auscultation pulmonaire anormale (en particulier une respiration sifflante) sont à risque de traitement inapproprié. Un traitement insuffisant est associé à la mortalité hospitalière, tandis que l'impact d'un traitement excessif n'est pas clair.

Comparison of mannitol and hypertonic saline solution for the treatment of suspected brain herniation during prehospital management of traumatic brain injury patients.
Codorniu A, Charbit E, Werner M, James A, Hanouz JL, Jost D, Severin A, Lang E, Pottecher J, Favreau M, Weiss E, Abback PS, Moyer JD; TraumaBase Group. | Eur J Emerg Med. 2024 Aug 1;31(4):287-293
DOI: https://doi.org/10.1097/mej.0000000000001138
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Occurrence of mydriasis during the prehospital management of traumatic brain injury (TBI) may suggest severe intracranial hypertension (ICH) subsequent to brain herniation. The initiation of hyperosmolar therapy to reduce ICH and brain herniation is recommended. Whether mannitol or hypertonic saline solution (HSS) should be preferred is unknown.

Méthode : The objective of this study is to assess whether HSS, compared with mannitol, is associated with improved survival in adult trauma patients with TBI and mydriasis.
Design/setting and participants: A retrospective observational cohort study using the French Traumabase national registry to compare the ICU mortality of patients receiving either HSS or mannitol. Patients aged 16 years or older with moderate to severe TBI who presented with mydriasis during prehospital management were included.
Outcome measures and analysis: We performed propensity score matching on a priori selected variables [i.e. age, sex and initial Coma Glasgow Scale (GCS)] with a ratio of 1 : 3 to ensure comparability between the two groups. The primary outcome was ICU mortality. The secondary outcomes were regression of pupillary abnormality during prehospital management, pulsatility index and diastolic velocity on transcranial Doppler within 24 h after TBI, early ICU mortality (within 48 h), ICU and hospital length of stay.

Résultats : Of 31 579 patients recorded in the registry between 2011 and 2021, 1417 presented with prehospital mydriasis and were included: 1172 (82.7%) received mannitol and 245 (17.3%) received HSS. After propensity score matching, 720 in the mannitol group matched 240 patients in the HSS group. Median age was 41 years [interquartile ranges (IQR) 26-60], 1058 were men (73%) and median GCS was 4 (IQR 3-6). No significant difference was observed in terms of characteristics and prehospital management between the two groups. ICU mortality was lower in the HSS group (45%) than in the mannitol group (54%) after matching [odds ratio (OR) 0.68 (0.5-0.9), P = 0.014]. No differences were identified between the groups in terms of secondary outcomes.

Conclusion : In this propensity-matched observational study, the prehospital osmotherapy with HSS in TBI patients with prehospital mydriasis was associated with a lower ICU mortality compared to osmotherapy with mannitol.

Conclusion (proposition de traduction) : Dans cette étude observationnelle appariée selon la propension, l'osmothérapie préhospitalière avec une solution salé hypertonique chez les patients souffrant de lésions cérébrales traumatiques avec mydriase préhospitalière a été associée à une mortalité plus faible en USI par rapport à l'osmothérapie avec du mannitol.

Lower or higher oxygenation targets in the intensive care unit: an individual patient data meta-analysis.
Nielsen FM, Klitgaard TL, Bruun NH, Møller MH, Schjørring OL, Rasmussen BS. | Intensive Care Med. 2024 Aug;50(8):1275-1286
DOI: 10.1007/s00134-024-07523-3  | Télécharger l'article au format  
Keywords: COVID-19; Hypoxia; Individual patient data meta-analysis; Intensive care units; Oxygen inhalation therapy; Respiratory insufficiency.

Original article

Introduction : Optimal oxygenation targets for patients with acute hypoxemic respiratory failure in the intensive care unit (ICU) are not clearly defined due to substantial variability in design of previous trials. This study aimed to perform a pre-specified individual patient data meta-analysis of the Handling Oxygenation Targets in the ICU (HOT-ICU) and the Handling Oxygenation Targets in coronavirus disease 2019 (COVID-19) (HOT-COVID) trials to compare targeting a partial pressure of arterial oxygen (PaO₂) of 8-12 kPa in adult ICU patients, assessing both benefits and harms.

Méthode : We assessed 90-day all-cause mortality and days alive without life support in 90 days using a generalised mixed model. Heterogeneity of treatment effects (HTE) was evaluated in 14 subgroups, and results graded using the Instrument to assess the Credibility of Effect Modification Analyses (ICEMAN).

Résultats : At 90 days, mortality was 40.4% (724/1792) in the 8 kPa group and 40.9% (733/1793) in the 12 kPa group (risk ratio, 0.99; 95% confidence interval [CI] 0.92-1.07; P = 0.80). No difference was observed in number of days alive without life support. Subgroup analyses indicated more days alive without life support in COVID-19 patients targeting 8 kPa (P = 0.04) (moderate credibility), and lower mortality (P = 0.03) and more days alive without life support (P = 0.02) in cancer-patients targeting 12 kPa (low credibility).

Conclusion : This study reported no overall differences comparing a PaO₂ target of 8-12 kPa on mortality or days alive without life support in 90 days. Subgroup analyses suggested HTE in patients with COVID-19 (moderate credibility) and cancer (low credibility).

Conclusion (proposition de traduction) : Cette étude ne fait état d'aucune différence globale entre un objectif de PaO₂ de 8 à 12 kPa et la mortalité ou le nombre de jours de survie sans assistance respiratoire à 90 jours. Les analyses de sous-groupes ont suggéré une hétérogénéité des effets du traitement chez les patients présentant un COVID-19 (crédibilité modérée) et un cancer (crédibilité faible).

Practical Recommendations for the Evaluation and Management of Cardiac Injury Due to Carbon Monoxide Poisoning.
Cho DH, Thom SR, Son JW, Ko SM, Cha YS. | JACC Heart Fail. 2024 Aug;12(8):1343-1352. 2024 Aug;12(8):1343-1352
DOI: https://doi.org/10.1016/j.jchf.2024.01.001
Keywords: carbon monoxide; cardiac imaging; cardiomyopathies; poisoning.

REVIEW TOPIC OF THE MONTH

Editorial : Carbon monoxide (CO) is a relatively frequent cause of poisoning evaluated in emergency departments. The risk of neurologic injuries, such as cognitive, psychological, vestibular, and motor deficits, is 25% to 50%. However, the risk of cardiac injuries should also be considered. Among patients with CO poisoning, the mortality in patients with myocardial injury is approximately 3 times greater than that in patients without myocardial injury. In large-scale studies, up to 69.2% of patients with acute CO poisoning exhibiting elevated troponin I levels and no underlying cardiovascular illnesses had late gadolinium enhancement on cardiac magnetic resonance, suggesting covert CO-induced myocardial fibrosis. Myocardial damage can be evaluated using electrocardiography, echocardiography, computed tomography, and cardiac magnetic resonance. This paper offers recommendations for cardiac evaluations based on our collective experience of managing >2,000 cases of acute CO poisoning with supporting information taken from peer-reviewed published reports on CO poisoning.

Conclusion : Recent advances in imaging modalities have revealed that myocardial injury is more common in patients with CO poisoning than previously thought, and this finding has implications for long-term mortality. Therefore, myocardial injury should be the foremost consideration in such patients, and early assessment and continuous monitoring are crucial (Illustration). In this review, we presented a system- atic evaluation tool for cardiac injury and a process for follow-up. Additional research on the treatment and prevention of cardiac injury is necessary.

Conclusion (proposition de traduction) : Les progrès récents des modalités d'imagerie ont révélé que les lésions myocardiques sont plus fréquentes qu'on ne le pensait chez les patients intoxiqués au CO, et cette constatation a des implications sur la mortalité à long terme. Par conséquent, les lésions myocardiques doivent être la première préoccupation chez ces patients, et une évaluation précoce et une surveillance continue sont cruciales (Illustration). Dans cette revue, nous avons présenté un outil d'évaluation systémique des lésions cardiaques et un processus de suivi. Des recherches supplémentaires sur le traitement et la prévention des lésions cardiaques sont nécessaires.

Commentaire : 

State of the art of sepsis care for the emergency medicine clinician.
Jayaprakash N, Sarani N, Nguyen HB, Cannon C. | J Am Coll Emerg Physicians Open. 2024 Aug 12;5(4):e13264
DOI: https://doi.org/10.1002/emp2.13264  | Télécharger l'article au format  
Keywords: sepsis; sepsis syndrome; septic shock; severe sepsis; systemic inflammatory response syndrome.

Review article

Editorial : Sepsis impacts 1.7 million Americans annually. It is a life-threatening disruption of organ function because of the body's host response to infection. Sepsis remains a condition frequently encountered in emergency departments (ED) with an estimated 850,000 annual visits affected by sepsis each year in the United States. The pillars of managing sepsis remain timely identification, initiation of antimicrobials while aiming for source control and resuscitation with a goal of restoring tissue perfusion. The focus herein is current evidence and best practice recommendations for state-of-the-art sepsis care that begins in the ED.

Conclusion : Sepsis continues to impact millions of Americans annually. Most sepsis cases in hospitalized patients are recognized upon admission to the hospital through the emergency department. Early recognition and intervention are essential, and the key pillars of sepsis management include a bundled approach of identifying the source, delivering timely antimicrobials, and prioritizing resuscitation. Although further research is necessary for early detection and ideal resuscitation, the CMS SEP-1 guidelines and bundle compliance provide an effective strategy for improving outcomes. Sepsis is a challenging disease to recognize, and the implementation of process improvement programs can enhance bundle adherence while reducing mortality.

Conclusion (proposition de traduction) : Le sepsis continue d'affecter des millions d'Américains chaque année. La plupart des cas de sepsis chez les patients hospitalisés sont reconnus lors de l'admission à l'hôpital par le service des urgences. La reconnaissance et la prise en charge précoces sont essentielles, et les piliers de la gestion du sepsis comprennent une approche combinée de l'identification de la cause, de l'administration d'antibiotiques en temps opportun et de la réanimation en priorité. Bien que des recherches supplémentaires soient nécessaires pour une détection précoce et une réanimation idéale, les lignes directrices SEP-1 du du Center for Medicare and Medicaid Services et le respect de l'ensemble des mesures constituent une stratégie efficace pour améliorer les résultats. Le sepsis est une maladie difficile à reconnaître, et la mise en œuvre de programmes d'amélioration des processus peut renforcer l'adhésion à l'ensemble des mesures tout en réduisant la mortalité.

Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review.
Douketis JD, Spyropoulos AC. | JAMA. 2024 Aug 12
DOI: https://doi.org/10.1001/jama.2024.12708
Keywords: Aucun

Review

Introduction : Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.

Méthode : For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.

Conclusion : When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.

Conclusion (proposition de traduction) : Lorsque les patients prenant un AOD doivent bénéficier d'une intervention chirurgicale non urgente ou non chirurgicale, des protocoles de prise en charge standardisés peuvent être appliqués sans qu'il soit nécessaire de tester les taux de AOD ou d'effectuer un relais à l'héparine. Lorsque les patients prenant un AOD doivent subir une intervention chirurgicale urgente ou semi-urgente, il peut être nécessaire d'utiliser des agents de réversion des anticoagulants lorsque les taux de AOD sont élevés ou qu'ils ne sont pas disponibles.

Evidence-based review and frontiers of migraine therapy.
Greene KA, Gelfand AA, Larry Charleston 4th. | Neurogastroenterol Motil. 2024 Aug 12:e14899
DOI: https://doi.org/10.1111/nmo.14899  | Télécharger l'article au format  
Keywords: calcitonin gene‐related protein (CGRP) therapy; cyclic vomiting syndrome; migraine; migraine treatment; neuromodulation; serotonin receptor agonist.

REVIEW ARTICLE

Introduction : Cyclic vomiting syndrome (CVS) is identified as one of the "episodic syndromes that may be associated with migraine," along with benign paroxysmal torticollis, benign paroxysmal vertigo, and abdominal migraine. It has been proposed that CVS and migraine may share pathophysiologic mechanisms of hypothalamic activation and altered dopaminergic signaling, and impaired sensorimotor intrinsic connectivity. The past decade has brought groundbreaking advances in the treatment of migraine and other headache disorders. While many of these therapies have yet to be studied in episodic syndromes associated with migraine including CVS and abdominal migraine, the potential shared pathophysiology among these conditions suggests that use of migraine-specific treatments may have a beneficial role even in those for whom headache is not the primary symptom.

Discussion : This manuscript highlights newer therapies in migraine. Calcitonin gene-related peptide (CGRP) and its relation to migraine pathophysiology and the therapies that target the CGRP pathway, as well as a 5HT1F receptor agonist and neuromodulation devices used to treat migraine are briefly discussed as they may potentially prove to be useful in the future treatment of CVS.

Conclusion (proposition de traduction) : Ce rapport met en lumière les nouvelles stratégies thérapeutiques dans le domaine de la migraine. Le peptide lié au gène de la calcitonine (CGRP) et sa relation avec la physiopathologie de la migraine et les traitements qui ciblent la voie du CGRP, ainsi qu'un agoniste du récepteur 5HT1F et les dispositifs de neuromodulation utilisés pour traiter la migraine sont brièvement abordés car ils pourraient potentiellement s'avérer utiles dans le traitement futur du syndrome des vomissements cycliques.

Early Glasgow Coma Scale Score and Prediction of Traumatic Brain Injury: A Secondary Analysis of Three Harmonized Prehospital Randomized Clinical Trials.
Iyanna N, Donohue JK, Lorence JM, Guyette FX, Gimbel E, Brown JB, Daley BJ, Eastridge BJ, Miller RS, Nirula R, Harbrecht BG, Claridge JA, Phelan HA, Vercruysse GA, O'Keefe T, Joseph B, Shutter LA, Sperry JL. | Prehosp Emerg Care. 2024 Aug 6:1-9
DOI: https://doi.org/10.1080/10903127.2024.2381048  | Télécharger l'article au format  
Keywords: Aucun

Article

Introduction : The prehospital prediction of the radiographic diagnosis of traumatic brain injury (TBI) in hemorrhagic shock patients has the potential to promote early therapeutic interventions. However, the identification of TBI is often challenging and prehospital tools remain limited. While the Glasgow Coma Scale (GCS) score is frequently used to assess the extent of impaired consciousness after injury, the utility of the GCS scores in the early prehospital phase of care to predict TBI in patients with severe injury and concomitant shock is poorly understood.

Méthode : We performed a post-hoc, secondary analysis utilizing data derived from three randomized prehospital clinical trials: the Prehospital Air Medical Plasma trial (PAMPER), the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport trial (STAAMP), and the Pragmatic Prehospital Type O Whole Blood Early Resuscitation (PPOWER) trial. Patients were dichotomized into two cohorts based on the presence of TBI and then further stratified into three groups based on prehospital GCS score: GCS 3, GCS 4-12, and GCS 13-15. The association between prehospital GCS score and clinical documentation of TBI was assessed.

Résultats : A total of 1,490 enrolled patients were included in this analysis. The percentage of patients with documented TBI in those with a GCS 3 was 59.5, 42.4% in those with a GCS 4-12, and 11.8% in those with a GCS 13-15. The positive predictive value (PPV) of the prehospital GCS score for the diagnosis of TBI is low, with a GCS of 3 having only a 60% PPV. Hypotension and prehospital intubation are independent predictors of a low prehospital GCS. Decreasing prehospital GCS is strongly associated with higher incidence or mortality over time, irrespective of the diagnosis of TBI.

Conclusion : The ability to accurately predict the presence of TBI in the prehospital phase of care is essential. The utility of the GCS scores in the early prehospital phase of care to predict TBI in patients with severe injury and concomitant shock is limited. The use of novel scoring systems and improved technology are needed to promote the accurate early diagnosis of TBI.

Conclusion (proposition de traduction) : Il est essentiel de pouvoir prédire avec précision la présence d'une lésion cérébrale traumatique au cours de la phase préhospitalière des soins. L'utilité des scores GCS dans la phase préhospitalière précoce des soins pour prédire les lésions cérébrales traumatiques chez les patients présentant des lésions graves et un choc concomitant est limitée. L'utilisation de nouveaux systèmes de notation et l'amélioration de la technologie sont nécessaires pour promouvoir un diagnostic précoce précis des lésions cérébrales traumatiques.

Commentaire : D'autres auteurs, sur ce constat, proposent le score FOUR.
Chattopadhyay I, Ramamoorthy L, Kumari M, Harichandrakumar KT, Lalthanthuami HT, Subramaniyan R. Comparison of the Prognostic Accuracy of Full Outline of Unresponsiveness (FOUR) Score with Glasgow Coma Scale (GCS) Score among Patients with Traumatic Brain Injury in a Tertiary Care Center. Asian J Neurosurg. 2024 Apr 16;19(1):1-7  .
Le score FOUR est donc plus précis que le score GCS dans la prédiction de la mortalité chez les patients souffrant de lésions cérébrales traumatiques.

Hemodynamic Collapse After Intubation in Critical Care Transport.
Fjeld KJ, Esteves AM, Ding RJ, Bates AM, Fay KA, Roginski MA. | Prehosp Emerg Care. 2024 Aug 27:1-11
DOI: https://doi.org/10.1080/10903127.2024.2396949
Keywords: airway; cardiovascular collapse; hemodynamic collapse; intubation; resuscitation; shock index

Original Contribution

Introduction : The aim of this study was to describe the incidence of and modifiable risk factors for post intubation hemodynamic collapse in prehospital and interfacility critical care transport.

Méthode : Single center retrospective chart review of adult patients (≥18 years) intubated by a critical care transport team between January 2017 and May 2023. The primary outcome was incidence of hemodynamic collapse (systolic blood pressure < 90 mmHg for greater than 30 minutes, new vasopressor requirement, vasopressor dose increase, fluid bolus of >15 mL/kg, systolic blood pressure < 65 mmHg at least once, or cardiac arrest). Secondary outcomes included post intubation hypoxia, as well as association of hemodynamic collapse with potentially modifiable risk factors including pre intubation shock index, pre intubation heart rate, pre intubation systolic blood pressure, and induction agent.

Résultats : Three hundred and thirty-three patients were included. Ninety-seven (29.1%) patients experienced hemodynamic collapse and 36 (10.8%) of patients experienced life threatening hemodynamic collapse. Pre intubation shock index >1 (OR 3.18, 95% CI 1.15-8.74) was associated with post intubation hemodynamic collapse. Choice of induction agent, fluid bolus prior to intubation, location of intubation, presence of traumatic injury, and age were not correlated with risk of hemodynamic collapse. The number of intubation attempts and methods of intubation were similar between groups.

Conclusion : Hemodynamic collapse and life-threatening hemodynamic collapse after intubation occurred frequently in this critical care transport cohort. Shock index greater than one was associated with significantly higher risk of hemodynamic collapse and life-threatening hemodynamic collapse.

Conclusion (proposition de traduction) : Le collapsus hémodynamique et le collapsus hémodynamique menaçant le pronostic vital après une intubation sont des phénomènes fréquents dans cette cohorte de transport en soins intensifs. Un indice de choc supérieur à 1 était associé à un risque significativement plus élevé de collapsus hémodynamique et de collapsus hémodynamique menaçant le pronostic vital.

The association of early naloxone use with outcomes in non-shockable out-of-hospital cardiac arrest.
Strong NH, Daya MR, Neth MR, Noble M, Sahni R, Jui J, Lupton JR. | Resuscitation. 2024 Aug;201:110263
DOI: https://doi.org/10.1016/j.resuscitation.2024.110263
Keywords: Cardiac arrest; Emergency Medical Services; Naloxone; Opioid associated cardiac arrest; Out-of-hospital Cardiac Arrest; Overdose; Prehospital; Pulseless electrical activity.

CLINICAL PAPER

Introduction : Evaluate the association between early naloxone use and outcomes after out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythms.

Méthode : This study was a secondary analysis of data collected in the Portland Cardiac Arrest Epidemiologic Registry, a database containing details of emergency medical services (EMS)-treated OHCA cases in the Portland, Oregon metropolitan region. Eligible patients had non-traumatic OHCA with an initial non-shockable rhythm and received naloxone by EMS or law enforcement prior to IV/IO access (exposure group). The primary outcome was ROSC at emergency department (ED) arrival. Secondary outcomes included survival to admission, survival to hospital discharge, and cerebral performance category score ≤2 at discharge (good neurologic outcome). We performed multivariable logistic regressions adjusting for age, sex, arrest location, witness status, bystander interventions, dispatch to EMS arrival time, initial rhythm, and county of arrest.

Résultats : There were 1807 OHCA cases from 2018 to 2021 meeting eligibility criteria, with 57 receiving naloxone before vascular access. Patients receiving naloxone prior to vascular access attempts had higher adjusted odds (aOR [95% CI]) of ROSC at any time (2.14 [1.20-3.81]), ROSC at ED arrival (2.14 [1.18-3.88]), survival to admission (2.86 [1.60-5.09]), survival to discharge (4.41 [1.78-10.97]), and good neurologic outcome (4.61 [1.74-12.19]).

Conclusion : Patients with initial non-shockable OHCA who received law enforcement or EMS naloxone prior to IV/IO access attempts had higher adjusted odds of ROSC at any time, ROSC at ED arrival, survival to admission, survival to discharge, and good neurologic outcome.

Conclusion (proposition de traduction) : Les patients ayant présenté un premier arrêt cardiaque extrahospitalier non choquable et ayant reçu de la naloxone de la part des forces de l'ordre ou des services médicaux d'urgence avant les tentatives d'accès IV/IO avaient des chances ajustées plus élevées de retrouver une circulation spontanée à tout moment, de retrouver une circulation spontanée à l'arrivée aux urgences, de survivre jusqu'à l'admission, de survivre jusqu'à la sortie, et d'avoir un bon résultat neurologique.

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

Clinical paper

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

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

Résultats : Among 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0-6.0) vs. 7.8 min (IQR 5.8-10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10-2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07-2.76).

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

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

The impact of time to defibrillation on return of spontaneous circulation in out-of-hospital cardiac arrest patients with recurrent shockable rhythms.
Awad E, Klapthor B, Morgan MH, Youngquist ST. | Resuscitation. 2024 Aug;201:110286
DOI: https://doi.org/10.1016/j.resuscitation.2024.110286  | Télécharger l'article au format  
Keywords: Cardiac arrest; Defibrillation; Emergency medical services; Shockable rhythm; Time to shock.

Clinical paper

Introduction : Optimal timing for subsequent defibrillation attempts for Out-of-hospital cardiac arrest (OHCA) patients with recurrent VF/pVT is uncertain. We investigated the relationship between VF/pVT duration and return of spontaneous circulation (ROSC) in OHCA patients with recurrent shockable rhythms.

Méthode : We analyzed data from the Salt Lake City Fire Department (SLCFD) spanning from 2012 to 2023. The implementation of rhythm-filtering technology since 2011 enabled real-time rhythm interpretation during CPR, with local protocols allowing early defibrillation for recurrent/refractory VF/pVT cases. We included patients experiencing four or five episodes of VF and pVT rhythms and employed generalized estimating equation (GEE) regression analysis to examine the association between VF/pVT durations preceding recurrent defibrillation and return of spontaneous circulation (ROSC).

Résultats : Analysis of 622 appropriate shocks showed that patients achieving ROSC had significantly shorter median VF/pVT duration than those who did not achieve ROSC (0.83 minutes vs. 1.2 minutes, p = 0.004). Adjusted analysis of those with 4 VF/pVT episodes (N = 142) revealed that longer VF/pVT durations were associated with lower odds of achieving ROSC (odds ratio: 0.81, 95% CI: 0.72-0.93, p = 0.005). Every one-minute delay in intra-arrest defibrillation is predicted to decrease the likelihood of achieving ROSC by 19%.

Conclusion : Every one-minute increase in intra-arrest VF/pVT duration was associated with a statistically significant 19% decrease in the chance of achieving ROSC. This highlights the importance of reducing time to shock in managing recurrent VF/pVT. The findings suggest reevaluating the current recommendations of two minutes intervals for rhythm check and shock delivery.

Conclusion (proposition de traduction) : Chaque augmentation d'une minute de la durée de la fibrillation ventriculaire ou de la tachycardie ventriculaire sans pouls pendant l'arrêt cardiaque a été associée à une diminution statistiquement significative de 19 % des chances d'obtenir une réanimation. Cela souligne l'importance de réduire le délai avant le choc électrique dans la prise en charge de la fibrillation ventriculaire récurrente et de la tachycardie ventriculaire sans pouls. Les résultats suggèrent de réévaluer les recommandations actuelles de deux minutes d'intervalle pour la vérification du rythme et l'administration du choc.

Effects of mild hypercapnia on myocardial injury after out-of-hospital cardiac arrest. A sub-study of the TAME trial.
Melberg MB, Flaa A, Andersen GØ, Sunde K, Bellomo R, Eastwood G, Olasveengen TM, Qvigstad E. | Resuscitation. 2024 Aug;201:110295
DOI: https://doi.org/10.1016/j.resuscitation.2024.110295  | Télécharger l'article au format  
Keywords: Acute myocardial infarction; High-sensitive cardiac Troponin T; Mild hypercapnia; Out-of-hospital cardiac arrest.

Clinical paper

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

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

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

Conclusion : Mild hypercapnia was not associated with increased myocardial injury in resuscitated OHCA-patients. In AMI-patients, mild hypercapnia was associated with lower hs-cTnT and lactate, and improved cardiac performance.

Conclusion (proposition de traduction) : Une légère hyperventilation peut réduire la PIC et améliorer l'autorégulation cérébrale, avec des effets cliniques minimes sur l'oxygénation cérébrale. Cependant, la composante artérielle de la rSO₂ a été considérablement réduite. Le neuromonitoring multimodal est essentiel lors de l'ajustement des valeurs de PaCO₂ pour la gestion de la PIC.

Early point-of-care focused echocardiographic asystole as a predictive factor for absence of return of spontaneous circulatory in out-of-hospital cardiac arrests: a study protocol for a prospective, multicentre observational study.
Javaudin F, Papin M, Le Bastard , Thibault M, Boishardy T, Brau F, Laribi S, Petrovic T, Peluchon T, Markarian T, Volteau C, Arnaudet I, Pes P, Le Conte P. | Resuscitation. 2024 August 20
DOI: https://doi.org/10.1016/j.resuscitation.2024.110373  | Télécharger l'article au format  
Keywords: point-of-care ultrasound; echocardiography; out-of-hospital cardiac arrest; cardiopulmonary resuscitation; prognostication

CLINICAL PAPER

Introduction : Early assessment of the prognosis of a patient in cardiac arrest during cardiopulmonary resuscitation is highly challenging. This study aims to evaluate the predictive outcome value of early point-of-care ultrasound (POCUS) in out-of-hospital settings.

Méthode : This observational, prospective, multicenter study's primary endpoint was the positive predictive value (PPV) of POCUS cardiac standstill within the first 12 minutes of advanced life support (ALS) initiation in determining the absence of return of spontaneous circulation (ROSC). A multivariate logistic regression model was constructed with adjustments for known predictive variables typically used in termination of resuscitation (TOR) rules.

Résultats : A total of 293 patients were analyzed, with a mean age of 66.6 ± 14.6 years, and a majority were men (75.8%). POCUS was performed on average 7.9 ± 2.6 minutes after ALS initiation. Among patients with cardiac standstill (72.4%), 16.0% achieved ROSC compared with 48.2% in those with visible cardiac motions. The PPV of early POCUS cardiac standstill for the absence of ROSC was 84.0%, 95% CI [78.3–88.6]. In multivariable analysis, only POCUS cardiac standstill (adjusted odds ratio [aOR] 3.89, 95% CI [1.86–8.17]) and end-tidal CO2 (ETCO2) value ≤ 37 mmHg (aOR 4.27, 95% CI [2.21–8.25]) were associated with the absence of ROSC.

Conclusion : Early POCUS cardiac standstill during CPR for out-of-hospital cardiac arrest was a reliable predictor of the absence of ROSC. However, its presence alone was not sufficient to determine the termination of resuscitation efforts.

Conclusion (proposition de traduction) : L'arrêt cardiaque précoce par échographie au point d'intervention pendant la RCP lors d'un arrêt cardiaque extrahospitalier est un facteur prédictif fiable de l'absence de retour de la circulation spontanée. Cependant, sa seule présence n'était pas suffisante pour déterminer l'arrêt des efforts de réanimation.

Evaluation of basic life support interventions for foreign body airway obstructions: A population-based cohort study.
Dunne CL, Cirone J, Blanchard IE, Holroyd-Leduc J, Wilson TA, Sauro K, McRae AD. | Resuscitation. 2024 Aug;201:110258
DOI: https://doi.org/10.1016/j.resuscitation.2024.110258  | Télécharger l'article au format  
Keywords: BLS; Choking; Emergency Medical Services; FBAO; Paramedic; Survival.

CLINICAL PAPER

Introduction : To quantify the associations of foreign body airway obstruction (FBAO) basic life support (BLS) interventions with FBAO relief and survival to discharge.

Méthode : We identified prehospital FBAO patient encounters in Alberta, Canada between Jan 1, 2018 and Dec 31,2021 using the provincial emergency medical services' medical records, deterministically linked to hospital data. Two physicians reviewed encounters to determine cases and extract data. Multivariable logistic regression determined the adjusted odds ratio of FBAO relief (primary outcome) and survival to discharge for the exposure of BLS interventions (abdominal thrusts [AT], chest compressions/thrusts [CC], or combinations) relative to back blows [BB]. Intervention-associated injuries were identified using International Classification of Diseases codes, followed by health records review.

Résultats : We identified 3,677 patient encounters, including 709 FBAOs requiring intervention. Bystanders performed the initial BLS intervention in 488 cases (77.4%). Bystanders and paramedics did not relieve the FBAO in 151 (23.5%) and 11 (16.7%) cases, respectively. FBAOs not relieved before paramedic arrival had a higher proportion of deaths (n = 4[0.4%] versus n = 92[42.4%], p < 0.001). AT and CC were associated with decreased odds of FBAO relief relative to BB (adjusted odds ratio [aOR] 0.49 [95%CI 0.30-0.80] and 0.14 [95%CI 0.07-0.28], respectively). CC were associated with decreased odds of survival to discharge (aOR 0.04 [95%CI 0.01-0.32]). AT, CC, and BB were implicated in intervention-associated injuries in four, nine, and zero cases, respectively.

Conclusion : Back blows are associated with improved outcomes compared to abdominal thrusts and chest compressions. These data can inform prospective studies aimed at improving response to choking emergencies.

Conclusion (proposition de traduction) : Les cinq claques dans le dos sont associés à de meilleurs résultats que les compressions abdominales (manœuvre de Heimlich). Ces données peuvent servir de base à des études prospectives visant à améliorer la réponse aux urgences liées à l'étouffement dû à l'obstruction des voies respiratoires supérieures par un corps étranger.

The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests.
Brebner C, Asamoah-Boaheng M, Zaidel B, Yap J, Scheuermeyer F, Mok V, Hutton J, Meckler G, Schlamp R, Christenson J, Grunau B. | Resuscitation. 2024 Aug 16;202:110360
DOI: https://doi.org/10.1016/j.resuscitation.2024.110360  | Télécharger l'article au format  
Keywords: Heart arrest; Intraosseous; Intravenous; Out-of-hospital cardiac arrest.

CLINICAL PAPER

Introduction : While intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes.

Méthode : We utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1-2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm.

Résultats : We included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1-2.7) and survival (AOR 1.5; 95% CI 1.0-2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1-8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39-1.4).

Conclusion : An IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

Conclusion (proposition de traduction) : Une approche IV humérale en premier, comparée à une approche intra-osseux humérale, dans la réanimation de l'arrêt cardiaque a été associée à une meilleure probabilité de résultats neurologiques favorables et de survie jusqu'à la sortie de l'hôpital. Cette association a été observée dans les sous-groupes où le rythme initial était choquable, mais pas dans les sous-groupes où le rythme n'était pas choquable.

Ventilation during cardiopulmonary resuscitation: A narrative review.
van Eijk JA, Doeleman LC, Loer SA, Koster RW, van Schuppen H, Schober P.. | Resuscitation. 2024 Aug 23;203:110366
DOI: https://doi.org/10.1016/j.resuscitation.2024.110366  | Télécharger l'article au format  
Keywords: Airway management; Cardiopulmonary resuscitation; Mechanical ventilation; Oxygenation; PEEP; Tidal volume; Ventilation; Ventilation rate.

Review

Editorial : Ventilation during cardiopulmonary resuscitation is vital to achieve optimal oxygenation but continues to be a subject of ongoing debate. This narrative review aims to provide an overview of various components and challenges of ventilation during cardiopulmonary resuscitation, highlighting key areas of uncertainty in the current understanding of ventilation management. It addresses the pulmonary pathophysiology during cardiac arrest, the importance of adequate alveolar ventilation, recommendations concerning the maintenance of airway patency, tidal volumes and ventilation rates in both synchronous and asynchronous ventilation. Additionally, it discusses ventilation adjuncts such as the impedance threshold device, the role of positive end-expiratory pressure ventilation, and passive oxygenation. Finally, this review offers directions for future research.

Discussion : Compressions and ventilations during CPR are both inherently crucial to facilitate oxygen delivery. In resuscitation science, studies on ventilation lag behind when compared to studies on chest compression and defibrillation. Ventilation has historically been difficult to measure, and what is unmeasured is hard to study and improve.
Currently, a significant amount of evidence in cardiac arrest originates from animal studies, however purported benefits observed in these healthy animals under anesthesia often fail to translate into clinical practice. While animal models are indispensable to spark hypotheses, it is crucial to extrapolate their findings with caution and avoid rigid interpretation without mechanistic corroboration in sound clinical studies. Such clinical studies, preferably quantifying flow, pressures and arterial blood gasses, are needed to evaluate the efficacy of currently delivered ventilation and can uncover valuable hypotheses for further interventional studies. Additionally, more readily available advanced monitoring techniques like capnography and thoracic impedance analysis could offer valuable physiological insights in the role of ventilation.
It is clear that atelectasis quickly develops as a result of chest compressions, causes hypoxia through ventilation-perfusion mismatch, and the resulting hypoxia is associated with a decrease in neurologically intact survival. Although positive pressure ventilation has the potential to reverse this atelec

Conclusion (proposition de traduction) : Les compressions et les ventilations pendant la réanimation cardio-pulmonaire sont toutes deux cruciales pour faciliter l'apport d'oxygène. Dans la science de la réanimation, les études sur la ventilation sont à la traîne par rapport aux études sur la compression thoracique et la défibrillation. La ventilation a toujours été difficile à mesurer, et ce qui n'est pas mesuré est difficile à étudier et à améliorer.
À l'heure actuelle, une grande partie des données relatives à l'arrêt cardiaque proviennent d'études animales, mais les avantages observés chez ces animaux sains sous anesthésie ne se traduisent souvent pas dans la pratique clinique. Si les modèles animaux sont indispensables pour émettre des hypothèses, il est crucial d'extrapoler leurs résultats avec prudence et d'éviter toute interprétation rigide sans corroboration mécaniste dans le cadre d'études cliniques solides. De telles études cliniques, quantifiant de préférence les débits, les pressions et les gaz du sang artériel, sont nécessaires pour évaluer l'efficacité de la ventilation actuellement délivrée et peuvent permettre de découvrir des hypothèses précieuses pour des études interventionnelles ultérieures. En outre, des techniques de surveillance avancées plus facilement disponibles, telles que la capnographie et l'analyse de l'impédance thoracique, pourraient offrir des informations physiologiques précieuses sur le rôle de la ventilation.
Il est clair que l'atélectasie se développe rapidement à la suite des compressions thoraciques, qu'elle provoque une hypoxie par inadéquation ventilation-perfusion et que l'hypoxie qui en résulte est associée à une diminution du taux de survie en l'absence de troubles neurologiques. Bien que la ventilation en pression positive permette d'inverser cette atélectasie et soit associée à une amélioration de la survie, il est difficile d'administrer les insufflations recommandées par la ventilation au BAVU et au masque pendant les pauses des compressions.
Sans nuire au débit cardiaque, l'augmentation modérée des volumes courants et de la PEP pourrait avoir des effets bénéfiques sur l'oxygénation grâce au recrutement de l'atélectasie. En outre, les effets de l'augmentation des volumes courants ou de la vitesse de ventilation pour atteindre la normocapnie méritent d'être étudiés plus en détail. Il est primordial de renforcer le niveau de preuve concernant le volume minute alvéolaire approprié pendant la ventilation synchrone et asynchrone. En outre, l'intégration des dispositifs de compression thoracique et des ventilateurs pourrait améliorer les performances de la ventilation. Enfin, un objectif à long terme pourrait être de personnaliser la ventilation grâce à un retour d'information en temps réel basé sur des paramètres physiologiques tels que l'indice d'ouverture des voies aériennes ou la fraction d'espace mort.

Prehospital treatment of severely burned patients: a retrospective analysis of patients admitted to the Berlin burn centre.
Josuttis D, Kruse M, Plettig P, Lenz IK, Gümbel D, Hartmann B, Kuepper SS, Gebhardt V, Schmittner MD. | Scand J Trauma Resusc Emerg Med. 2024 Aug 14;32(1):70
DOI: https://doi.org/10.1186/s13049-024-01239-5  | Télécharger l'article au format  
Keywords: Advanced trauma care; Burn injury; Critical care; Emergency Medical Service; Fluid resuscitation; Prehospital airway management; Prehospital emergency care.

ORIGINAL RESEARCH

Introduction : Prehospital management of severely burned patients is extremely challenging. It should include adequate analgesia, decision-making on the necessity of prehospital endotracheal intubation and the administration of crystalloid fluids. Guidelines recommend immediate transport to specialised burn centres when certain criteria are met. To date, there is still insufficient knowledge on the characteristics of prehospital emergency treatment. We sought to investigate the current practice and its potential effects on patient outcome.

Méthode : We conducted a single centre, retrospective cohort analysis of severely burned patients (total burned surface area > 20%), admitted to the Berlin burn centre between 2014 and 2019. The relevant data was extracted from Emergency Medical Service reports and digital patient charts for exploratory data analysis. Primary outcome was 28-day-mortality.

Résultats : Ninety patients (male/female 60/30, with a median age of 52 years [interquartile range, IQR 37-63], median total burned surface area 36% [IQR 25-51] and median body mass index 26.56 kg/m2 [IQR 22.86-30.86] were included. The median time from trauma to ED arrival was 1 h 45 min; within this time, on average 1961 ml of crystalloid fluid (0.48 ml/kg/%TBSA, IQR 0.32-0.86) was administered. Most patients received opioid-based analgesia. Times from trauma to ED arrival were longer for patients who were intubated. Neither excessive fluid treatment (> 1000 ml/h) nor transport times > 2 h was associated with higher mortality. A total of 31 patients (34,4%) died within the hospital stay. Multivariate regression analysis revealed that non-survival was linked to age > 65 years (odds ratio (OR) 3.5, 95% CI: 1.27-9.66), inhalation injury (OR 3.57, 95% CI: 1.36-9.36), burned surface area > 60% (OR 5.14, 95% CI 1.57-16.84) and prehospital intubation (5.38, 95% CI: 1.92-15.92).

Conclusion : We showed that severely burned patients frequently received excessive fluid administration prehospitally and that this was not associated with more hemodynamic stability or outcome. In our cohort, patients were frequently intubated prehospitally, which was associated with increased mortality rates. Further research and emergency medical staff training should focus on adequate fluid application and cautious decision-making on the risks and benefits of prehospital intubation.

Conclusion (proposition de traduction) : Nous avons montré que les patients gravement brûlés recevaient fréquemment une administration excessive de liquides de remplissage en préhospitalier et que cela n'était pas associé à une plus grande stabilité hémodynamique ou à un meilleur résultat. Dans notre cohorte, les patients ont souvent été intubés en préhospitalier, ce qui a été associé à des taux de mortalité plus élevés. Les recherches futures et la formation du personnel médical d'urgence devraient se concentrer sur l'application adéquate de liquides de remplissage et la prise de décision prudente sur les risques et les avantages de l'intubation préhospitalière.

Commentaire : Retrouvez l'article de l'équipe de Nantes…
Arnaudet I, Montassier E, Javaudin F, Naux E, Le Bastard Q. Prise en charge des brûlures en préhospitalier et aux urgences. Ann Fr Med Urgence 2021;11(6):367-384  .

The value of ammonia as a biomarker in patients with cirrhosis.
Ballester MP, Durmazer EN, Qi T, Jalan R. | Semin Liver Dis. 2024 Aug 2
DOI: https://doi.org/10.1055/a-2378-8942  | Télécharger l'article au format  
Keywords: Aucun

Review Article

Editorial : Ammonia is a product of amino acid metabolism that accumulates in the blood of patients with cirrhosis and plays a pivotal role in the pathogenesis of hepatic encephalopathy (HE). Despite being one of the main drivers of brain dysfunction, for many years international societies stated that increased blood ammonia does not add any diagnostic, staging, or prognostic value for HE in patients with cirrhosis. Nonetheless, in the last decades, evidence is emerging that supports the utility of ammonia for risk stratification, but its role in guiding HE diagnosis, staging and treatment is unclear and there is equipoise in its use in clinical practice. This review provides the latest evidence on the value of ammonia as a biomarker in patients with cirrhosis. Although correct measurement of ammonia requires disciplined sample collection, it provides extremely useful clinical guidance for the diagnosis of HE, offers prognostic information and it defines a therapeutic target.

Conclusion : In conclusion, although correct measurement of ammonia requires disciplined sample collection and rapid transport to the laboratory, the measurement is widely available, relatively straightforward, and cheap. As discussed in this review, ammonia offers extremely useful prognostic information in both outpatients and acutely decompensated patients with cirrhosis, provides clinical guidance for the diagnosis of HE and, more importantly, it defines a therapeutic target for personalized medicine approaches. It is important to note that like every other biomarker used in clinical practice, ammonia needs to be measured properly and interpretation of a given ammonia level needs to be contextualised to the patient and the clinical situation.

Conclusion (proposition de traduction) : En conclusion, bien qu'une mesure correcte de l'ammoniaque nécessite une collecte rigoureuse des échantillons et un transport rapide au laboratoire, la mesure est largement disponible, relativement simple et peu coûteuse. Comme nous l'avons vu dans cette revue, l'ammoniac offre des informations pronostiques extrêmement utiles à la fois chez les patients ambulatoires et chez les patients présentant une décompensation aiguë de la cirrhose, fournit une orientation clinique pour le diagnostic de l'encéphalopathie hépatique et, plus important encore, définit une cible thérapeutique pour les approches de médecine personnalisée. Il est important de noter que, comme tout autre biomarqueur utilisé en pratique clinique, l'ammoniac doit être mesuré correctement et l'interprétation d'un taux d'ammoniac donné doit être contextualisée en fonction du patient et de la situation clinique.

Commentaire : 

Predictors of mortality in severe pneumonia patients: a systematic review and meta-analysis.
Xie K, Guan S, Kong X, Ji W, Du C, Jia M, Wang H. | Syst Rev. 2024 Aug 5;13(1):210
DOI: https://doi.org/10.1186/s13643-024-02621-1  | Télécharger l'article au format  
Keywords: Mortality; Severe pneumonia; Systematic review.

Systematic review update

Introduction : Severe pneumonia has consistently been associated with high mortality. We sought to identify risk factors for the mortality of severe pneumonia to assist in reducing mortality for medical treatment.

Méthode : Electronic databases including PubMed, Web of Science, EMBASE, Cochrane Library, and Scopus were systematically searched till June 1, 2023. All human research were incorporated into the analysis, regardless of language, publication date, or geographical location. To pool the estimate, a mixed-effect model was used. The Newcastle-Ottawa Scale (NOS) was employed for assessing the quality of included studies that were included in the analysis.

Résultats : In total, 22 studies with a total of 3655 severe pneumonia patients and 1107 cases (30.29%) of death were included in the current meta-analysis. Significant associations were found between age [5.76 years, 95% confidence interval [CI] (3.43, 8.09), P < 0.00001], male gender [odds ratio (OR) = 1.47, 95% CI (1.07, 2.02), P = 0.02], and risk of death from severe pneumonia. The comorbidity of neoplasm [OR = 3.37, 95% CI (1.07, 10.57), P = 0.04], besides the presence of complications such as diastolic hypotension [OR = 2.60, 95% CI (1.45, 4.67), P = 0.001], ALI/ARDS [OR = 3.63, 95% CI (1.78, 7.39), P = 0.0004], septic shock [OR = 9.43, 95% CI (4.39, 20.28), P < 0.00001], MOF [OR = 4.34, 95% CI (2.36, 7.95), P < 0.00001], acute kidney injury [OR = 2.45, 95% CI (1.14, 5.26), P = 0.02], and metabolic acidosis [OR = 5.88, 95% CI (1.51, 22.88), P = 0.01] were associated with significantly higher risk of death among patients with severe pneumonia. Those who died, compared with those who survived, differed on multiple biomarkers on admission including serum creatinine [Scr: + 67.77 mmol/L, 95% CI (47.21, 88.34), P < 0.00001], blood urea nitrogen [BUN: + 6.26 mmol/L, 95% CI (1.49, 11.03), P = 0.01], C-reactive protein [CRP: + 33.09 mg/L, 95% CI (3.01, 63.18), P = 0.03], leukopenia [OR = 2.63, 95% CI (1.34, 5.18), P = 0.005], sodium < 136 mEq/L [OR = 2.63, 95% CI (1.34, 5.18), P = 0.005], albumin [- 5.17 g/L, 95% CI (- 7.09, - 3.25), P < 0.00001], PaO₂/FiO₂ [- 55.05 mmHg, 95% CI (- 60.11, - 50.00), P < 0.00001], arterial blood PH [- 0.09, 95% CI (- 0.15, - 0.04), P = 0.0005], gram-negative microorganism [OR = 2.56, 95% CI (1.17, 5.62), P = 0.02], and multilobar or bilateral involvement [OR = 3.65, 95% CI (2.70, 4.93), P < 0.00001].

Conclusion : Older age and male gender might face a greater risk of death in severe pneumonia individuals. The mortality of severe pneumonia may also be significantly impacted by complications such diastolic hypotension, ALI/ARDS, septic shock, MOF, acute kidney injury, and metabolic acidosis, as well as the comorbidity of neoplasm, and laboratory indicators involving Scr, BUN, CRP, leukopenia, sodium, albumin, PaO₂/FiO₂, arterial blood PH, gram-negative microorganism, and multilobar or bilateral involvement.

Conclusion (proposition de traduction) : L'âge avancé et le sexe masculin pourraient être confrontés à un plus grand risque de décès chez les personnes atteintes de pneumopathie sévère. La mortalité de la pneumopathiegrave peut également être influencée de manière significative par des complications telles que l'hypotension diastolique, les lésions pulmonaires aiguës/respiratoires aiguës, le choc septique, le syndrome de défaillance d'organes multiples, les lésions rénales aiguës et l'acidose métabolique, ainsi que la comorbidité des néoplasmes et les indicateurs de laboratoire tels que la créatinine sérique, l'azote uréique du sang, la CRP, la leucopénie, le sodium, l'albumine, la PaO2/FiO2, le PH du sang artériel, les micro-organismes gram-négatifs et l'atteinte multilobaire ou bilatérale.

Prehospital care for traumatic brain injuries: A review of U.S. state emergency medical services protocols.
Kolb LM, Peters GA, Cash RE, Ordoobadi AJ, Castellanos MJ, Goldberg SA. | Am J Emerg Med. 2024 Aug 5;84:158-161
DOI: https://doi.org/10.1016/j.ajem.2024.07.063  | Télécharger l'article au format  
Keywords: Aucun

Editorial : Traumatic brain injury (TBIs) necessitates a rapid and comprehensive medical response to minimize secondary brain injury and reduce mortality [1]. Importantly, emergency medical services (EMS) implementation of evidence-based guidelines and quality monitoring can improve the quality of care and outcomes. However, while national guidelines for prehospital TBI management have been established and disseminated, statewide EMS protocols for TBI management vary widely. We therefore studied the extent to which national evidence-based guidelines have been adopted across statewide EMS treatment protocols. Our objective was to identify variability in statewide EMS protocols for prehospital TBI care in the U.S. and assess alignment of these protocols with current national guidelines.

Conclusion : In conclusion, we found inconsistent adoption of national recommendations in available statewide protocols for prehospital traumatic brain injuries management. We identified gaps and variation in statewide protocols regarding patient monitoring and reassessment, as well as in several key areas of severe traumatic brain injuries management. We recommend future work to study the prehospital identification and management of traumatic brain injuries, possible barriers to implementation of national recommendations, and current patterns in EMS education and practice regarding prehospital management of traumatic brain injuries.

Conclusion (proposition de traduction) : En conclusion, nous avons constaté une adoption incohérente des recommandations nationales dans les protocoles disponibles au niveau de l'État pour la prise en charge préhospitalière des lésions cérébrales traumatiques. Nous avons identifié des lacunes et des variations dans les protocoles nationaux concernant la surveillance et la réévaluation des patients, ainsi que dans plusieurs domaines clés de la gestion des lésions cérébrales traumatiques graves. Nous recommandons des travaux futurs pour étudier l'identification et la prise en charge préhospitalière des lésions cérébrales traumatiques, les obstacles éventuels à la mise en œuvre des recommandations nationales et les modèles actuels de formation et de pratique des services médicaux d'urgence en ce qui concerne la prise en charge préhospitalière des lésions cérébrales traumatiques.

Commentaire : National Association of State EMS Officials. National Model EMS Clinical Guidelines.
Disponible sur : https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines_2022.pdf  ; 2023. Visité le 26/08/2024.

The effect of intravenous ondansetron on QT interval in the emergency department.
Yürük Mısırlıoğlu H, Öztürk İnce E, Akkaş M. | Am J Emerg Med. 2024 Aug 10;85:7-12. 2024 Aug 10;85:7-12
DOI: https://doi.org/10.1016/j.ajem.2024.08.011
Keywords: Antiemetic; Cardiac conduction disorder; Emergency department; Ondansetron; QT prolongation.

Research article

Introduction : Ondansetron, a 5HT3 receptor antagonist, is commonly used in emergency departments to treat nausea and vomiting. In 2011, the Food and Drug Administration (FDA) issued a warning that this medicine may cause QT prolongation, potentially leading to deadly arrhythmias. The objective of this study was to characterize the QT interval prolongation associated with ondansetron use in the Emergency Department.

Méthode : This was a prospective, observational cohort study of adult patients who presented to the emergency department during a one-year period and were treated with intravenous ondansetron. We investigated the QT prolongation associated with dosages. ECGs were obtained before the medication and 5, 15, and 30 minutes after IV drug administration. Every QT measurement was recorded and compared to the zero point. The severity of drug-induced QT prolongation was determined according to the recommendations of the International Conference on Compliance (ICH). QTc prolongation was categorized as 'negligible' (<5 ms), 'significant' (>20 ms), 'potential concern' (>30 ms), or 'definitely worrying' (>60 ms).

Résultats : Of the 435 patients enrolled in the study, 60% (261 patients) were female and the mean age was 39 (±18). The QT prolongation peaked at the fifth minute and remained consistent at the fifteenth and thirty-first minutes. The maximum prolongation of the mean QT duration occured at the fifth minute (7.9 ± 18.1 ms). No patient revealed any problems with cardiac conduction. The prolonged QT interval was not related to the dose of ondansetron, but QT measurements were higher in the 30th minute in patients treated with 8 mg of ondansetron. The effect of ondansetron administration on QT prolongation was found to be above the 'negligible' but below the 'significant' value, according to the ICH recommendations.

Conclusion : In this study, QT prolongation due to ondansetron administration was below the 'important' value according to the recommendations of the ICH. No cases of cardiac arrhythmia were reported in any of the partients. Thus, routine ECG monitoring in patients given ondansetron due to the risk of QTc prolongation does not seem cost-effective when evaluated together with additional factors such as its negative impact on emergency patient flow, waste of personnel and time, and increase in healthcare costs. In the absence of a known risk of cardiac arrhythmia, IV administration of 4 mg and 8 mg of ondansetron doses no risk of QT prolongation in the emergency population.

Conclusion (proposition de traduction) : Dans cette étude, l'allongement de l'intervalle QT dû à l'administration d'ondansétron était inférieur à la valeur « importante » selon les recommandations de l'ICH. Aucun cas d'arythmie cardiaque n'a été signalé chez les patients. Ainsi, la surveillance ECG de routine chez les patients recevant de l'ondansétron en raison du risque d'allongement de l'intervalle QTc ne semble pas rentable si l'on tient compte d'autres facteurs tels que l'impact négatif sur le flux des patients aux urgences, la perte de temps et de personnel et l'augmentation des coûts des soins de santé. En l'absence de risque connu d'arythmie cardiaque, l'administration IV de 4 mg et 8 mg d'ondansétron ne présente aucun risque d'allongement de l'intervalle QT dans la population des urgences.