Discharge instruction comprehension by older adults in the emergency department: A systematic review and meta-analysis.
Haimovich AD, Mulqueen S, Carreras-Tartak J, Gettel C, Schonberg MA, Hastings SN, Carpenter C, Liu SW, Thomas SH. | Acad Emerg Med. 2024 Sep 12
DOI: https://doi.org/10.1111/acem.15013
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Older adults are at high risk of adverse health outcomes in the post-emergency department (ED) discharge period. Prior work has shown that discharged older adults have variable understanding of their discharge instructions which may contribute to these outcomes. To identify discharge comprehension gaps amenable to future interventions, we utilize meta-analysis to determine patient comprehension across five domains of discharge instructions: diagnosis, medications, self-care, routine follow-up, and return precautions.

Méthode : Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers sourced evidence from databases including Medline (PubMed), EMBASE, Web of Science, CINAHL, and Google Scholar (for gray literature). Publications or preprints appearing before April 2024 were included if they focused on geriatric ED discharge instructions and reported a proportion of patients with comprehension of at least one of five predefined discharge components. Meta-analysis of eligible studies for each component was executed using random-effects modeling to describe the proportion of geriatric ED cases understanding the discharge instructions; where appropriate we calculated pooled estimates, reported as percentages with 95% confidence interval (CI).

Résultats : Of initial records returned (N = 2898), exclusions based on title or abstract assessment left 51 studies for full-text review; of these, seven constituted the study set. Acceptable heterogeneity and absence of indication of publication bias supported pooled estimates for proportions comprehending instructions on medications (41%, 95% CI 31%-50%, I² = 43%), self-care (81%, 95% CI 76%-85%, I² = 43%), and routine follow-up (76%, 95% CI 72%-79%, I² = 25%). Key findings included marked heterogeneity with respect to comprehending two discharge parameters: diagnosis (I² = 73%) and return precautions (I² = 95%).

Conclusion : Older patients discharged from the ED had greater comprehension of self-care and follow-up instructions than about their medications. These findings suggest that medication instructions may be a priority domain for future interventions.

Conclusion (proposition de traduction) : Les patients âgés ayant quitté le service des urgences comprenaient mieux les instructions relatives aux soins personnels et au suivi que celles concernant leurs médicaments. Ces résultats suggèrent que les instructions relatives aux médicaments pourraient être un domaine prioritaire pour les interventions futures.

Management of atrial fibrillation in older adults.
Parks AL, Frankel DS, Kim DH, Ko D, Kramer DB, Lydston M, Fang MC, Shah SJ. | BMJ. 2024 Sep 17;386:e076246
DOI: https://doi.org/10.1136/bmj-2023-076246  | Télécharger l'article au format  
Keywords: Aucun

STATE OF THE ART REVIEW

Editorial : Most people with atrial fibrillation are older adults, in whom atrial fibrillation co-occurs with other chronic conditions, polypharmacy, and geriatric syndromes such as frailty. Yet most randomized controlled trials and expert guidelines use an age agnostic approach. Given the heterogeneity of aging, these data may not be universally applicable across the spectrum of older adults. This review synthesizes the available evidence and applies rigorous principles of aging science. After contextualizing the burden of comorbidities and geriatric syndromes in people with atrial fibrillation, it applies an aging focused approach to the pillars of atrial fibrillation management, describing screening for atrial fibrillation, lifestyle interventions, symptoms and complications, rate and rhythm control, coexisting heart failure, anticoagulation therapy, and left atrial appendage occlusion devices. Throughout, a framework is suggested that prioritizes patients' goals and applies existing evidence to all older adults, whether atrial fibrillation is their sole condition, one among many, or a bystander at the end of life.

Conclusion : Conclusion Decades of research and clinical care dedicated to atrial fibrillation have dramatically reduced morbidity and mortality. Yet atrial fibrillation remains a quintessential disease of aging, for which exclusive use of a disease focused approach can lead one to miss the forest for the trees. We present a framework to apply existing evidence to the heterogeneous needs of older adults. In doing so, we also highlight the need for a dedicated effort to strengthen the evidence that informs individualized care for the growing population of older adults with atrial fibrillation. The increasing number of pragmatic clinical trials enrolling complex, frail participants and examining outcomes that are important to older adults such as cognition is heartening. Future clinical trials should avoid stringent exclusion criteria and enroll patients reflective of those we encounter in the clinic. Building on the increasing use of patient reported outcomes, primary and secondary outcomes in clinical trials should be grounded in patients’ priorities, emphasizing quality of life and function over narrow clinical events. Evidence based shared decision making approaches, which are most well developed for anticoagulation, should be expanded to include all decisions about management of atrial fibrillation. Recognizing that most patients with atrial fibrillation must also adhere to guidelines for multiple other burdensome chronic conditions, we should embrace a framework predicated on care directed to patients’ goals.

Conclusion (proposition de traduction) : Des décennies de recherche et de soins cliniques consacrés à la fibrillation atriale ont permis de réduire considérablement la morbidité et la mortalité. Pourtant, la fibrillation atriale reste une maladie typique du vieillissement, pour laquelle l'utilisation exclusive d'une approche centrée sur la maladie peut conduire à ne pas voir la forêt caché par l'arbre. Nous présentons un cadre permettant d'appliquer les données existantes aux besoins hétérogènes des personnes âgées. Ce faisant, nous soulignons également la nécessité d'un effort particulier pour renforcer les données probantes qui éclairent les soins individualisés pour la population croissante de personnes âgées souffrant de fibrillation atriale. Le nombre croissant d'essais cliniques pragmatiques recrutant des participants complexes et fragiles et examinant des résultats importants pour les personnes âgées, tels que la capacité cognitive, est encourageant. Les futurs essais cliniques devraient éviter les critères d'exclusion stricts et recruter des patients reflétant ceux que nous rencontrons en clinique. En s'appuyant sur l'utilisation croissante des résultats rapportés par les patients, les résultats primaires et secondaires des essais cliniques devraient être fondés sur les priorités des patients, en mettant l'accent sur la qualité de vie et la fonction plutôt que sur des événements cliniques étroits. Les approches de prise de décision partagée fondées sur des données probantes, qui sont les mieux développées pour l'anticoagulation, devraient être étendues à toutes les décisions relatives à la prise en charge de la fibrillation atriale. Sachant que la plupart des patients atteints de fibrillation atriale doivent également se conformer à des directives pour de multiples autres maladies chroniques lourdes, nous devrions adopter un cadre fondé sur des soins orientés vers les objectifs des patients.

Cardiopulmonary Resuscitation Without Aortic Valve Compression Increases the Chances of Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Prospective Observational Cohort Study.
Chu SE, Huang CY, Cheng CY, Chan CH, Chen HA, Chang CH, Tsai KC, Chiu KM, Ma MH, Chiang WC, Sun JT. | Crit Care Med. 2024 Sep 1;52(9):1367-1379
DOI: https://doi.org/10.1097/ccm.0000000000006336
Keywords: Aucun

CLINICAL INVESTIGATIONS

Introduction : Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA.

Méthode : Prospective observational cohort study.
Setting: Single center.
Patients: This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings.
Interventions: None.

Résultats : The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Et co2 ) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Et co2 , post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups.

Conclusion : Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

Conclusion (proposition de traduction) : L'absence de compression de la valve aortique lors de la réanimation d'un arrêt cardiaque extrahospitalier est associée à une augmentation des chances de retour à la circulation spontanée et de survie aux soins intensifs. Cependant, son effet sur les résultats à long terme n'est pas clair.

Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. | Crit Care Med. 2024 Sep 1;52(9):1427-1438
DOI: https://doi.org/10.1097/ccm.0000000000006314
Keywords: Aucun

REVIEW ARTICLE

Introduction : Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality.

Méthode : We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024.
Study selection: Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings.
Data extraction: The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928.

Résultats : Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes.

Conclusion : Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.

Conclusion (proposition de traduction) : Sur la base d'essais randomisés regroupés, un objectif de pression artérielle plus bas que plus élevé entraîne une réduction de la mortalité, de l'apparition d'une fibrillation auriculaire et des besoins en transfusion. L'abaissement des objectifs de pression artérielle peut être bénéfique, mais l'incertitude demeure. Cependant, la présente méta-analyse ne confirme pas les résultats et les recommandations antérieurs. Ces résultats pourraient éclairer les futures lignes directrices et promouvoir l'étude du concept d'hémodynamique protectrice.

Commentaire : Les objectifs de PAM étaient de 45 à 70 mmHg dans le groupe à pression artérielle basse et de 65 à 100 mmHg dans le groupe à pression artérielle élevée.

Echocardiography in Cardiac Arrest: Incremental Diagnostic and Prognostic Role during Resuscitation Care.
Mauriello A, Marrazzo G, Del Vecchio GE, Ascrizzi A, Roma AS, Correra A, Sabatella F, Gioia R, Desiderio A, Russo V, D'Andrea A. | Diagnostics (Basel). 2024 Sep 23;14(18):2107
DOI: https://doi.org/10.3390/diagnostics14182107  | Télécharger l'article au format  
Keywords: ACLS; CPR; POCUS; ROSC; cardiac arrest; echocardiogram; echocardiography; post-cardiac arrest

Review

Introduction : Cardiac arrest (CA) is a life-critical condition. Patients who survive after CA go into a defined post-cardiac arrest syndrome (PCAS). In this clinical context, the role of the echocardiogram in recent years has become increasingly important to assess the causes of arrest, the prognosis, and any direct and indirect complications dependent on cardiopulmonary resuscitation (CPR) maneu-vers.

Méthode : We have conduct a narrative revision of literature.

Résultats : The aim of our review is to evaluate the increasingly important role of the transthoracic and transesophageal echocardiogram in the CA phase and especially post-arrest, analyzing the data already present in the literature.

Conclusion : Transthoracic and transesophageal echocardiogram in the CA phase take on important diagnostic and prognostic role.

Conclusion (proposition de traduction) : L'échocardiographie transthoracique et transœsophagienne dans la phase d'arrêt cardiaque joue un rôle diagnostique et pronostique important.

From guidelines to clinical practice in care for ischaemic stroke patients: A systematic review and expert opinion.
Lens C, Demeestere J, Casolla B, Christensen H, Fischer U, Kelly P, Molina C, Sacco S, Sandset EC, Strbian D, Thomalla G, Tsivgoulis G, Vanhaecht K, Weltens C, Coeckelberghs E, Lemmens R. | Eur J Neurol. 2024 Sep 5:e16417
DOI: https://doi.org/10.1111/ene.16417  | Télécharger l'article au format  
Keywords: expert testimony; guidelines; ischaemic stroke; quality improvement; systematic review.

Review article

Introduction : Guidelines help physicians to provide optimal care for stroke patients, but implementation is challenging due to the quantity of recommendations. Therefore a practical overview related to applicability of recommendations can be of assistance.

Méthode : A systematic review was performed on ischaemic stroke guidelines published in scientific journals, covering the whole acute care process for patients with ischaemic stroke. After data extraction, experts rated the recommendations on dimensions of applicability, that is, actionability, feasibility and validity, on a 9-point Likert scale. Agreement was defined as a score of ≥8 by ≥80% of the experts.

Résultats : Eighteen articles were identified and 48 recommendations were ultimately extracted. Papers were included only if they described the whole acute care process for patients with ischaemic stroke. Data extraction and analysis revealed variation in terms of both content and comprehensiveness of this description. Experts reached agreement on 34 of 48 (70.8%) recommendations in the dimension actionability, for 16 (33.3%) in feasibility and for 15 (31.3%) in validity. Agreement on all three dimensions was reached for seven (14.6%) recommendations: use of a stroke unit, exclusion of intracerebral haemorrhage as differential diagnosis, administration of intravenous thrombolysis, performance of electrocardiography/cardiac evaluation, non-invasive vascular examination, deep venous thrombosis prophylaxis and administration of statins if needed.

Conclusion : Substantial variation in agreement was revealed on the three dimensions of the applicability of recommendations. This overview can guide stroke physicians in improving the care process and removing barriers where implementation may be hampered by validity and feasibility.

Conclusion (proposition de traduction) : Une variation importante de consensus a été mise en évidence sur les trois dimensions de l'applicabilité des recommandations. Cette vue d'ensemble peut guider les médecins spécialistes de l'AVC dans l'amélioration du processus de soins et l'élimination des obstacles lorsque la mise en œuvre peut être limitée par la validité et la faisabilité.

Clinical Review of Non-invasive Ventilation.
Criner GJ, Gayen S, Zantah M, Dominguez Castillo E, Naranjo-Tovar M, Lashari B, Pourshahid S, Gangemi A. | Eur Respir J. 2024 Sep 3:2400396
DOI: https://doi.org/10.1183/13993003.00396-2024  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : Noninvasive ventilation (NIV) is the mainstay to treat patients who need augmentation of ventilation for acute and chronic forms of respiratory failure. The last several decades has witnessed an extension of the indications for NIV to a variety of acute and chronic lung diseases. Evolving advancements in technology and personalised approaches to patient care make it feasible to prioritise patient centered care models that deliver home-based management using telemonitoring and telemedicine systems support. These trends may improve patient outcomes, reduce healthcare costs, and improve the quality of life for patients who suffer from chronic diseases that precipitate respiratory failure.

Conclusion : NIV, both bilevel and CPAP, has many indications across acute and chronic respiratory failure. When used appropriately, NIV has numerous physiologic and clinical benefits, including improved gas exchange, improved respiratory muscle function, improvement in breathlessness, quality of life, and survival. In the future, technological advances in NIV devices will hopefully make them more user-friendly, portable, and customizable to meet specific individual patient needs. This should help to improve patient comfort and compliance with device use thus leading to better patient outcomes. With improvements in the integration of data analytics with artificial intelligence, clinicians may be able to titrate NIV therapy more precisely to meet each patient's individual's needs thereby leading to optimization of treatment outcomes and minimization of complications. Moreover, advances in remote monitoring technologies will enhance the capabilities of telemonitoring and telemedicine programs to provide real-time adjustments to treatment plans to address fluctuating changes in the patient's medical condition. This aspect is extremely important in dynamic diseases like COPD and will significantly increase the potential for patients to receive NIV therapy in the home to enhance their quality of life. The opportunities for an enhancement of NIV therapies to provide personalized medicine to meet the patient's needs for treatment of respiratory failure in a variety of settings outside of the hospital is bright, and hopefully will enhance the management of patients with advanced lung diseases who suffer from a range of disorders causing respiratory failure.

Conclusion (proposition de traduction) : La VNI, qu'il s'agisse de la VNI à deux niveaux ou de la CPAP, a de nombreuses indications dans le domaine de l'insuffisance respiratoire aiguë et chronique. Lorsqu'elle est utilisée de manière appropriée, la VNI présente de nombreux avantages physiologiques et cliniques, notamment l'amélioration des échanges gazeux, l'amélioration de la fonction des muscles respiratoires, l'amélioration de la dyspnée, de la qualité de vie et de la survie. À l'avenir, les progrès technologiques des appareils de VNI devraient les rendre plus conviviaux, plus portables et plus adaptables aux besoins spécifiques des patients. Cela devrait permettre d'améliorer le confort du patient et l'observance de l'utilisation de l'appareil, ce qui se traduira par de meilleurs résultats pour le patient. Grâce à l'amélioration de l'intégration de l'analyse des données et de l'intelligence artificielle, les cliniciens pourraient être en mesure de titrer la technique de VNI avec plus de précision pour répondre aux besoins individuels de chaque patient, ce qui permettrait d'optimiser les résultats du traitement et de minimiser les complications. En outre, les progrès des technologies de télésurveillance amélioreront les capacités des programmes de télésurveillance et de télémédecine à fournir des ajustements en temps réel aux plans de traitement pour répondre aux changements fluctuants de l'état de santé du patient. Cet aspect est extrêmement important dans le cas de maladies dynamiques comme la BPCO et augmentera considérablement la possibilité pour les patients à recevoir un traitement par VNI à domicile afin d'améliorer leur qualité de vie. Les possibilités d'amélioration des traitements par VNI pour fournir une médecine personnalisée répondant aux besoins du patient en matière de traitement de l'insuffisance respiratoire dans divers contextes en dehors de l'hôpital sont prometteuses et, espérons-le, amélioreront la prise en charge des patients atteints de maladies pulmonaires avancées et souffrant d'une série de troubles entraînant une insuffisance respiratoire.

An interplay between orthopaedic trauma and pregnancy-A case series of 42 patients.
Raj P, Ahmed O, Roy Wilson Armstrong B, Perumal R, Jayaramaraju D, Rajasekaran S. | Injury. 2024 Sep 1;55(11):111854
DOI: https://doi.org/10.1016/j.injury.2024.111854
Keywords: Complications; Fracture fixation; Internal fixation; Pregnancy; Radiation exposure; Trauma.

RESEARCH ARTICLE

Introduction : Pregnancy and trauma are complex situations with significant implications for maternal and fetal health. Physical and psychological trauma during pregnancy can lead to pre-term labor, abruptio-placenta, and fetal injury or death. Management of trauma is challenging due to physiological and anatomical changes, which can affect fracture management and the risk of radiation exposure. A multidisciplinary approach is beneficial for patient care. This study aimed to determine the impact of orthopaedic trauma on pregnancy and its outcome, and influence of pregnancy on fracture management.

Méthode : A retrospective-study was conducted at a Level-1 trauma-care-center, focusing on 54 pregnant women who sustained trauma between January 2015 and December 2022. The study included patients with closed or open fractures, but excluded those without fractures. Forty-two patients were available with minimum 1 year follow-up. Data was collected from hospital records and PACS, including demographic details, emergency care, and laboratory parameters. Changes made in protocol in fracture management due to pregnancy (primary definitive fixation vs staged management), and impact of trauma on pregnancy outcome; mode-of-delivery, maternal and fetal loss were evaluated.

Résultats : The mean age was 30-years (range: 21-43years). Road-traffic-collision was most-common mode-of-injury (66.7 %). 38.1 % were in the first-trimester, 35.7 % in second, and 26.2 % in third-trimester. Eight patients had polytrauma, seven had multiple-injuries, and 27 had isolated-injuries. The maternal-mortality-rate was 0.45 %. Three polytraumatized patients ended up with intrauterine death, two polytrauma patients underwent elective abortion, one patient presented with spontaneous-abortion, and fetal loss was 14.3 % (6-of-42). Out of 42 patients, 10 had open-injuries and 32 had closed-injuries. Nine patients underwent LSCS(lower-segment-caesarean-section), six of them were planned for elective-LSCS due to injury and associated fractures (two patients with pelvic injuries, two neck femur fracture patients, one open distal femur fracture, and one ankle fracture dislocation).

Conclusion : Orthopaedic trauma during pregnancy can significantly affect pregnancy outcomes and is associated with a notably higher risk of fetal loss. An elective-caesarean-section is recommended for patients with polytrauma, pelvic-injuries, and those who are immobilized for longer-duration. During the third-trimester and in polytraumatized patients, external-fixator-application for lower-limb-injuries is a safe strategy, and definitive fixation could be performed post-delivery.

Conclusion (proposition de traduction) : Les traumatismes orthopédiques pendant la grossesse peuvent affecter de manière significative l'évolution de la grossesse et sont associés à un risque nettement plus élevé de perte fœtale. Une césarienne est conseillée aux patientes présentant des polytraumatismes, des lésions pelviennes et celles qui sont immobilisées pendant une longue période. Au cours du troisième trimestre et chez les patientes polytraumatisées, l'application d'un fixateur externe pour les lésions des membres inférieurs est une stratégie sûre, et la fixation définitive peut être effectuée après l'accouchement.

Management of cardiogenic shock: state-of-the-art.
Jung C, Bruno RR, Jumean M, Price S, Krychtiuk KA, Ramanathan K, Dankiewicz J, French J, Delmas C, Mendoza AA, Thiele H, Soussi S. | Intensive Care Med. 2024 Sep 10
DOI: https://doi.org/10.1007/s00134-024-07618-x  | Télécharger l'article au format  
Keywords: Assist device; Cardiogenic shock; Heart failure; Intensive care; Myocardial infarction; Outcome.

Review

Editorial : The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

Conclusion : Management of CS remains an ongoing challenge. Despite all efforts made on improving diagnosis and offering multimodal therapy, mortality remains high. More efforts are needed to identify the right therapy for the right CS patient needs more insight also in the light of comorbidities and metabolic demands. Smaller sizes of MCS devices might also help to reduce negative side effects. Novel pharmacological substances might target the systemic syndrome CS. Innovative developments in biomarkers and use of artificial intelligence to assess trends might enhance personalized care in CS patients globally.

Conclusion (proposition de traduction) : La prise en charge du choc cardiogénique reste un défi permanent. Malgré tous les efforts déployés pour améliorer le diagnostic et proposer une solution thérapeutique multimodale, la mortalité reste élevée. Des efforts supplémentaires sont nécessaires pour identifier la bonne stratégie thérapeutique pour le bon patient en état de choc cardiogénique, en tenant compte des comorbidités et des impératifs métaboliques. Des dispositifs d'assistance circulatoire mécanique de plus petite taille pourraient également contribuer à réduire les effets secondaires négatifs. De nouvelles substances pharmacologiques pourraient cibler le syndrome systémique du choc cardiogénique. Des développements innovants en matière de biomarqueurs et l'utilisation de l'intelligence artificielle pour évaluer les besoins pourraient améliorer la personnalisation des soins pour les patients souffrant de choc cardiogénique dans le monde entier.

Central venous catheter insertion site and infection prevention in 2024.
de Grooth HJ, Hagel S, Mimoz O. | Intensive Care Med. 2024 Sep 30
DOI: https://doi.org/10.1007/s00134-024-07664-5  | Télécharger l'article au format  
Keywords: Aucun

Editorial

Editorial : Among the fast-paced and hectic demands of daily practice in the intensive care unit (ICU), the choice of insertion site for a central venous catheter may feel like a relatively minor medical decision. But given the sheer number of catheterizations, it is in fact an important determinant of overall quality of care. It is worth getting it right.

Conclusion : In making a rational choice for catheterization site, it’s important not to play a ‘blame game’. Mechanical complications like pneumothorax or arterial puncture are directly attributable to the clinician performing the procedure. In contrast, infectious complications that arise days to weeks later are often perceived as bad luck rather than the result of procedural decisions. This asymmetry is a perfect setup for cognitive bias, and clinicians should be careful not to prefer distant complications over immediate ones. We should weigh the nature of different complication rather than their immediacy. Figure proposes an algorithm to help choose the best central venous catheter insertion site according to the indication and clinical condition. The strength of the study by Cosme et al., despite the challenges associated with an observational design, lies in the large number of observations across many intensive care units and the observed low rate of bloodstream infections with small absolute differences between insertion sites. While this does not invalidate randomized evidence that shows the subclavian site leads to the lowest risk of bloodstream infections, it does bring other considerations aside from infection prevention into purview.

Conclusion (proposition de traduction) : En choisissant rationnellement le site de cathétérisme, il est important de ne pas jouer au « jeu des blâmes ». Les complications mécaniques telles que le pneumothorax ou la ponction artérielle sont directement imputables au clinicien qui a pratiqué l'intervention. En revanche, les complications infectieuses qui surviennent des jours ou des semaines plus tard sont souvent perçues comme de la malchance plutôt que comme le résultat de décisions procédurales. Cette asymétrie est un terrain propice aux biais cognitifs, et les cliniciens doivent veiller à ne pas préférer les complications lointaines aux complications immédiates. Nous devrions évaluer la nature des différentes complications plutôt que leur immédiateté. La figure propose un algorithme pour aider à choisir le meilleur site d'insertion du cathéter veineux central en fonction de l'indication et de l'état clinique. La force de l'étude de Cosme et al, malgré les obstacles liés à un modèle d'observation, réside dans le grand nombre d'observations réalisées dans de nombreuses unités de soins intensifs et dans le faible taux d'infections sanguines observé avec de petites différences absolues entre les sites d'insertion. Bien que cela n'invalide pas les données randomisées qui montrent que le site sous-clavier entraîne le risque le plus faible d'infections sanguines, d'autres considérations que la prévention des infections entrent en ligne de compte.

Commentaire : Cosme V and al.; REAREZO study group. Central venous catheter-related infection: does insertion site still matter? A French multicentric cohort study. Intensive Care Med. 2024 Sep 17  .

Algorithme de décision pour le choix du site d'insertion du cathéter veineux central

Lactated Ringer vs Normal Saline Solution During Sickle Cell Vaso-Occlusive Episodes.
Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. | JAMA Intern Med. 2024 Sep 9:e244428. JAMA Intern Med. 2024 Sep 9:e244428
DOI: https://doi.org/10.1001/jamainternmed.2024.4428
Keywords: Aucun

Original Investigation

Introduction : Sickle cell disease (SCD), a clinically heterogenous genetic hemoglobinopathy, is characterized by painful vaso-occlusive episodes (VOEs) that can require hospitalization. Patients admitted with VOEs are often initially resuscitated with normal saline (NS) to improve concurrent hypovolemia, despite preclinical evidence that NS may promote erythrocyte sickling. The comparative effectiveness of alternative volume-expanding fluids (eg, lactated Ringer [LR]) for resuscitation during VOEs is unclear.

Méthode : To compare the effectiveness of LR to NS fluid resuscitation in patients with SCD and VOEs.
Design, setting, and participants: This multicenter cohort study and target trial emulation included inpatient adults with SCD VOEs who received either LR or NS on hospital day 1. The Premier PINC AI database (2016-2022), a multicenter clinical database including approximately 25% of US hospitalizations was used. The analysis took place between October 6, 2023, and June 20, 2024.
Exposure: Receipt of LR (intervention) or NS (control) on hospital day 1.
Main outcome and measures: The primary outcome was hospital-free days (HFDs) by day 30. Targeted maximum likelihood estimation was used to calculate marginal effect estimates. Heterogeneity of treatment effect was explored in subgroups.

Résultats : A total of 55 574 patient encounters where LR (n = 3495) or NS (n = 52 079) was administered on hospital day 1 were included; the median (IQR) age was 30 (25-37) years. Patients who received LR had more HFDs compared with those who received NS (marginal mean difference, 0.4; 95% CI, 0.1-0.6 days). Patients who received LR also had shorter hospital lengths of stay (marginal mean difference, -0.4; 95% CI, -0.7 to -0.1 days) and lower risk of 30-day readmission (marginal risk difference, -5.8%; 95% CI, -9.8% to -1.8%). Differences in HFDs between LR and NS were heterogenous based on fluid volume received: among patients who received less than 2 L, there was no difference in LR vs NS; among those who received 2 or more L, LR was superior to NS.

Conclusion : This cohort study found that, compared with NS, LR had a small but significant improvement in HFDs and secondary outcomes including 30-day readmission. These results suggest that, among patients with VOEs in whom clinicians plan to give volume resuscitation fluids on hospital admission, LR should be preferred over NS.

Conclusion (proposition de traduction) : Cette étude de cohorte a montré que, par rapport au sérum physiologique, les solutions de Ringer lactate présentaient une amélioration faible mais significative du nombre de jours sans hospitalisation et des résultats secondaires, y compris la réadmission à 30 jours. Ces résultats suggèrent que, parmi les patients présentant des épisodes vaso-occlusifs chez lesquels les praticiens prévoient d'administrer un remplissage vasculaire à grand volume lors de l'admission à l'hôpital, le Ringer lactate devraient être préférés au sérum physiologique.

Commentaire : Chez les patients drépanocytaires (en particulier Hgb SS) présentant un épisode vaso-occlusif (VOE), il a été démontré que que le remplissage vasculaire à grand volume (> 2L) avec du Ringer lactate (LR) améliorait les résultats par rapport au sérum physiologique (NS).

Short-Term Effects of Lower Air Temperature and Cold Spells on Myocardial Infarction Hospitalizations in Sweden.
Ni W, Stafoggia M, Zhang S, Ljungman P, Breitner S, Bont J, Jernberg T, Atar D, Agewall S, Schneider A. | J Am Coll Cardiol. 2024 Sep 24;84(13):1149-1159
DOI: https://doi.org/10.1016/j.jacc.2024.07.006
Keywords: cold spells; lower air temperature; myocardial infarction; short-term effects.

Original Research

Introduction : Lower air temperature and cold spells have been associated with an increased risk of various diseases. However, the short-term effect of lower air temperature and cold spells on myocardial infarction (MI) remains incompletely understood.

Méthode : The purpose of this study was to investigate the short-term effects of lower air temperature and cold spells on the risk of hospitalization for MI in Sweden.
Methods: This population-based nationwide study included 120,380 MI cases admitted to hospitals in Sweden during the cold season (October to March) from 2005 to 2019. Daily mean air temperature (1 km² resolution) was estimated using machine learning, and percentiles of daily temperatures experienced by individuals in the same municipality were used as individual exposure indicators to account for potential geographic adaptation. Cold spells were defined as periods of at least 2 consecutive days with a daily mean temperature below the 10th percentile of the temperature distribution for each municipality. A time-stratified case-crossover design incorporating conditional logistic regression models with distributed lag nonlinear models using lag 0 to 1 (immediate) and 2 to 6 days (delayed) was used to evaluate the short-term effects of lower air temperature and cold spells on total MI, non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI).

Résultats : A decrease of 1-U in percentile temperature at a lag of 2 to 6 days was significantly associated with increased risks of total MI, NSTEMI, and STEMI, with ORs of 1.099 (95% CI: 1.057-1.142), 1.110 (95% CI: 1.060-1.164), and 1.076 (95% CI: 1.004-1.153), respectively. Additionally, cold spells at a lag of 2 to 6 days were significantly associated with increased risks for total MI, NSTEMI, and STEMI, with ORs of 1.077 (95% CI: 1.037-1.120), 1.069 (95% CI: 1.020-1.119), and 1.095 (95% CI: 1.023-1.172), respectively. Conversely, lower air temperature and cold spells at a lag of 0 to 1 days were associated with decreased risks for MI.

Conclusion : This nationwide case-crossover study reveals that short-term exposures to lower air temperature and cold spells are associated with an increased risk of hospitalization for MI at lag 2 to 6 days.

Conclusion (proposition de traduction) : Cette étude nationale croisée révèle que l'exposition à court terme à une température atmosphérique plus basse et à des vagues de froid est associée à un risque accru d'hospitalisation pour infarctus du myocarde au bout de 2 à 6 jours.

Recovery of Left Ventricular Function and Long-Term Outcomes in Patients With Takotsubo Syndrome.
Almendro-Delia M, López-Flores L, Uribarri A, Vedia O, Blanco-Ponce E, López-Flores MDC, Rivas-García AP, Fernández-Cordón C, Sionis A, Martín-García AC, Vazirani R, Corbí-Pascual M, Salamanca J, Pérez-Castellanos A, Martínez-Sellés M, Becerra VM, Aritza-Conty D, López-País J, Guillén-Marzo M, Lluch-Requerey C, García-Rubira JC, Núñez-Gil IJ; RETAKO Investigators. | J Am Coll Cardiol. 2024 Sep 24;84(13):1163-1174
DOI: https://doi.org/10.1016/j.jacc.2024.05.075  | Télécharger l'article au format  
Keywords: function recovery; left ventricular function; takotsubo syndrome.

Original Research

Introduction : Takotsubo syndrome (TTS) is a form of transient left ventricular (LV) dysfunction that usually resolves within days to weeks.

Méthode : We aimed to assess the predictors and prognostic impact of time-to-LV recovery after TTS.
Methods: Prospective serial imaging data from the nationwide, multicenter RETAKO (REgistry on TAKOtsubo Syndrome) were comprehensively reviewed to assess the timing of LV recovery. Multivariable logistic regression was used to assess factors associated with late (≥10 days) vs early (<10 days) recovery. The long-term risk of all-cause mortality was compared between the late and early recovery groups using fully adjusted Cox models, and using flexible parametric survival models with recovery time included as a continuous variable.

Résultats : Of 1,463 patients included (median age 73 years, 13% men), 373 (25%) had late and 1,090 (75%) had early LV recovery. Older age, history of neurological disorders, bystander coronary artery disease, active cancer, physical triggers, elevated inflammatory biomarkers, cardiogenic shock, and lower LV ejection fraction at admission were independent predictors of late recovery. At 4-year follow-up, the adjusted risk of death was significantly higher in patients with late recovery compared with those with early recovery (16.0% vs 8.6%, adjusted HR: 1.31; 95% CI: 1.12-1.60), with the risk of death increasing by 8% for every additional 10-day delay in time-to-LV recovery (adjusted HR: 1.08; 95% CI: 1.04-1.13).

Conclusion : Late recovery of LV function after TTS is associated with reduced short- and long-term survival. In TTS patients without early LV recovery, closer clinical follow-up might be considered.

Conclusion (proposition de traduction) : La récupération tardive de la fonction ventriculaire gauche après un syndrome de Takotsubo est associée à une réduction de la survie à court et à long terme. Chez les patients présentant un syndrome de Takotsubo sans récupération précoce de la fonction ventriculaire gauche, un suivi clinique plus étroit peut être envisagé.

Initial Defibrillator Pad Position and Outcomes for Shockable Out-of-Hospital Cardiac Arrest.
Lupton JR, Newgard CD, Dennis D, Nuttall J, Sahni R, Jui J, Neth MR, Daya MR. | JAMA Netw Open. 2024 Sep 3;7(9):e2431673
DOI: https://doi.org/10.1001/jamanetworkopen.2024.31673
Keywords: Aucun

Original Investigation

Introduction : Ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) are the most treatable causes of out-of-hospital cardiac arrest (OHCA). Yet, it remains unknown if defibrillator pad position, placement in the anterior-posterior (AP) or anterior-lateral (AL) locations, impacts patient outcomes in VF or pVT OHCA.

Méthode : To determine the association between initial defibrillator pad placement position and OHCA outcomes for patients presenting with VF or pVT.
Design, setting, and participants: This prospective cohort study included patients with OHCA and VF or pVT treated by a single North American emergency medical services (EMS) agency from July 1, 2019, through June 30, 2023. The study included patients with OHCA treated by a large suburban fire-based EMS agency that covers a population of 550 000. Consecutive patients with an initial EMS-assessed rhythm of VF or pVT receiving EMS defibrillation were included. Pediatric patients (younger than 18 years), interfacility transfers, arrests of obvious traumatic etiology, and patients with preexisting do-not-resuscitate status were excluded.
Exposure: AP or AL pad placement.
Main outcomes and measures: Return of spontaneous circulation (ROSC) at any time with secondary outcomes of pulses present at emergency department (ED) arrival, survival to hospital admission, survival to hospital discharge, and functional survival at hospital discharge (cerebral performance category score of 2 or less). Measures included adjusted odds ratios (aOR), multivariable logistic regressions, and Fine-Gray competing risks regression.

Résultats : A total of 255 patients with OHCA were included (median [IQR] age, 66 [55-74] years; 63 females [24.7%]), with initial pad positioning documented as either AP (158 patients [62.0%]; median [IQR] age, 65 [54-74] years; 37 females [23.4%]) or AL (97 patients [38.0%]; median [IQR] age, 66 [57-74] years; 26 females [26.8%]). Patients with AP placement had higher adjusted odds ratio (aOR) of ROSC at any time (aOR, 2.64 [95% CI, 1.50-4.65]), but not significantly different odds of pulses present at ED arrival (1.34 [95% CI, 0.78-2.30]), survival to hospital admission (1.41 [0.82-2.43]), survival to hospital discharge (1.55 [95% CI, 0.83-2.90]), or functional survival at hospital discharge (1.86 [95% CI, 0.98-3.51]). Competing risk analysis found significantly greater cumulative incidence of ROSC among those at risk with initial AP placement compared with AL (subdistribution hazard ratio, 1.81 [95% CI, 1.23-2.67]; P = .003).

Conclusion : In this cohort study of patients with OHCA and VF or pVT, AP defibrillator pad placement was associated with higher ROSC compared with AL placement.

Conclusion (proposition de traduction) : Dans cette étude de cohorte de patients ayant fait un arrêt cardiaque extrahospitalier et présentant une fibrillation ventriculaire ou une tachycardie ventriculaire sans pouls, la mise en place antérieure-postérieure du défibrillateur a été associée à un retour plus important à une circulation spontanée par rapport à la mise en place antérieure-latérale.

Diagnostic Performance of GFAP, UCH-L1, and MAP-2 Within 30 and 60 Minutes of Traumatic Brain Injury.
Papa L, McKinley WI, Valadka AB, Newman ZC, Nordgren RK, Pramuka PE, Barbosa CE, Brito AMP, Loss LJ, Tinoco-Garcia L, Hinson HE, Schreiber MA, Rowell SE. | JAMA Netw Open. 2024 Sep 3;7(9):e2431115
DOI: https://doi.org/10.1001/jamanetworkopen.2024.31115  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Data on the performance of traumatic brain injury (TBI) biomarkers within minutes of injury are lacking.

Méthode : To examine the performance of glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and microtubule-associated protein 2 (MAP-2) within 30 and 60 minutes of TBI in identifying intracranial lesions on computed tomography (CT) scan, need for neurosurgical intervention (NSI), and clinically important early outcomes (CIEO).
Design, setting, and participants: This cohort study is a biomarker analysis of a multicenter prehospital TBI cohort from the Prehospital Tranexamic Acid Use for TBI clinical trial conducted across 20 centers and 39 emergency medical systems in North America from May 2015 to March 2017. Prehospital hemodynamically stable adult patients with traumatic injury and suspected moderate to severe TBI were included. Blood samples were measured for GFAP, UCH-L1, and MAP-2. Data were analyzed from December 1, 2023, to March 15, 2024.
Main outcomes and measures: The presence of CT lesions, diffuse injury severity on CT, NSI within 24 hours of injury, and CIEO (composite outcome including early death, neurosurgery, or prolonged mechanical ventilation ≥7 days) within 7 days of injury.

Résultats : Of 966 patients enrolled, 804 patients (mean [SD] age, 41 [19] years; 418 [74.2%] male) had blood samples, including 563 within 60 minutes and 375 within 30 minutes of injury. Among patients with blood drawn within 30 minutes of injury, 212 patients (56.5%) had CT lesions, 61 patients (16.3%) had NSI, and 112 patients (30.0%) had CIEO. Among those with blood drawn within 60 minutes, 316 patients (56.1%) had CT lesions, 95 patients (16.9%) had NSI, and 172 patients (30.6%) had CIEO. All biomarkers showed significant elevations with worsening diffuse injury on CT within 30 and 60 minutes of injury. Among blood samples taken within 30 minutes, GFAP had the highest area under the receiver operating characteristic curve (AUC) to detect CT lesions, at 0.88 (95% CI, 0.85-0.92), followed by MAP-2 (AUC, 0.78; 95% CI, 0.73-0.83) and UCH-L1 (AUC, 0.75; 95% CI, 0.70-0.80). Among blood samples taken within 60 minutes, AUCs for CT lesions were 0.89 (95% CI, 0.86-0.92) for GFAP, 0.76 (95% CI, 0.72-0.80) for MAP-2, and 0.73 (95% CI, 0.69-0.77) for UCH-L1. Among blood samples taken within 30 minutes, AUCs for NSI were 0.78 (95% CI, 0.72-0.84) for GFAP, 0.75 (95% CI, 0.68-0.81) for MAP-2, and 0.69 (95% CI, 0.63-0.75) for UCH-L1; and for CIEO, AUCs were 0.89 (95% CI, 0.85-0.93) for GFAP, 0.83 (95% CI, 0.78-0.87) for MAP-2, and 0.77 (95% CI, 0.72-0.82) for UCH-L1. Combining the biomarkers was no better than GFAP alone for all outcomes. At GFAP of 30 pg/mL within 30 minutes, sensitivity for CT lesions was 98.1% (95% CI, 94.9%-99.4%) and specificity was 34.4% (95% CI, 27.2%-42.2%). GFAP levels greater than 6200 pg/mL were associated with high risk of NSI and CIEO.

Conclusion : In this cohort study of prehospital patients with TBI, GFAP, UCH-L1, and MAP-2 measured within 30 and 60 minutes of injury were significantly associated with traumatic intracranial lesions and diffuse injury severity on CT scan, 24-hour NSI, and 7-day CIEO. GFAP was the strongest independent marker associated with all outcomes. This study sets a precedent for the early utility of GFAP in the first 30 minutes from injury in future clinical and research endeavors.

Conclusion (proposition de traduction) : Dans cette étude de cohorte de patients préhospitaliers victimes d'un traumatisme cérébral, la GFAP, l'UCH-L1 et la MAP-2 mesurées dans les 30 et 60 minutes suivant le traumatisme ont été associées de manière significative aux lésions intracrâniennes traumatiques et à la gravité des lésions diffuses au scanner, à l'intervention neurochirurgicale dans les 24 heures et aux résultats précoces importants sur le plan clinique à 7 jours. La GFAP était le marqueur indépendant le plus fortement associé à tous les résultats. Cette étude crée un précédent pour l'utilité précoce de la GFAP dans les 30 premières minutes suivant la blessure dans les futurs efforts cliniques et de recherche.

Commentaire : Voir le commentaire de Ramon Diaz-Arrastia  .

Plasma Biomarkers of Traumatic Brain Injury in Adolescents With Sport-Related Concussion.
Tabor JB, Penner LC, Galarneau JM, Josafatow N, Cooper J, Ghodsi M, Huang J, Fraser DD, Smirl J, Esser MJ, Yeates KO, Wellington CL, Debert CT, Emery CA. | JAMA Netw Open. 2024 Sep 3;7(9):e2431959
DOI: https://doi.org/10.1001/jamanetworkopen.2024.31959  | Télécharger l'article au format  
Keywords: Aucun

OriginalInvestigation

Introduction : Blood-based biomarkers may clarify underlying neuropathology and potentially assist in clinical management of adolescents with sport-related concussion (SRC).
Objective: To investigate the association between SRC and plasma biomarkers in adolescents.

Méthode : Prospective cohort study in Canadian sport and clinic settings (Surveillance in High Schools and Community Sport to Reduce Concussions and Their Consequences study; September 2019 to November 2022). Participants were a convenience sample of 849 adolescent (ages 10-18 years) sport participants with blood samples. Data were analyzed from February to September 2023.
Exposures: Blood collection and clinical testing preseason (uninjured) and post-SRC follow-ups (ie, ≤72 hours, 1 week, and biweekly until medical clearance to return to play [RTP]).
Main outcomes and measures: Plasma glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase-L1 (UCH-L1), neurofilament light (NfL), and total tau (t-tau) were assayed. Group-level comparisons of biomarker levels were conducted between uninjured and post-SRC intervals (postinjury day [PID] 0-3, 4-10, 11-28, and >28) considering age and sex as modifiers. Secondary analyses explored associations between biomarker concentrations and clinical outcomes (Sport Concussion Assessment Tool, Fifth Edition [SCAT5] symptom scores and time to RTP).

Résultats : This study included 1023 plasma specimens from 695 uninjured participants (467 male participants [67.2%]; median [IQR] age, 15.90 [15.13-16.84] years) and 154 participants with concussion (78 male participants [51.0%]; median [IQR] age, 16.12 [15.31-17.11] years). Acute (PID 0-3) differences relative to uninjured levels were found for GFAP (female participants: 17.8% increase; β = 0.164; 95% CI, 0.064 to 0.263; P = .001; male participants: 17.1% increase; β = 0.157; 95% CI, 0.086 to 0.229; P < .001), UCH-L1 (female participants: 43.4% increase; β = 0.361; 95% CI, 0.125 to 0.596; P = .003), NfL (male participants: 19.0% increase; β = 0.174; 95% CI, 0.087 to 0.261; P < .001), and t-tau (female participants: -22.9%; β = -0.260; 95% CI, -0.391 to -0.130; P < .001; male participants: -18.4%; β = -0.203; 95% CI, -0.300 to -0.106; P < .001). Differences were observed for all biomarkers at PID 4 to 10, 11 to 28, and greater than 28 compared with uninjured groups. GFAP, NfL, and t-tau were associated with SCAT5 symptom scores across several PID intervals. Higher GFAP after 28 days post-SRC was associated with earlier clearance to RTP (hazard ratio, 4.78; 95% CI, 1.59 to 14.31; P = .01). Male participants exhibited lower GFAP (-9.7%), but higher UCH-L1 (21.3%) compared with female participants. Age was associated with lower GFAP (-5.4% per year) and t-tau (-5.3% per year).

Conclusion : In this cohort study of 849 adolescents, plasma biomarkers differed between uninjured participants and those with concussions, supporting their continued use to understand concussion neuropathology. Age and sex are critical considerations as these biomarkers progress toward clinical validation.

Conclusion (proposition de traduction) : Dans cette étude de cohorte de 849 adolescents, les biomarqueurs plasmatiques différaient entre les participants non blessés et ceux ayant subi une commotion cérébrale, ce qui justifie leur utilisation continue pour comprendre la neuropathologie des commotions cérébrales. L'âge et le sexe sont des considérations essentielles dans la progression de ces biomarqueurs vers la validation clinique.

How to perform Point of Care Ultrasound at resuscitation and when it is useful.
Wastl D, Blaivas M, Horn R, Michels G, Seibel A, Schwarz S, Hoffmann BH, Hoffmann O, Von Ow D, Dietrich CF. | Med Ultrason. 2024 Sep 30
DOI: https://doi.org/10.11152/mu-4439  | Télécharger l'article au format  
Keywords: cardiopulmonary resuscitation; POCUS; hemodynamics, guideline; advanced cardiovascular life support (ACLS)

Article

Editorial : Point of Care Ultrasound (POCUS) can be useful as a tool before, during and after the performance of cardiopulmonary resuscitation (CPR). Before or after resuscitation it can help with monitoring unstable hemodynamics, has the potential to identify reversible causes if patient deteriorates. During resuscitation POCUS can help detect potentially treatable causes of the cardiac arrest. Performance of POCUS while resuscitation requires experienced sonologists and a good team structure to embed the examination in advanced cardiovascular life support (ACLS) algorithms. This article gives an overview and tips about how to detect potential reversible causes of patient deterioration in all three phases of CPR. We describe some special situations in which resuscitation could take place. Further we give a comment about sonographic education of physicians and nonacademic medical staf.

Conclusion : Ultrasound can help to avoid resuscitation and to guide therapy after resuscitation. POCUS should be used accord- ing to an appropriate protocol. During CPR POCUS should only be carried out by sufficiently experienced and trained users or user teams. Unnecessary and pro- longed interruptions during chest compression should be avoided (max. 10 seconds during rhythm analysis).

Conclusion (proposition de traduction) : L'échographie peut contribuer à éviter la réanimation et à guider la thérapie après la réanimation. L'échographie au point d'intervention doit être utilisée conformément à un protocole approprié. Pendant la RCP, l'échographie au point d'intervention ne doit être effectuée que par des utilisateurs ou des équipes d'utilisateurs suffisamment expérimentés et formés. Les interruptions inutiles et prolongées pendant la compression thoracique doivent être évitées (max. 10 secondes pendant l'analyse du rythme).

Commentaire : Nouvel article qui argumente l’apport de l’échographie dans la prise en charge de l’arrêt cardiaque en mettant un prérequis sur le formation.

Association between early airway intervention in the pre-hospital setting and outcomes in out of hospital cardiac arrest patients: A post-hoc analysis of the Target Temperature Management-2 (TTM2) trial.
Battaglini D, Schiavetti I, Ball L, Jakobsen JC, Lilja G, Friberg H, Wendel-Garcia PD, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Martin A, Solar M, Taccone FS, Dankiewicz J, Nielsen N, Morten Grejs A, Wise MP, Hängghi M, Smid O, Patroniti N, Robba C; TTM2 trial investigators. | Resuscitation. 2024 Sep 5;203:110390
DOI: https://doi.org/10.1016/j.resuscitation.2024.110390
Keywords: Airway devices; Airway management; Cardiac arrest; Outcome, endotracheal intubation; Supraglottic device.

CLINICAL PAPER

Introduction : Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. The primary aim of this study was to describe pre-hospital airway management in adult patients post-OHCA. Secondary aims were to investigate whether tracheal intubation (TI) versus use of supraglottic airway device (SGA) was associated with patients' outcomes, including ventilator-free days within 26 days of randomization, 6 months neurological outcome and mortality.

Méthode : Secondary analysis of the Target Temperature Management-2 (TTM2) trial conducted in 13 countries, including adult patients with OHCA and return of spontaneous circulation, with data available on pre-hospital airway management. A multivariate logistic regression model with backward stepwise selection was employed to assess whether TI versus SGA was associated with outcomes.

Résultats : Of the 1900 TTM2 trial patients, 1702 patients (89.5%) were included, with a mean age of 64 years (Standard Deviation, SD = 13.53); 79.1% were males. Pre-hospital airway management was SGA in 484 (28.4%), and TI in 1218 (71.6%) patients. At hospital admission, 87.8% of patients with SGA and 98.5% with TI were mechanically ventilated (p < 0.001). In the multivariate analysis, TI in comparison with SGA was not independently associated with an increase in ventilator-free days within 26 days of randomization, improved neurological outcomes, or decreased mortality. The hazard ratio for mortality with TI vs. SGA was 1.06, 95%Confidence Interval (CI) 0.88-1.28, p = 0.54.

Conclusion : In the multicentre randomized TTM2-trial including patients with OHCA, most patients received prehospital endotracheal intubation to manage their airway. The choice of pre-hospital airway device was not independently associated with patient clinical outcomes.

Conclusion (proposition de traduction) : Dans l'essai multicentrique randomisé TTM2 portant sur des patients ayant fait un arrêt cardiaque extrahospitalier, la plupart des patients ont bénéficié d'une intubation endotrachéale préhospitalière pour la gestion de leurs voies respiratoires. Le choix du dispositif préhospitalier pour les voies aériennes n'a pas été associé de manière indépendante aux résultats cliniques des patients.

Artificial intelligence for predicting shockable rhythm during cardiopulmonary resuscitation: In-hospital setting.
Ahn S, Jung S, Park JH, Cho H, Moon S, Lee S. | Resuscitation. 2024 Sep;202:110325
DOI: https://doi.org/10.1016/j.resuscitation.2024.110325
Keywords: Artificial intelligence; Cardio-pulmonary resuscitation; Electrocardiogram.

CLINICAL PAPER

Introduction : This study aimed to develop an artificial intelligence (AI) model capable of predicting shockable rhythms from electrocardiograms (ECGs) with compression artifacts using real-world data from emergency department (ED) settings. Additionally, we aimed to explore the black box nature of AI models, providing explainability.

Méthode : This study is retrospective, observational study using a prospectively collected database. Adult patients who presented to the ED with cardiac arrest or experienced cardiac arrest in the ED between September 2021 and February 2024 were included. ECGs with a compression artifact of 5 s before every rhythm check were used for analysis. The AI model was designed based on convolutional neural networks. The ECG data were assigned into training, validation, and testing sets on a per-patient basis to ensure that ECGs from the same patient did not appear in multiple sets. Gradient-weighted class activation mapping was employed to demonstrate AI explainability.

Résultats : A total of 1,889 ECGs with compression artifacts from 172 patients were used. The area under the receiver operating characteristic curve (AUROC) for shockable rhythm prediction was 0.8672 (95% confidence interval [CI]: 0.8161-0.9122). The AUROCs for manual and mechanical compression were 0.8771 (95% CI: 0.8054-0.9408) and 0.8466 (95% CI: 0.7630-0.9138), respectively.

Conclusion : This study was the first to accurately predict shockable rhythms during compression using an AI model trained with actual patient ECGs recorded during resuscitation. Furthermore, we demonstrated the explainability of the AI. This model can minimize interruption of cardiopulmonary resuscitation and potentially lead to improved outcomes.

Conclusion (proposition de traduction) : Cette étude est la première à prédire avec précision les rythmes choquables pendant la compression à l'aide d'un modèle d'intelligence artificielle entraîné avec des ECG de patients réels enregistrés pendant la réanimation. En outre, nous avons démontré que l'IA était facile à comprendre. Ce modèle peut minimiser l'interruption de la réanimation cardio-pulmonaire et potentiellement conduire à de meilleurs résultats.

Prediction of blood pressure using chest compression waveform during cardiopulmonary resuscitation.
Han J, Ahn KJ, Cha KC, Kim SJ, Jung WJ, Roh YI, Yoon YR, Hwang SO. | Resuscitation. 2024 Sep;202:110331
DOI: https://doi.org/10.1016/j.resuscitation.2024.110331
Keywords: Blood pressure determination; Cardiac arrest; Cardiopulmonary resuscitation; Machine learning.

CLINICAL PAPER

Introduction : This study aimed to predict blood pressure during CPR using chest compression waveform information obtained from a CPR feedback device.

Méthode : Quantitative data including chest compression waveforms from a CPR feedback device and the blood pressure measured by arterial cannulation in patients with cardiac arrest during CPR were used. Forty-one features to predict blood pressure were selected from chest compression waveform and demographic characteristics with neighborhood component analysis algorithm. Optimized Gaussian process regression was used as a machine learning algorithm.

Résultats : A total of 14,619 datasets from 19 patients with cardiac arrest (mean age: 66 ± 13 years, 14 men) were used in the analysis. The model could predict blood pressure with high precision and low bias for almost the whole range of systolic (SBP), diastolic (DBP), and mean arterial blood pressure (MAP). The correlation coefficients (r) between the predicted and actual values were 0.954 (95% confidence interval: 0.951-0.957, p < 0.001) for SBP, 0.926 (95% confidence interval: 0.921-0.931, p < 0.001) for DBP, and 0.958 (95% confidence interval: 0.955-0.961, p < 0.001) for MBP, which all indicated a very good agreement.

Conclusion : Blood pressure generated by chest compressions can be predicted with high accuracy by a machine learning method using chest compression waveform information obtained from a CPR feedback device and the patient's demographic characteristics. Real-time provision of the predicted blood pressure can be used to monitor the quality and efficacy of CPR.

Conclusion (proposition de traduction) : La pression artérielle générée par les compressions thoraciques peut être prédite avec une grande précision par une méthode d'apprentissage automatique utilisant les informations sur la forme d'onde des compressions thoraciques obtenues à partir d'un dispositif de retour d'information sur la réanimation cardio-pulmonaire et les caractéristiques démographiques du patient. La fourniture en temps réel de la pression sanguine prédite peut être utilisée pour contrôler la qualité et l'efficacité de la réanimation cardio-pulmonaire.

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 Sep;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 d'abord, comparée à une approche humérale-IO, pour la réanimation intra-arrêt 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.

Analysis during chest compressions in out-of-hospital cardiac arrest patients, a cross/sectional study: The DEFI 2022 study.
Derkenne C, Frattini B, Menetre S, Hong Tuan Ha V, Lemoine F, Beganton F, Didon JP, Rozenberg E, Salome M, Trichereau J, Corcostegui SP, Lemoine S, Kedzierewicz R, Burlaton G, Vial V, Dessertaine T, Miron De L'Espinay A, Jouven X, Travers S, Jost D; Paris Fire Brigade Cardiac Arrest Task Force. | Resuscitation. 2024 Sep;202:110292
DOI: https://doi.org/10.1016/j.resuscitation.2024.110292
Keywords: Artifact-filtering algorithm; Automated external defibrillator; Cardiac arrest; Ventricular fibrillation.

Clinical paper

Introduction : During out-of-hospital cardiac arrest (OHCA), an automatic external defibrillator (AED) analyzes the cardiac rhythm every two minutes; however, 80% of refibrillations occur within the first minute post-shock. We have implemented an algorithm for Analyzing cardiac rhythm While performing chest Compression (AWC). When AWC detects a shockable rhythm, it shortens the time between analyses to one minute. We investigated the effect of AWC on cardiopulmonary resuscitation quality.

Méthode : In this cross-sectional study, we compared patients treated in 2022 with AWC, to a historical cohort from 2017. Inclusion criteria were OHCA patients with a shockable rhythm at the first analysis. Primary endpoint was the chest compression fraction (CCF). Secondary endpoints were cardiac rhythm evolution and survival, including survival analysis of non-prespecified subgroups.

Résultats : In 2017 and 2022, 355 and 377 OHCAs met the inclusion criteria, from which we analyzed the 285 first consecutive cases in each cohort. CCF increased in 2022 compared to 2017 (77% [72-80] vs 72% [67-76]; P < 0.001) and VF recurrences were shocked more promptly (53 s [32-69] vs 117 s [90-132]). Survival did not differ between 2017 and 2022 (adjusted hazard-ratio 0.96 [95% CI, 0.78-1.18]), but was higher in 2022 within the sub-group of OHCAs that occurred in a public place and within a short time from call to AED switch-on (adjusted hazard ratio 0.85[0.76-0.96]).

Conclusion : OHCA patients treated with AWC had higher CCF, shorter time spent in ventricular fibrillation, but no survival difference, except for OHCA that occurred in public places with short intervention time.

Conclusion (proposition de traduction) : Les patients ayant fait un arrêt cardiaque en dehors de l'hôpital et traités par l'analyse du rythme cardiaque pendant les compressions thoraciques avaient une fraction de compression thoracique plus élevée, une durée plus courte de fibrillation ventriculaire, mais aucune différence en termes de survie, sauf pour les arrêts cardiaques survenus en dehors de l'hôpital dans des lieux publics avec un temps d'intervention court.

Artificial intelligence-based evaluation of carotid artery compressibility via point-of-care ultrasound in determining the return of spontaneous circulation during cardiopulmonary resuscitation.
Park S, Yoon H, Yeon Kang S, Joon Jo I, Heo S, Chang H, Eun Park J, Lee G, Kim T, Yeon Hwang S, Park S, Jin Chung M. | Resuscitation. 2024 Sep;202:110302
DOI: https://doi.org/10.1016/j.resuscitation.2024.110302  | Télécharger l'article au format  
Keywords: Artificial intelligence; Cardiopulmonary resuscitation; Carotid artery; Point-of-care ultrasound; Pulse check; Return of spontaneous circulation.

CLINICAL PAPER

Introduction : This study introduces RealCAC-Net, an artificial intelligence (AI) system, to quantify carotid artery compressibility (CAC) and determine the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation.

Méthode : A prospective study based on data from a South Korean emergency department from 2022 to 2023 investigated carotid artery compressibility in adult patients with cardiac arrest using a novel AI model, RealCAC-Net. The data comprised 11,958 training images from 161 cases and 15,080 test images from 134 cases. RealCAC-Net processes images in three steps: TransUNet-based segmentation, the carotid artery compressibility measurement algorithm for improved segmentation and CAC calculation, and CAC-based classification from 0 (indicating a circular shape) to 1 (indicating high compression). The accuracy of the ROSC classification model was tested using metrics such as the dice similarity coefficient, intersection-over-union, precision, recall, and F1 score.

Résultats : RealCAC-Net, which applied the carotid artery compressibility measurement algorithm, performed better than the baseline model in cross-validation, with an average dice similarity coefficient of 0.90, an intersection-over-union of 0.84, and a classification accuracy of 0.96. The test set achieved a classification accuracy of 0.96 and an F1 score of 0.97, demonstrating its efficacy in accurately identifying ROSC in cardiac arrest situations.

Conclusion : RealCAC-Net enabled precise CAC quantification for ROSC determination during cardiopulmonary resuscitation. Future research should integrate this AI-enhanced ultrasound approach to revolutionize emergency care.

Conclusion (proposition de traduction) : RealCAC-Net a permis une quantification précise de la compressibilité de l'artère carotide pour déterminer la reprise d'activité cardiaque spontanée pendant la réanimation cardio-pulmonaire. Les recherches futures devraient intégrer cette approche de l'échographie améliorée par l'IA pour révolutionner les soins d'urgence.

Commentaire : Voir :
Özlü S and al. Comparison of carotid artery ultrasound and manual method for pulse check in cardiopulmonary resuscitation. Am J Emerg Med. 2023 Aug;70:157-162  .

Inflammatory response after prehospital high-dose glucocorticoid to patients resuscitated from out-of-hospital cardiac arrest: A sub-study of the STEROHCA trial.
Obling LER, Beske RP, Meyer MAS, Grand J, Wiberg S, Damm-Hejmdal A, Bjerre M, Frikke-Schmidt R, Folke F, Møller JE, Kjaergaard J, Hassager C. | Resuscitation. 2024 Sep;202:110340
DOI: https://doi.org/10.1016/j.resuscitation.2024.110340  | Télécharger l'article au format  
Keywords: Cytokines; Glucocorticoid; Inflammation; Out-of-Hospital Cardiac Arrest; Post-Cardiac Arrest Syndrome; Prehospital Intervention.

CLINICAL PAPER

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

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

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

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

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

Commentaire : Voir l'article :
Obling LER and al. Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial. Crit Care. 2024 Jan 22;28(1):28  .
Le traitement préhospitalier par glucocorticoïde à forte dose (méthylprednisolone 250 mg) a été associé à une réduction de la consommation de noradrénaline chez les patients ayant présenté un arrêt cardiaque en dehors de l'hôpital et ayant été réanimés.

The impact of real-time feedback on ventilation quality during out-of-hospital cardiac arrest: A before-and-after study.
Drennan IR, Lee M, Héroux JP, Lee A, Riches J, Peppler J, Poitras A, Cheskes S. | Resuscitation. 2024 Sep 18;204:110381
DOI: https://doi.org/10.1016/j.resuscitation.2024.110381  | Télécharger l'article au format  
Keywords: Feedback, Out-of-Hospital Cardiac Arrest; Resuscitation; Ventilation.

Clinical paper

Introduction : Ventilations are a critical component of cardiopulmonary resuscitation (CPR). There is conflicting evidence, however, on the most appropriate method of ventilation during cardiac arrest management. Recent evidence has suggested that regardless of the optimal ventilation strategy, ventilations are often not delivered compliant with guideline recommendations. Recent technological advancements have allowed for accurate measurement and real-time feedback of ventilation rate and volume during resuscitation. Simulation studies have found significant improvements in ventilations with the use of real-time feedback during simulated cardiac arrest. The use of feedback has not been studied in clinical practice. The objective of this study was to determine whether the use of real-time feedback improves compliance with pre-defined targets for ventilation rate and volume during out-of-hospital cardiac resuscitation.

Méthode : This was a before-and-after study with four paramedic services in Ontario, Canada. We enrolled adult, out-of-hospital cardiac arrest (OHCA) patients where the ZOLL Accuvent® device was utilized to measure ventilation rate and volume. In the before phase (without feedback), the Accuvent® was used to measure ventilations, however, providers were blinded to the real-time feedback. In the after phase (with feedback), the feedback dashboard was activated and providers used the real-time feedback to guide their ventilations. All other aspects of resuscitation remained consistent throughout the study. The main objective of the study was to compare the proportion of each case that was compliant with pre-defined ventilation targets with real-time feedback and without real-time feedback. We also examined the use of advanced airways on ventilation quality and examined for associations between ventilation parameters and return of circulation.

Résultats : We enrolled 412 patients in the study (191 in the before phase without feedback and 221 in the after phase with feedback). Overall, we found significant improvements in both ventilation rate and volume in the after phase (with real-time feedback) compared to the before phase (without real-time feedback). We did not find any differences in ventilation compliance with or without advanced airways, or intra-arrest or post-cardiac arrest.

Conclusion : The use of real-time feedback was associated with an increased proportion of ventilations that were compliant with pre-defined targets during cardiac resuscitation. Further work is required to improve the use of real-time ventilation feedback, and to determine the impact of ventilations on patient outcomes.

Conclusion (proposition de traduction) : L'utilisation d'un dispositif de retour d'information en temps réel a été associée à une proportion accrue de ventilations conformes aux objectifs prédéfinis pendant la réanimation cardiaque. D'autres travaux sont nécessaires pour améliorer l'utilisation de la rétroaction sur la ventilation en temps réel et pour déterminer l'impact des ventilations sur le devenir des patients.

Commentaire : van Eijk JA, Doeleman LC, Loer SA, Koster RW, van Schuppen H, Schober P. Ventilation during cardiopulmonary resuscitation: A narrative review. Resuscitation. 2024 Oct;203:110366  .

Emergency medicine updates: Endotracheal intubation.
Long B, Gottlieb M. | Am J Emerg Med. 2024 Sep 3;85:108-116
DOI: https://doi.org/10.1016/j.ajem.2024.08.042  | Télécharger l'article au format  
Keywords: Airway; Apneic oxygenation; Bougie; Endotracheal intubation; Induction; Noninvasive ventilation; Paralysis; Preoxygenation; Resuscitation; Sedation; Tracheal intubation.

Article

Introduction : Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI.

Méthode : This paper evaluates key evidence-based updates concerning ETI for the emergency clinician.

Discussion : ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube.

Conclusion : An understanding of literature updates can improve the ED care of patients requiring emergent intubation.

Conclusion (proposition de traduction) : La compréhension des mises à jour de la littérature peut améliorer la prise en charge aux urgences des patients nécessitant une intubation urgente.

Comparison of initial adenosine dose conversion rate for supraventricular tachycardia in the emergency department.
Krug N, Baize P, Barre S, Barnes R, Weigartz K. | Am J Emerg Med. 2024 Sep 3;85:117-122
DOI: https://doi.org/10.1016/j.ajem.2024.08.044  | Télécharger l'article au format  
Keywords: Adenosine; Emergency department; SVT; Sinus rhythm; Supraventricular tachycardia; Termination.

Article

Introduction : o evaluate the rate of supraventricular tachycardia (SVT) termination between 6 mg and 12 mg initial adenosine doses.

Méthode : This multi-center, retrospective cohort study evaluated patients presenting to the emergency department (ED) from January 1, 2020 to June 30, 2022 in SVT and received adenosine. The primary objective of the study is to compare the rate of SVT termination between adenosine 6 mg and 12 mg as documented on a formal electrocardiogram. Secondary endpoints include termination of SVT with subsequent adenosine dose, time to ED disposition, adverse effects, and subgroup analyses of patients with a body mass index greater than or equal to 40 kg/m2 and a history of SVT.

Résultats : Of 213 patients included, a 6 mg initial adenosine dose was administered to 117 patients (54.9 %) and a 12 mg initial adenosine dose was administered to 96 patients (45.1 %). SVT termination following the initial dose of 6 mg or 12 mg was 56.4 % and 79.1 %, respectively (p < 0.001). Among the 46 patients who failed to terminate SVT with an initial 6 mg dose, 33 converted to sinus rhythm with a subsequent adenosine dose in comparison to 1 of the 7 patients receiving an initial dose of 12 mg (71.7 % vs 14.3 %, p = 0.007). Median time to ED disposition, either inpatient admission or discharge, was 209 and 161 min, respectively (p = 0.104). There was no statistical difference in either subgroup analyses.

Conclusion : A higher rate of SVT termination was observed with an initial adenosine dose of 12 mg in the ED in comparison to the guideline recommended dose of 6 mg. There were no significant differences in adverse effects observed.

Conclusion (proposition de traduction) : Un taux plus élevé de réduction de tachycardie supraventriculaire a été obtenu avec une dose initiale d'adénosine de 12 mg dans le service d'urgence par rapport à la dose de 6 mg recommandée par les lignes directrices. Il n'y a pas eu de différences significatives dans les effets indésirables observés.

High risk and low incidence diseases: Lisfranc injury.
McDermott A, Repanshek Z, Koyfman A, Long B. | Am J Emerg Med. 2024 Sep 11;85:172-178
DOI: https://doi.org/10.1016/j.ajem.2024.09.019  | Télécharger l'article au format  
Keywords: Ankle; Dislocation; Foot; Fracture; Lisfranc injury; Neurovascular; Orthopedics; Tarsometatarsal joint complex.

Article

Introduction : Lisfranc injuries are uncommon but frequently misdiagnosed and carry a high rate of morbidity.

Méthode : This review highlights the pearls and pitfalls of Lisfranc injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion : Lisfranc injuries are caused by high- or low-energy trauma to the tarsometatarsal (TMT) joint complex. The severity of injury exists on a spectrum, ranging from minor subluxations to fractures and dislocations involving the TMT joint complex. They can be complicated by compartment syndrome, neurovascular compromise, and open fractures. Prompt diagnosis is critical in preventing chronic pain and mobility challenges, as even small subluxations can result in significant morbidity. Lisfranc injuries should be considered in all patients with a foot injury. Patients with Lisfranc injuries most commonly present with midfoot pain, swelling, or ecchymosis. Despite the importance of a timely diagnosis, Lisfranc injuries are commonly missed on plain radiographs due to their often subtle findings. When x-rays are negative but there is significant clinical suspicion, emergency clinicians should obtain advanced imaging such as computed tomography to aid in diagnosis. All Lisfranc injuries should be discussed with orthopedic surgery to determine definitive management. Patients who can be discharged should be made non-weightbearing and placed in a short-leg splint.

Conclusion : The consideration of Lisfranc injuries can help emergency clinicians make a timely diagnosis to prevent future complications.

Conclusion (proposition de traduction) : La prise en compte des lésions de Lisfranc peut aider les cliniciens d'urgence à poser un diagnostic rapide afin d'éviter des complications futures.

Commentaire : Les lésions de Lisfranc sont rares, mais un diagnostic manqué ou retardé peut entraîner des complications importantes, voire graves. La suspicion clinique et l'identification rapide sont cruciales pour établir le diagnostic. Les lésions du Lisfranc doivent être envisagées chez tous les patients souffrant d'une blessure au pied. L'anamnèse et l'examen fournissent des indices importants. Les patients présentent le plus souvent une douleur au milieu du pied, un œdème et une ecchymose. Lorsque les radiographies simples ne permettent pas de poser un diagnostic, il convient de recourir à la tomodensitométrie et/ou à l'imagerie par résonance magnétique (IRM). Tous les patients doivent être mis en décharge et faire l'objet d'une évaluation orthopédique. Un diagnostic et une prise en charge précoces peuvent prévenir les douleurs et les handicaps futurs.

High risk and low prevalence diseases: Cavernous sinus thrombosis.
Long B, Field SM, Singh M, Koyfman A. | Am J Emerg Med. 2024 Sep;83:47-53
DOI: https://doi.org/10.1016/j.ajem.2024.06.024  | Télécharger l'article au format  
Keywords: Aucun

Article

Introduction : Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality.

Méthode : This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion : CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation.

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

Conclusion (proposition de traduction) : Comprendre la thrombose du sinus caverneux thrombose du sinus caverneux peut aider les médecins urgentistes à diagnostiquer et à prendre en charge cette maladie potentiellement mortelle.

Contemporary management of patients with multiple rib fractures: What you need to know.
Sarani B, Pieracci F. | J Trauma Acute Care Surg. 2024 Sep 1;97(3):337-342. 2024 Sep 1;97(3):337-342
DOI: https://doi.org/10.1097/ta.0000000000004338  | Télécharger l'article au format  
Keywords: Rib fracture; rib plating; surgical stabilization of rib fractures.

WHAT YOU NEED TO KNOW SERIES – REVIEWS

Editorial : Ten percent of all injured patients and 55% of patients with blunt chest trauma experience rib fractures. The incidence of death due to rib fractures is related to the number of fractured ribs, severity of fractured ribs, and patient age and comorbid conditions. Death due to rib fracture is mostly caused by pneumonia because of inability to expectorate and take deep breaths. Over the last 25 to 30 years, there has been renewed interest in surgical stabilization of rib fractures (SSRF), known colloquially as "rib plating." This review will present what you need to know in regard to triage decisions on whether to admit a patient to the hospital, the location to which they should be admitted, criteria and evidentiary support for SSRF, timing to SSRF, and operative technique. The review also addresses the cost-effectiveness of this operation and stresses nonoperative treatment modalities that should be implemented prior to operation.

Conclusion : Surgical stabilization of rib fractures is associated with decreased need for mechanical ventilation, pneumonia, length of stay, and, possibly, mortality in patients with respiratory failure due to flail chest. Because of this, it is cost-effective in this cohort regardless of patient age or the presence of brain injury. The role of SSRF in patients without ventilator dependent flail chest injury and in patients without flail chest remains more controversial. There may be a role for SSRF in these cohorts if their pain cannot be managed medically, but further studies are needed to more accurately identify those who are most likely to benefit from operation.

Conclusion (proposition de traduction) : La stabilisation chirurgicale des fractures de côtes est associée à une diminution du besoin de ventilation mécanique, de pneumopathie, de la durée du séjour et, éventuellement, de la mortalité chez les patients souffrant d'insuffisance respiratoire due à un thorax déformé. Pour cette raison, elle est rentable dans cette cohorte, indépendamment de l'âge du patient ou de la présence d'une lésion cérébrale. Le rôle de la stabilisation chirurgicale des fractures de côtes chez les patients ne souffrant pas de lésions de la cage thoracique sous ventilation assistée et chez les patients ne souffrant pas de la cage thoracique reste plus controversé. La stabilisation chirurgicale des fractures de côtes peut avoir un rôle à jouer dans ces cohortes si leur douleur ne peut pas être gérée médicalement, mais d'autres études sont nécessaires pour identifier plus précisément ceux qui sont les plus susceptibles de bénéficier d'une opération.

Long-Term Oxygen Therapy for 24 or 15 Hours per Day in Severe Hypoxemia.
Ekström M, Andersson A, Papadopoulos S, Kipper T, Pedersen B, Kricka O, Sobrino P, Runold M, Palm A, Blomberg A, Hamed R, Lindberg E, Sundberg B, Hadziosmanovic N, Björklund F, Janson C, McDonald CF, Currow DC, Sundh J; REDOX Collaborative Research Group. | N Engl J Med. 2024 Sep 19;391(11):977-988
DOI: https://doi.org/10.1056/nejmoa2402638
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Long-term oxygen supplementation for at least 15 hours per day prolongs survival among patients with severe hypoxemia. On the basis of a nonrandomized comparison, long-term oxygen therapy has been recommended to be used for 24 hours per day, a more burdensome regimen.

Méthode : To test the hypothesis that long-term oxygen therapy used for 24 hours per day does not result in a lower risk of hospitalization or death at 1 year than therapy for 15 hours per day, we conducted a multicenter, registry-based, randomized, controlled trial involving patients who were starting oxygen therapy for chronic, severe hypoxemia at rest. The patients were randomly assigned to receive long-term oxygen therapy for 24 or 15 hours per day. The primary outcome, assessed in a time-to-event analysis, was a composite of hospitalization or death from any cause within 1 year. Secondary outcomes included the individual components of the primary outcome assessed at 3 and 12 months.

Résultats : Between May 18, 2018, and April 4, 2022, a total of 241 patients were randomly assigned to receive long-term oxygen therapy for 24 hours per day (117 patients) or 15 hours per day (124 patients). No patient was lost to follow-up. At 12 months, the median patient-reported daily duration of oxygen therapy was 24.0 hours (interquartile range, 21.0 to 24.0) in the 24-hour group and 15.0 hours (interquartile range, 15.0 to 16.0) in the 15-hour group. The risk of hospitalization or death within 1 year in the 24-hour group was not lower than that in the 15-hour group (mean rate, 124.7 and 124.5 events per 100 person-years, respectively; hazard ratio, 0.99; 95% confidence interval [CI], 0.72 to 1.36; 90% CI, 0.76 to 1.29; P = 0.007 for nonsuperiority). The groups did not differ substantially in the incidence of hospitalization for any cause, death from any cause, or adverse events.

Conclusion : Among patients with severe hypoxemia, long-term oxygen therapy used for 24 hours per day did not result in a lower risk of hospitalization or death within 1 year than therapy for 15 hours per day.

Conclusion (proposition de traduction) : Chez les patients souffrant d'hypoxémie sévère, l'oxygénothérapie à long terme utilisée 24 heures par jour n'a pas entraîné un risque plus faible d'hospitalisation ou de décès dans l'année qui suit que l'oxygénothérapie utilisée 15 heures par jour.