Clinical Policy: Critical Issues in the Evaluation of Adult Patients Presenting to the Emergency Department With Acute Blunt Trauma.
Gerardo CJ, American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Blunt Trauma; Gerardo CJ, Blanda M, Garg N, Shah KH, Byyny R, Wolf SJ, Diercks DB; Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee); Wolf SJ, Diercks DB, Anderson J, Byyny R, Carpenter CR, Finnell JT, Friedman BW, Gemme SR, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE. | Ann Emerg Med. 2024 Oct;84(4):e25-e55.
DOI: https://doi.org/10.1016/j.annemergmed.2024.05.027
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Keywords: Aucun
CLINICAL POLICY
Editorial : This clinical policy from the American College of Emergency Physicians is a revision of the 2018 Clinical Policy: Critical Issues in the Evaluation of Adult Patients Presenting to the Emergency Department with Acute Blunt Abdominal Trauma. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) In adult patients presenting to the emergency department (ED) with blunt trauma, does whole-body computed tomography improve clinically important outcomes in hemodynamically stable patients? 2) In geriatric patients presenting to the ED with blunt trauma, does age-based, differential trauma triage reduce morbidity and/or mortality? 3) In adult patients presenting to the ED with blunt trauma, what is the ideal blood product ratio to reduce morbidity and/or mortality in patients requiring transfusion? 4) In adult patients presenting to the ED with blunt trauma, does resuscitative endovascular balloon occlusion of the aorta reduce morbidity and/or mortality in arrested or peri-arrest patients compared with ED thoracotomy? Evidence was graded, and recommendations were made based on the strength of the available data.
Conclusion : This policy is not intended to be a complete manual on the evaluation and management of patients with penetrating trauma but rather a focused examination of critical questions that have particular relevance to the current practice of emergency medicine. The potential benefits and harms of implementing recommendations are briefly summarized within each critical question.
This clinical policy is not intended to represent a legal standard of care for emergency physicians. Recommendations offered in this policy are not intended to represent the only diagnostic or management options available to the emergency physician. ACEP recognizes the importance of the individual physician’s judgment and patient preferences. This guideline provides clinical strategies based on medical literature to inform the critical questions addressed in this policy. ACEP funds all staff support and methodologists; the writing committee is composed of unpaid volunteer members of ACEP who are required to disclose all conflicts in line with the organization’s policy statement.
Conclusion (proposition de traduction) : Cette directive ne se veut pas un manuel complet sur l'évaluation et la prise en charge des patients souffrant de traumatismes fermés, mais plutôt un examen ciblé des questions critiques qui ont une pertinence particulière pour la pratique actuelle de la médecine d'urgence. Les avantages et les inconvénients potentiels de la mise en œuvre des recommandations sont brièvement résumés dans chaque question critique.
Cette directive clinique n'a pas pour but de représenter une norme légale de soins pour les médecins urgentistes. Les recommandations proposées dans cette directive ne sont pas destinées à représenter les seules options de diagnostic ou de gestion disponibles pour le médecin urgentiste. L'ACEP reconnaît l'importance du jugement individuel du médecin et des préférences du patient. Cette ligne directrice fournit des stratégies cliniques basées sur la littérature médicale afin d'éclairer les questions critiques abordées dans cette directive. L'ACEP finance tout le soutien du personnel et les méthodologistes ; le comité de rédaction est composé de membres bénévoles non rémunérés de l'ACEP qui sont tenus de divulguer tous les conflits conformément à la déclaration de principe de l'organisation.
Association Between Neuromuscular Blocking Agents and Outcomes of Emergency Tracheal Intubation: A Secondary Analysis of Randomized Trials.
DeMasi SC, Self WH, Aggarawal NR, April MD, Andrea L, Barnes CR, Brainard J, Blinder V, Dagan A, Driver B, Doerschug KC, Douglas I, Exline M, Fein DG, Gaillard JP, Gandotra S, Gibbs KW, Ginde AA, Halliday SJ, Han JH, Herbert T, High K, Hughes CG, Khan A, Latimer AJ, Maiga AW, Mitchell SH, Muhs AL, Mohamed A, Moskowitz A, Page DB, Palakshappa JA, Prekker ME, Qian ET, Resnick-Ault D, Rice TW, Russel DW, Schauer SG, Seitz KP, Shapiro NI, Smith LM, Sottile P, . | Ann Emerg Med. 2024 Oct 8:S0196-0644(24)00962-4
DOI: https://doi.org/10.1016/j.annemergmed.2024.08.509
Keywords: Aucun
AIRWAY/BRIEF RESEARCH REPORT
Introduction : To examine the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt and severe complications during tracheal intubation of critically ill adults in an emergency department (ED) or ICU.
Méthode : We performed a secondary analysis of data from 2 multicenter randomized trials in critically ill adults undergoing tracheal intubation in an ED or ICU. Using a generalized linear mixed-effects model with prespecified baseline covariates, we examined the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt (primary outcome) and severe complications during tracheal intubation (secondary outcome).
Résultats : Among the 2,440 patients in the trial data sets, 2,339 (95.9%) were included in the current analysis; 475 patients (20.3%) received succinylcholine and 1,864 patients (79.7%) received rocuronium. Successful intubation on the first attempt occurred in 375 patients (78.9%) who received succinylcholine and 1,510 patients (81.0%) who received rocuronium (an adjusted odds ratio of 0.87; 95% CI 0.65 to 1.15). Severe complications occurred in 67 patients (14.1%) who received succinylcholine and 456 patients (24.5%) who received rocuronium (adjusted odds ratio, 0.88; 95% CI 0.62 to 1.26).
Conclusion : Among critically ill adults undergoing tracheal intubation, the incidences of successful intubation on the first attempt and severe complications were not significantly different between patients who received succinylcholine and patients who received rocuronium.
Conclusion (proposition de traduction) : Parmi les adultes en situation critique bénéficiant d'une intubation trachéale, les incidences d'intubation réussie à la première tentative et de complications sévères n'étaient pas significativement différentes entre les patients ayant reçu de la succinylcholine et les patients ayant reçu du rocuronium.
Commentaire : Les curares font partie d’une anesthésie dite balancée, qui consiste en un judicieux mélange de trois composantes : 1) la perte de conscience, habituellement produite par un hypnotique (intraveineux ou inhalé) ; 2) l’analgésie, ou absence de douleur, pour laquelle on administre généralement un morphinique ; 3) et l’immobilité, ou relâchement musculaire, qui provient de l’action des curares.
Les curares sont utilisés en urgence et aux soins intensifs pour l’intubation trachéale et pour faciliter la ventilation mécanique. L’injection de curare provoque un arrêt respiratoire, qui est insupportable pour des sujets éveillés. L’administration de curare doit donc être réalisée que chez des patients chez qui on a induit une sédation profonde et pour qui on prévoit une prise en charge des voies aériennes et une ventilation mécanique.
Le rocuronium est un relaxant musculaire ayant moins d'effets secondaires que la succinylcholine qui peut être responsable de graves réactions ou déséquilibres salins et qui peut être reversé facilement. Le rocuronium (1 à 1,2 mg/kg, curarisation prolongée de 45 à 60 min) est un curare intéressant sur le plan pharmacologique pour l’induction lors d’une procédure d’intubation en séquence rapide. Mais attention à sa durée d’action, plus longue que celle de la succinylcholine. L’urgentiste doit prendre des mesures renforcées d’entretien de l’analgésie-sédation au décours de l’ISR afin de prévenir la survenue d’une paralysie en pleine conscience. Son antidote est le sugammadex qui doit être administré à la dose de 16 mg/kg.
Pour mémoire : Le suxaméthonium (1 à 1,5 mg/kg, curarisation de 8 à 12 min) est le seul curare dépolarisant utilisé en clinique et ce, largement. Son action rapide (45 à 50 sec) en fait un agent curarisant de choix lors d’une induction à séquence rapide (estomac plein, RGO, obésité, femme enceinte >12 SA). Il est rapidement métabolisé par les pseudocholinestérases plasmatiques. Il est principalement contre-indiqué en cas d’hyperkaliémie (grand brûlé, paraplégie, IR terminale) ou d’hyperthermie maligne. En cas de contre-indication et si l’indication à séquence rapide est posée, l’alternative consiste à utiliser une double dose de rocuronium.
Références complémentaires choisies :
1. Rech MA, Gottlieb M. Sugammadex should be used to reverse rocuronium in emergency department patients with neurologic injuries.
Ann Emerg Med. 2024 Oct 15:S0196-0644(24)00224-5 .
2. Peschanski N. esanum | La communauté des médecins en ligne [En ligne]. Induction séquence rapide pour l’intubation aux urgences : succinylcholine versus rocuronium ; 14 déc 2022.
3. Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2015 Oct 29;2015(10):CD002788 .
4. Plaud PB, Donati F. Précis d'anesthésie et de réanimation - Abrégé de la cinquième édition [En ligne]. [lieu inconnu] : Les Presses de l’Université de Montréal ; 2012. Les curares. p. 110-9 .
A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting.
Muldowney M, Counts CR, Maider MC, Sharar SR, McCoy AM, Nathwani R, Wall JJ, Pache K, Maynard C, Rea TD, Kudenchuk PJ, Sayre MR. | Ann Emerg Med. 2024 Oct 21:S0196-0644(24)01069-2
DOI: https://doi.org/10.1016/j.annemergmed.2024.09.003
Keywords: Aucun
EMERGENCY MEDICAL SERVICES/ORIGINAL RESEARCH
Introduction : Acute behavioral disturbance is characterized by altered mental status and psychomotor agitation. Pharmacological sedation may be required, risking potential respiratory compromise. We compared the need for emergent airway support following administration of midazolam or ketamine to treat acute behavioral disturbance in the out-of-hospital setting.
Méthode : In this retrospective cohort study of patients with acute behavioral disturbance in an urban emergency medical service system between 2017 and 2021, we compared the likelihood of out-of-hospital advanced airway management following administration of midazolam or ketamine. Advanced airway management was defined as out-of-hospital endotracheal intubation or supraglottic airway insertion.
Résultats : Among 376 eligible patients, the median age was 35, and 78% were men. The most common etiologies of acute behavioral disturbance were substance use (51%), trauma (18%), and presumed postictal agitation (11%). In all, 162 patients (43%) initially received midazolam and 214 (57%) ketamine. The frequency of advanced airway management was similar between these respective groups (12% [n=19] versus 11% [n=24], difference 0.5%, 95% CI -6.0% to 7.0%). Adjusted for potential confounders, the odds of receiving advanced airway management did not differ between midazolam and ketamine (aOR 1.02, 95% CI 0.44 to 2.38), and no differences were observed in emergency department intubation rates (14% in midazolam recipients, 11% for ketamine) or overall mortality (2% in midazolam recipients, 1% for ketamine).
Conclusion : In this cohort study of patients with acute behavioral disturbance, emergent airway support and other outcomes did not differ following out-of-hospital treatment with midazolam or ketamine.
Conclusion (proposition de traduction) : Dans cette étude de cohorte de patients souffrant de troubles comportementaux aigus, l'assistance respiratoire d'urgence et les autres résultats n'ont pas différé après un traitement extrahospitalier au midazolam ou à la kétamine.
Commentaire : Il n'existe aucun avantage en termes de sécurité entre les doses standard protocolées de midazolam (2 à 5 mg IM) ou de kétamine (4 à 5 mg/kg IM, 1 à 2 mg/kg IV) pour la gestion comportementale dans les services médicaux d'urgence aigus. Il faut rappeler que l'utilisation de la contrainte non coercitive doit être une priorité. Une traçabilité rigoureuse de la procédure est nécessaire pour garantir la conformité à réglementation en vigueur.
Tranexamic Acid in Pediatric Traumatic Brain Injury: A Multicenter Retrospective Observational Study.
Utsumi S, Ohki S, Amagasa S, Ohshimo S, Shime N. | Ann Emerg Med. 2024 Oct 2:S0196-0644(24)00408-6. Ann Emerg Med. 2024 Oct 2:S0196-0644(24)00408-6
DOI: https://doi.org/10.1016/j.annemergmed.2024.07.014
Keywords: Aucun
PEDIATRICS/ORIGINAL RESEARCH
Introduction : Tranexamic acid (TXA) can be used after trauma to prevent bleeding. Our goal was to examine the influence of TXA on morbidity and mortality for children with severe traumatic brain injury (TBI).
Méthode : We identified children aged <18 years with a severe TBI (Glasgow Coma Scale score less than 8) presenting to 1 of the 291 hospitals contributing to the Japanese Trauma Data Bank between 2019 and 2023. The primary outcome was inhospital death, and the secondary outcome was poor neurologic outcome defined with Glasgow Outcome Scale (GOS) score of 1 to 3 at hospital discharge. Our primary exposure was any TXA administered in the hospital. Using propensity score-based inverse probability weighting, we used logistic regression to measure the association between TXA administration and death as well as poor neurologic outcome.
Résultats : Of the 342 included patients, 30 (14%) died, and 102/225 (45%) had a GOS score less than 4 at discharge. After inverse propensity weighting, TXA administration was not associated with either mortality (adjusted odds ratio [aOR] 1.25, 95% confidence interval [CI] 0.61 to 2.54) or poor neurologic outcome (aOR 0.86, 95% CI 0.47 to 1.56).
Conclusion : TXA administration was not associated with either death or poor neurologic outcome. Prospective clinical trials of TXA usage in children with severe TBI are needed.
Conclusion (proposition de traduction) : L'administration d'acide tranexamique n'a pas été associée à un décès ou à de mauvais résultats neurologiques. Des essais cliniques prospectifs sur l'utilisation de l'acide tranexamique chez les enfants présentant des lésions cérébrales traumatiques graves sont nécessaires.
Oxygen therapy and noninvasive respiratory supports in acute hypoxemic respiratory failure: a narrative review.
Thille AW, Balen F, Carteaux G, Chouihed T, Frat JP, Girault C, L'Her E, Marjanovic N, Nay MA, Ray P, Reffienna M, Retenauer L, Roch A, Thiery G, Truchot J. | Ann Intensive Care. 2024 Oct 18;14(1):158
DOI: https://doi.org/10.1186/s13613-024-01389-w
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Keywords: Aucun
REVIEW
Introduction : This narrative review was written by an expert panel to the members of the jury to help in the development of clinical practice guidelines on oxygen therapy.
Résultats : According to the expert panel, acute hypoxemic respiratory failure was defined as PaO2 < 60 mm Hg or SpO2 < 90% on room air, or PaO2/FiO2 ≤ 300 mm Hg. Supplemental oxygen should be administered according to the monitoring of SpO2, with the aim at maintaining SpO2 above 92% and below 98%. Noninvasive respiratory supports are generally reserved for the most hypoxemic patients with the aim of relieving dyspnea. High-flow nasal cannula oxygen (HFNC) seems superior to conventional oxygen therapy (COT) as a means of avoiding intubation and may therefore be should probably be used as a first-line noninvasive respiratory support in patients requiring more than 6 L/min of oxygen or PaO2/FiO2 ≤ 200 mm Hg and a respiratory rate above 25 breaths/minute or clinical signs of respiratory distress, but with no benefits on mortality. Continuous positive airway pressure (CPAP) cannot currently be recommended as a first-line noninvasive respiratory support, since its beneficial effects on intubation remain uncertain. Despite older studies favoring noninvasive ventilation (NIV) over COT, recent clinical trials fail to show beneficial effects with NIV compared to HFNC. Therefore, there is no evidence to support the use of NIV or CPAP as first-line treatment if HFNC is available. Clinical trials do not support the hypothesis that noninvasive respiratory supports may lead to late intubation. The potential benefits of awake prone positioning on the risk of intubation in patients with COVID-19 cannot be extrapolated to patients with another etiology.
Conclusion : Whereas oxygen supplementation should be initiated for patients with acute hypoxemic respiratory failure defined as PaO2 below 60 mm Hg or SpO2 < 90% on room air, HFNC should be the first-line noninvasive respiratory support in patients with PaO2/FiO2 ≤ 200 mm Hg with increased respiratory rate. Further studies are needed to assess the potential benefits of CPAP, NIV through a helmet and awake prone position in patients with acute hypoxemic respiratory failure not related to COVID-19.
Conclusion (proposition de traduction) : Alors que la supplémentation en oxygène doit être initiée chez les patients présentant une insuffisance respiratoire hypoxémique aiguë définie par une PaO2 inférieure à 60 mmHg ou une SpO2 < 90 % en air ambiant, l'oxygénothérapie nasales à haut débit doit être l'aide respiratoire non invasive de première intention chez les patients présentant une PaO2/FiO2 ≤ 200 mm Hg avec une augmentation de la fréquence respiratoire. D'autres études sont nécessaires pour évaluer les avantages potentiels de la CPAP, de la VNI avec « Helmet » (casque) et le décubitus ventral éveillée chez les patients présentant une insuffisance respiratoire hypoxémique aiguë non liée à la COVID-19.
Survival Without Neurological Sequelae Following Massive Pulmonary Embolism and Prolonged Cardiac Arrest.
Paciorkowski F, Nahban W, Jacques JM. | Cureus. 2024 Oct 19;16(10):e71898
DOI: https://doi.org/10.7759/cureus.71898
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Keywords: Aucun
Open Access Case Report
Editorial : We present the case of a 17-year-old female who survived cardiac arrest caused by a massive pulmonary embolism leading to obstructive shock. Despite a prolonged low-flow period of 193 minutes, she fully recovered without apparent neurological damage, thanks to immediate cardiopulmonary resuscitation (CPR) initiated by her father, timely intervention by paramedics and medical teams, and the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Key factors in her recovery included the absence of a no-flow period, maintenance of end-tidal CO2 (ETCO2 ) levels above 25-30 mmHg during resuscitation, and the vital role of VA-ECMO in supporting organ perfusion. This case highlights the importance of prompt bystander intervention, continuous ETCO2 monitoring during CPR, and the integration of advanced circulatory support measures in post-cardiac arrest care. Additionally, it underscores the potential for favorable neurological outcomes even after extended resuscitation, provided there is adequate cerebral perfusion and timely mechanical support. The report emphasizes the need for public education on basic life support (BLS).
Conclusion : This young woman survived a cardiac arrest caused by a massive pulmonary embolism with obstructive shock. Despite a prolonged low-flow period of 193 minutes, the absence of a no-flow period, maintenance of ETCO2 levels greater than 25-30 mmHg, and timely intervention with veno-arterial mechanical assistance contributed to her recovery without any apparent neurological damage
Conclusion (proposition de traduction) : Cette jeune femme a survécu à un arrêt cardiaque provoqué par une embolie pulmonaire massive avec choc obstructif. Malgré une période de bas débit prolongée de 193 minutes, l'absence de période de no-flow, le maintien de niveaux d'ETCO2 supérieurs à 25-30 mmHg et l'intervention rapide d'une assistance mécanique veino-artérielle ont contribué à son rétablissement sans aucune lésion neurologique apparente
Commentaire : Le monitorage de l'EtCO2 n'est possible que sur l'intubation. Ici il s'agissait d'une asystolie puis d'un rythme électrique sans pouls. La patiente a été intubé contrairement à la tendance actuelle de ne pas intuber les ACR au cours de la réanimation cardio-pulmonaire. Pour rappel, l'article :
Heradstveit BE, Heltne JK. PQRST - A unique aide-memoire for capnography interpretation during cardiac arrest. Resuscitation [Internet]. 2014;85(11):1619–20 .
On peut penser que l'intubation (avec aussi l'intervention immédiate d'une témoin pour débuter la RCP) peut améliorer la qualité de la RCP (pour s'assurer d'une EtCO2 supérieurs à 25 à 30 mmHg).
Enfin, les protocoles eCPR sont indiqués dans la fibrillation ventriculaire réfractaire, mais on parle ici, d'une asystolie puis d'un rythme électrique sans pouls…
Short-term Dual Therapy or Mono Therapy With Acetaminophen and Ibuprofen for Fever: A Network Meta-Analysis.
De la Cruz-Mena JE, Veroniki AA, Acosta-Reyes J, Estupiñán-Bohorquez A, Ibarra JA, Pana MC, Sierra JM, Florez ID. | Pediatrics. 2024 Oct 1;154(4):e2023065390
DOI: https://doi.org/10.1542/peds.2023-065390
Keywords: Aucun
REVIEW ARTICLE
Introduction : There is uncertainty whether acetaminophen and ibuprofen are similar in their effects and safety when used as single or dual (alternating or combined) therapies.
Méthode : To assess the comparative efficacy of acetaminophen, ibuprofen alone, alternating, or combined through a systematic review and network meta-analysis.
Data sources: Medline, Embase, and CENTRAL from inception to September 20, 2023.
Study selection: Randomized trials comparing acetaminophen, ibuprofen, both alternating, and both combined, for treating children with fever.
Data extraction: Two reviewers independently screened abstracts and full texts, extracted the data, and assessed the risk of bias. We performed pairwise and network meta-analysis using the random-effects model.
Résultats : We included 31 trials (5009 children). We found that combined (odds ratio [OR], 0.19; confidence interval [CI], 0.09-0.42) and alternating therapies (OR, 0.20; CI, 0.06-0.63) may be superior to acetaminophen, whereas ibuprofen at a high dose may be comparable (OR, 0.98; CI, 0.63-1.59) in terms of proportion of afebrile children at the fourth hour. These results were similar at the sixth hour. There were no differences between ibuprofen (low or high dose), or alternating, or combined with acetaminophen in terms of adverse events.
Limitations: We only evaluated the efficacy and safety during the first 6 hours.
Conclusion : Dual may be superior to single therapies for treating fever in children. Acetaminophen may be inferior to combined or alternating therapies to get children afebrile at 4 and 6 hours. Compared with ibuprofen, acetaminophen was also inferior to ibuprofen alone at 4 hours, but similar at 6 hours.
Conclusion (proposition de traduction) : La bithérapie peut être supérieure à la monothérapie pour traiter la fièvre chez l'enfant. Le paracétamol peut être inférieur aux traitements combinés ou alternés pour rendre les enfants apyrétiques au bout de 4 et 6 heures. Comparé à l'ibuprofène, le paracétamol était également inférieur à l'ibuprofène seul à 4 heures, mais similaire à 6 heures.
Increased rate of anoxic brain damage with laryngeal tube compared to endotracheal intubation in patients with shockable out-of-hospital cardiac arrest - Experience from the HAnnover COoling REgistry (HACORE).
Garcheva V, Sanchez Martinez C, Adel J, Pfeffer TJ, Akin M, Bauersachs J, Schäfer A. | Resuscitation. 2024 Oct 20:110416
DOI: https://doi.org/10.1016/j.resuscitation.2024.110416
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Keywords: Anoxic brain damage; Cardiac arrest; Cardiopulmonary resuscitation; Neurological outcome; Supraglottic airway device.
Resuscitation European Resuscitation Council Submit Log in R
Introduction : Supraglottic airway devices such as the laryngeal tube (LT) are recommended in current guidelines for simplified airway management in patients during and immediately after out-of-hospital cardiac arrest (OHCA). Trials evaluating LTs included predominantly OHCA patients with non-shockable rhythms and low survival rates. Hence, LTs are widely used, but their impact on preventing hypoxic brain damage during resuscitation has not been evaluated yet.
Méthode : We analysed 452 OHCA-patients with shockable-rhythms from the HAnnover COoling REgistry (HACORE) who had return of spontaneous circulation prior to transport. Of those, 405 patients received primary airway management by endotracheal intubation (ETI) and 47 by LT. Patients were afterwards treated according to the Hannover Cardiac Resuscitation Algorithm (HaCRA) applying a strict post-resuscitation management including therapeutic hypothermia and avoiding routine prognostication.
Résultats : While mortality in this group was moderate with both airway strategies (ETI 29 % vs LT 34 %, p = 0.487), the rate of anoxic brain damage was much higher in the LT compared to the ETI group (38 % vs 21 %, p = 0.011). Survivors in the ETI group were more likely to have good neurological outcome (cerebral performance category 1&2) compared to the LT group (35 % vs 17 %, p = 0.013). Pneumonia was more common in the LT vs ETI group (81 % vs 53 %, p < 0.001).
Conclusion : While the original prehospital pragmatic trials comparing LT to ETI mostly included patients with non-shockable rhythm in settings with high mortality, our analysis is based on a real-world registry and focuses on successfully resuscitated patients, whose cause of arrest was most probably not due to hypoxia. In this cohort, use of LT was associated with a higher rate of anoxic brain damage and worse functional neurological outcome compared to use of ETI.
Conclusion (proposition de traduction) : Alors que les essais pragmatiques préhospitaliers originaux comparant le tube laryngé à l'intubation endotrachéale incluaient principalement des patients ayant un rythme non choquable dans des contextes de mortalité élevée, notre analyse est basée sur un registre du monde réel et se concentre sur des patients réanimés avec succès, dont la cause de l'arrêt n'était très probablement pas due à l'hypoxie. Dans cette cohorte, l'utilisation d'un tube laryngé était associée à un taux plus élevé de lésions cérébrales anoxiques et à un résultat neurologique fonctionnel plus mauvais que l'intubation endotrachéale.
Commentaire : L’intubation orotrachéale reste donc la technique de référence dans l’arrêt cardiaque quand une gestion avancée des voies aériennes supérieures est indiquée.
The accuracy of Gemini, GPT-4, and GPT-4o in ECG analysis: A comparison with cardiologists and emergency medicine specialists.
Günay S, Öztürk A, Yiğit Y. | Am J Emerg Med. 2024 Oct;84:68-73
DOI: https://doi.org/10.1016/j.ajem.2024.07.043
Keywords: Artificial intelligence; ChatGPT; Electrocardiography; GPT-4; GPT-4o; Gemini.
Article
Introduction : GPT-4, GPT-4o and Gemini advanced, which are among the well-known large language models (LLMs), have the capability to recognize and interpret visual data. When the literature is examined, there are a very limited number of studies examining the ECG performance of GPT-4. However, there is no study in the literature examining the success of Gemini and GPT-4o in ECG evaluation. The aim of our study is to evaluate the performance of GPT-4, GPT-4o, and Gemini in ECG evaluation, assess their usability in the medical field, and compare their accuracy rates in ECG interpretation with those of cardiologists and emergency medicine specialists.
Méthode : The study was conducted from May 14, 2024, to June 3, 2024. The book "150 ECG Cases" served as a reference, containing two sections: daily routine ECGs and more challenging ECGs. For this study, two emergency medicine specialists selected 20 ECG cases from each section, totaling 40 cases. In the next stage, the questions were evaluated by emergency medicine specialists and cardiologists. In the subsequent phase, a diagnostic question was entered daily into GPT-4, GPT-4o, and Gemini Advanced on separate chat interfaces. In the final phase, the responses provided by cardiologists, emergency medicine specialists, GPT-4, GPT-4o, and Gemini Advanced were statistically evaluated across three categories: routine daily ECGs, more challenging ECGs, and the total number of ECGs.
Résultats : Cardiologists outperformed GPT-4, GPT-4o, and Gemini Advanced in all three groups. Emergency medicine specialists performed better than GPT-4o in routine daily ECG questions and total ECG questions (p = 0.003 and p = 0.042, respectively). When comparing GPT-4o with Gemini Advanced and GPT-4, GPT-4o performed better in total ECG questions (p = 0.027 and p < 0.001, respectively). In routine daily ECG questions, GPT-4o also outperformed Gemini Advanced (p = 0.004). Weak agreement was observed in the responses given by GPT-4 (p < 0.001, Fleiss Kappa = 0.265) and Gemini Advanced (p < 0.001, Fleiss Kappa = 0.347), while moderate agreement was observed in the responses given by GPT-4o (p < 0.001, Fleiss Kappa = 0.514).
Conclusion : While GPT-4o shows promise, especially in more challenging ECG questions, and may have potential as an assistant for ECG evaluation, its performance in routine and overall assessments still lags behind human specialists. The limited accuracy and consistency of GPT-4 and Gemini suggest that their current use in clinical ECG interpretation is risky.
Conclusion (proposition de traduction) : Bien que le GPT-4o soit prometteur, en particulier sur les questions d'ECG les plus difficiles, et qu'il puisse avoir un potentiel en tant qu'assistant pour l'évaluation de l'ECG, ses performances dans les évaluations de routine et les évaluations globales restent inférieures à celles des spécialistes humains. La précision et la cohérence limitées du GPT-4 et du Gemini suggèrent que leur utilisation actuelle dans l'interprétation clinique de l'ECG est risquée.
Ketamine for acute pain after trauma: A pragmatic, randomized clinical trial.
Klugh JM, Puzio TJ, Wandling MW, Guy-Frank CJ, Green C, Sergot PB, Prater SJ, Balogh J, Stephens CT, Wade CE, Kao LS, Harvin JA. | J Trauma Acute Care Surg. 2024 Oct 1;97(4):514-519
DOI: https://doi.org/10.1097/ta.0000000000004325
Keywords: Aucun
AAST PODIUM 2023
Introduction : Non-narcotic intravenous medications may be a beneficial adjunct to oral multimodal pain regimens (MMPRs) which reduce but do not eliminate opioid exposure and prescribing after trauma. We hypothesized that the addition of a subdissociative ketamine infusion (KI) to a standardized oral MMPR reduces inpatient opioid exposure.
Méthode : Eligible adult trauma patients admitted to the intermediate or intensive care unit were randomized upon admission to our institutional MMPR per usual care (UC) or UC plus subdissociative KI for 24 hours to 72 hours after arrival. The primary outcome was morphine milligram equivalents per day (MME/d) and secondary outcomes included total MME, discharge with an opioid prescription (OP%), and rates of ketamine side effects. Bayesian posterior probabilities (pp) were calculated using neutral priors.
Résultats : A total of 300 patients were included in the final analysis with 144 randomized to KI and 156 to UC. Baseline characteristics were similar between groups. The Injury Severity Scores for KI were 19 [14, 29] versus UC 22 [14, 29]. The KI group had a lower rate of long-bone fracture (37% vs. 49%) and laparotomy (16% vs. 24%). Patients receiving KI had an absolute reduction of 7 MME/day, 96 total MME, and 5% in OP%. In addition, KI had a relative risk (RR) reduction of 19% in MME/day (RR, 0.81 [0.69-0.95], pp = 99%), 20% in total MME (RR, 0.80 [0.64-0.99], pp = 98%), and 8% in OP% (RR, 0.92 [0.76-1.11], pp = 81%). The KI group had a higher rate of delirium (11% vs. 6%); however, rates of other side effects such as arrythmias and unplanned intubations were similar between groups.
Conclusion : Addition of a subdissociative ketamine infusion to an oral MMPR resulted in a decrease in opioid exposure in severely injured patients. Subdissociative ketamine infusions can be used as a safe adjunct to decrease opioid exposure in monitored settings.
Conclusion (proposition de traduction) : L'ajout d'une perfusion de kétamine subdissociative à un traitement multimodal oral de la douleur a entraîné une diminution de la consommation d'opioïdes chez les patients gravement blessés. Les perfusions de kétamine sous-dissociative peuvent être utilisées comme un complément sûr pour réduire la consommation d'opioïdes dans des environnements monitorés.
Four-factor prothrombin complex concentrate is not inferior to andexanet alfa for the reversal or oral factor Xa inhibitors: An Eastern Association for the Surgery of Trauma multicenter study.
Estroff JM, Devlin J, Hoteit L, Hassoune A, Neal MD, Brown JB, Lu L, Kotch S, Hazelton JP, Christian AB, Yeates EO, Nahmias J, Jacobson LE, Williams J, Schuster KM, O'Connor R, Semon GR, Straughn AD, Cullinane D, Egodage T, Kincaid M, Rollins A, Amdur R, Sarani B. | J Trauma Acute Care Surg. 2024 Oct 1;97(4):541-545
DOI: https://doi.org/10.1097/ta.0000000000004345
Keywords: Aucun
EAST PODIUM 2022 Four-factor
Introduction : Andexanet alfa (AA) is the only FDA-approved reversal agent for apixaban and rivaroxaban (DOAC). There are no studies comparing its efficacy with four-factor prothrombin complex concentrate (PCC). This study aimed to compare PCC to AA for DOAC reversal, hypothesizing noninferiority of PCC.
Méthode : We performed a retrospective, noninferiority multicenter study of adult patients admitted from July 1, 2018, to December 31, 2019, who had taken a DOAC within 12 hours of injury, were transfused red blood cells (RBCs) or had traumatic brain injury, and received AA or PCC. Primary outcome was PRBC unit transfusion. Secondary outcome with intensive care unit length of stay. MICE imputation was used to account for missing data and zero-inflated Poisson regression was used to account for an excess of zero units of RBC transfused. Two units difference in RBC transfusion was selected as noninferior.
Résultats : From 263 patients at 10 centers, 77 (29%) received PCC and 186 (71%) AA. Patients had similar transfusion rates across reversal treatment groups (23.7% AA vs. 19.5% PCC) with median transfusion in both groups of 0 RBC. According to the Poisson component, PCC increases the amount of RBC transfusion by 1.02 times (95% confidence interval, 0.79-1.33) compared with AA after adjusting for other covariates. The average amount of RBC transfusion (nonzero group) is 6.13. Multiplying this number by the estimated rate ratio, PCC is estimated to have an increase RBC transfusion by 0.123 (95% confidence interval, 0.53-2.02) units compared with AA.
Conclusion : PCC appears noninferior to AA for reversal of DOACs for RBC transfusion in traumatically injured patients. Additional prospective, randomized trials are necessary to compare PCC and AA for the treatment of hemorrhage in injured patients on DOACs.
Conclusion (proposition de traduction) : Le concentré de complexe prothrombique semble non inférieur à l'Andexanet alfa pour la réversion des anticoagulants oraux directs (apixaban et rivaroxaban) pour la transfusion de globules rouges chez les patients ayant eu un traumatisme. D'autres études prospectives et randomisées sont nécessaires pour comparer le concentré de complexe prothrombique et l'Andexanet alfa pour le traitement des hémorragies chez les patients blessés sous anticoagulants oraux directs.
Whole blood: Total blood product ratio impacts survival in injured children.
Feeney EV, Morgan KM, Spinella PC, Gaines BA, Leeper CM. | J Trauma Acute Care Surg. 2024 Oct 1;97(4):546-551
DOI: https://doi.org/10.1097/ta.0000000000004362
Keywords: Aucun
EAST PODIUM 2024
Introduction : Some studies in both children and adults have shown a mortality benefit for the use of low titer group O whole blood (LTOWB) compared with component therapy for traumatic resuscitation. Although LTOWB is not widely available at pediatric trauma centers, its use is increasing. We hypothesized that in children who received whole blood after injury, the proportion of whole blood in relation to the total blood product resuscitation volume would impact survival.
Méthode : The trauma database from a single academic pediatric Level I trauma center was queried for pediatric (age <18 years) recipients of LTOWB after injury (years 2015-2022). Weight-based blood product (LTOWB, red blood cells, plasma, and platelet) transfusion volumes during the first 24 hours of admission were recorded. The ratio of LTOWB to total transfusion volume was calculated. The primary outcome was in-hospital mortality. Multivariable logistic regression model adjusted for the following variables: age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score. Adjusted odds ratio representing the change in the odds of mortality by a 10% increase in the LTOWB/total transfusion volume ratio was reported.
Résultats : There were 95 pediatric LTOWB recipients included in the analysis, with median (interquartile range [IQR]) age of 10 years (5-14 years), 58% male, median (IQR) Injury Severity Score of 26 (17-35), 25% penetrating mechanism. The median (IQR) volume of LTOWB transfused was 17 mL/kg (15-35 mL/kg). Low titer group O whole blood comprised a median (IQR) of 59% (33-100%) of the total blood product resuscitation. Among patients who received LTOWB, there was a 38% decrease in in-hospital mortality for each 10% increase in the proportion of WB within total transfusion volume ( p < 0.001) after adjusting for age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score.
Conclusion : Increased proportions of LTOWB within the total blood product resuscitation was independently associated with survival in injured children. Based on existing data that suggests safety and improved outcomes with whole blood, consideration may be given to increasing the use of LTOWB over CT resuscitation in pediatric trauma resuscitation.
Conclusion (proposition de traduction) : L'augmentation de la proportion de sang total de groupe O à faible titre dans la réanimation par produit sanguin total a été associée de manière indépendante à la survie des enfants blessés. Sur la base des données existantes qui suggèrent la sécurité et l'amélioration des résultats avec le sang total, on peut envisager d'augmenter l'utilisation du sang total de groupe O à faible titre par rapport à la réanimation par tomodensitométrie dans la réanimation des traumatismes pédiatriques.
The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: A subgroup analysis from the prehospital TXA for TBI trial.
Rowell S, Meier EN, Hoyos Gomez T, Fleming M, Jui J, Morrison L, Bulger E, Sopko G, Weisfeldt M, Christenson J, Klotz P, McMullan J, Callum J, Sheehan K, Tibbs B, Aufderheide T, Cotton B, Gandhi R, Idris A, Frascone RJ, Ferrara M, Richmond N, Kannas D, Schlamp R, Robinson B, Dries D, Tallon J, Hendrickson A, Gamber M, Garrett J, Simonson R, McKinley WI, Schreiber M. | J Trauma Acute Care Surg. 2024 Oct 1;97(4):572-580
DOI: https://doi.org/10.1097/ta.0000000000004354
Keywords: Aucun
INDEPENDENT SUBMISSIONS
Introduction : In the prehospital tranexamic acid (TXA) for traumatic brain injury (TBI) trial, TXA administered within 2 hours of injury in the out-of-hospital setting did not reduce mortality in all patients with moderate/severe traumatic brain injury (TBI). We examined the association between TXA dosing arms, neurologic outcome, and mortality in patients with intracranial hemorrhage (ICH) on computed tomography (CT).
Méthode : This was a secondary analysis of the Prehospital Tranexamic Acid for TBI Trial that randomized adults with moderate/severe TBI (Glasgow Coma Scale score < 13) and systolic blood pressure ≥ 90 mm Hg within 2 hours of injury to a 2-g out-of-hospital TXA bolus followed by an in-hospital saline infusion, a 1-g out-of-hospital TXA bolus/1-g in-hospital TXA infusion, or an out-of-hospital saline bolus/in-hospital saline infusion (placebo). This analysis included the subgroup with ICH on initial CT. Primary outcomes included 28-day mortality, 6-month Glasgow Outcome Scale-Extended (GOSE) ≤ 4, and 6-month Disability Rating Scale (DRS). Outcomes were modeled using linear regression with robust standard errors.
Résultats : The primary trial included 966 patients. Among 541 participants with ICH, 28-day mortality was lower in the 2-g TXA bolus group (17%) compared with the other two groups (1-g bolus/1-g infusion 26%, placebo 27%). The estimated adjusted difference between the 2-g bolus and placebo groups was -8·5 percentage points (95% confidence interval [CI], -15.9 to -1.0) and between the 2-g bolus and 1-g bolus/1-g infusion groups was -10.2 percentage points (95% CI, -17.6 to -2.9). Disability Rating Scale at 6 months was lower in the 2-g TXA bolus group than the 1-g bolus/1-g infusion (estimated difference - 2.1 [95% CI, -4.2 to -0.02]) and placebo groups (-2.2 [95% CI, -4.3, -0.2]). Six-month GOSE did not differ among groups.
Conclusion : A 2-g out-of-hospital TXA bolus in patients with moderate/severe TBI and ICH resulted in lower 28-day mortality and lower 6-month DRS than placebo and standard TXA dosing.
Conclusion (proposition de traduction) : Un bolus d'acide tranexamique de 2 g administré en dehors de l'hôpital à des patients souffrant d'une lésion cérébrale traumatique modérée/sévère et d'une hémorragie intracrânienne a permis de réduire la mortalité à 28 jours et l'échelle d'évaluation du handicap à 6 mois par rapport au placebo et à la posologie standard d'acide tranexamique.
Association of timing and agent for venous thromboembolism prophylaxis in patients with severe traumatic brain injury on venous thromboembolism events, mortality, neurosurgical intervention, and discharge disposition.
Johnson PL, Dualeh SHA, Ward AL, Jean RA, Aubry ST, Chapman AJ, Curtiss WJ, Joseph JR, Scott JW, Hemmila MR. | J Trauma Acute Care Surg. 2024 Oct 1;97(4):590-603
DOI: https://doi.org/10.1097/ta.0000000000004383
Keywords: Aucun
INDEPENDENT SUBMISSIONS
Introduction : Trauma patients are at increased risk for venous thromboembolism events (VTEs). The decision of when to initiate VTE chemoprophylaxis (VTEP) and with what agent remains controversial in patients with severe traumatic brain injury (TBI).
Méthode : This comparative effectiveness study evaluated the impact of timing and agent for VTEP on outcomes for patients with severe TBI (Abbreviated Injury Scale head score of 3, 4, or 5). Data were collected at 35 Level 1 and 2 trauma centers from January 1, 2017, to June 1, 2022. Patients were placed into analysis cohorts: no VTEP, low-molecular-weight heparin (LMWH) ≤48 hours, LMWH >48 hours, heparin ≤48 hours, and heparin >48 hours. Propensity score matching accounting for patient factors and injury characteristics was used with logistic regression modeling to evaluate in-hospital mortality, VTEs, and discharge disposition. Neurosurgical intervention after initiation of VTEP was used to evaluate extension of intracranial hemorrhage.
Résultats : Of 12,879 patients, 32% had no VTEP, 36% had LMWH, and 32% had heparin. Overall mortality was 8.3% and lowest among patients receiving LMWH ≤48 hours (4.1%). Venous thromboembolism event rates were lower with use of LMWH (1.6% vs. 4.5%; odds ratio, 2.98; 95% confidence interval, 1.40-6.34; p = 0.005) without increasing mortality or neurosurgical interventions. Venous thromboembolism event rates were lower with early prophylaxis (2.0% vs. 3.5%; odds ratio, 1.76; 95% confidence interval, 1.15-2.71; p = 0.01) without increasing mortality ( p = 1.0). Early VTEP was associated with more nonfatal intracranial operations ( p < 0.001). However, patients undergoing neurosurgical intervention after VTEP initiation had no difference in rates of mortality, withdrawal of care, or unfavorable discharge disposition ( p = 0.7, p = 0.1, p = 0.5).
Conclusion : In patients with severe TBI, LMWH usage was associated with lower VTE incidence without increasing mortality or neurosurgical interventions. Initiation of VTEP ≤48 hours decreased VTE incidence and increased nonfatal neurosurgical interventions without affecting mortality. Low-molecular-weight heparin is the preferred VTEP agent for severe TBI, and initiation ≤48 hours should be considered in relation to these risks and benefits.
Conclusion (proposition de traduction) : Chez les patients présentant une lésion cérébrale traumatique grave, l'utilisation d'héparine de faible poids moléculaire a été associée à une incidence plus faible d'événements thromboemboliques veineux sans augmenter la mortalité ou les interventions neurochirurgicales. L'instauration d'une chimioprophylaxie thromboembolique veineuse ≤48 heures a diminué l'incidence des événements thromboemboliques veineux et augmenté le nombre d'interventions neurochirurgicales non fatales sans affecter la mortalité. L'héparine de bas poids moléculaire est l'agent de chimioprophylaxie préféré en cas d'accident thromboembolique veineux pour les traumatismes crâniens graves, et l'initiation ≤48 heures doit être envisagée en fonction de ces risques et avantages.
Small versus large-bore thoracostomy for traumatic hemothorax: A systematic review and meta-analysis.
Lyons NB, Abdelhamid MO, Collie BL, Ramsey WA, O'Neil CF, Delamater JM, Cobler-Lichter MD, Shagabayeva L, Proctor KG, Namias N, Meizoso JP. | J Trauma Acute Care Surg. 2024 Oct 1;97(4):631-638
DOI: https://doi.org/10.1097/ta.0000000000004412
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Keywords: Aucun
INDEPENDENT SUBMISSIONS
Introduction : Traumatic hemothorax (HTX) is common, and while it is recommended to drain it with a tube thoracostomy, there is no consensus on the optimal catheter size. We performed a systematic review to test the hypothesis that small bore tube thoracostomy (SBTT) (≤14 F) is as effective as large-bore tube thoracostomy (LBTT) (≥20F) for the treatment of HTX.
Méthode : Pubmed, EMBASE, Scopus, and Cochrane review were searched from inception to November 2022 for randomized controlled trials or cohort studies that included adult trauma patients with HTX who received a tube thoracostomy. Data was extracted and Critical Appraisal Skills Program checklists were used for study appraisal. The primary outcome was failure rate, defined as incompletely drained or retained HTX requiring a second intervention. Cumulative analysis was performed with χ 2 test for dichotomous variables and an unpaired t-test for continuous variables. Meta-analysis was performed using a random effects model.
Résultats : There were 2,008 articles screened, of which nine were included in the analysis. The studies included 1,847 patients (714 SBTT and 1,233 LBTT). The mean age of patients was 46 years, 75% were male, average ISS was 20, and 81% had blunt trauma. Failure rate was not significantly different between SBTT (17.8%) and LBTT (21.5%) ( p = 0.166). Additionally, there were no significant differences between SBTT vs. LBTT in mortality (2.9% vs. 6.1%, p = 0.062) or complication rate (12.3% vs. 12.5%, p = 0.941), however SBTT had significantly higher initial drainage volumes (753 vs. 398 mL, p < 0.001) and fewer tube days (4.3 vs. 6.2, p < 0.001). There are several limitations. Some studies did not report all the outcomes of interest, and many of the studies are subject to selection bias.
Conclusion : SBTT may be as effective as LBTT for the treatment of HTX.
Conclusion (proposition de traduction) : La thoracostomie par tube de petit calibre peut être aussi efficace que la thoracostomie par tube de gros calibre dans le traitement de l'hémothorax traumatique.
The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: A subgroup analysis from the prehospital TXA for TBI trial.
Rowell S, Meier EN, Hoyos Gomez T, Fleming M, Jui J, Morrison L, Bulger E, Sopko G, Weisfeldt M, Christenson J, Klotz P, McMullan J, Callum J, Sheehan K, Tibbs B, Aufderheide T, Cotton B, Gandhi R, Idris A, Frascone RJ, Ferrara M, Richmond N, Kannas D, Schlamp R, Robinson B, Dries D, Tallon J, Hendrickson A, Gamber M, Garrett J, Simonson R, McKinley WI, Schreiber M. | J Trauma Acute Care Surg. 2024 Oct 1;97(4):572-580
DOI: https://doi.org/10.1097/ta.0000000000004354
Keywords: Aucun
INDEPENDENT SUBMISSIONS
Introduction : In the prehospital tranexamic acid (TXA) for traumatic brain injury (TBI) trial, TXA administered within 2 hours of injury in the out-of-hospital setting did not reduce mortality in all patients with moderate/severe traumatic brain injury (TBI). We examined the association between TXA dosing arms, neurologic outcome, and mortality in patients with intracranial hemorrhage (ICH) on computed tomography (CT).
Méthode : This was a secondary analysis of the Prehospital Tranexamic Acid for TBI Trial ( ClinicalTrials.gov [NCT01990768]) that randomized adults with moderate/severe TBI (Glasgow Coma Scale score < 13) and systolic blood pressure ≥ 90 mm Hg within 2 hours of injury to a 2-g out-of-hospital TXA bolus followed by an in-hospital saline infusion, a 1-g out-of-hospital TXA bolus/1-g in-hospital TXA infusion, or an out-of-hospital saline bolus/in-hospital saline infusion (placebo). This analysis included the subgroup with ICH on initial CT. Primary outcomes included 28-day mortality, 6-month Glasgow Outcome Scale-Extended (GOSE) ≤ 4, and 6-month Disability Rating Scale (DRS). Outcomes were modeled using linear regression with robust standard errors.
Résultats : The primary trial included 966 patients. Among 541 participants with ICH, 28-day mortality was lower in the 2-g TXA bolus group (17%) compared with the other two groups (1-g bolus/1-g infusion 26%, placebo 27%). The estimated adjusted difference between the 2-g bolus and placebo groups was -8·5 percentage points (95% confidence interval [CI], -15.9 to -1.0) and between the 2-g bolus and 1-g bolus/1-g infusion groups was -10.2 percentage points (95% CI, -17.6 to -2.9). Disability Rating Scale at 6 months was lower in the 2-g TXA bolus group than the 1-g bolus/1-g infusion (estimated difference - 2.1 [95% CI, -4.2 to -0.02]) and placebo groups (-2.2 [95% CI, -4.3, -0.2]). Six-month GOSE did not differ among groups.
Conclusion : A 2-g out-of-hospital TXA bolus in patients with moderate/severe TBI and ICH resulted in lower 28-day mortality and lower 6-month DRS than placebo and standard TXA dosing.
Conclusion (proposition de traduction) : Un bolus de 2 g d'acide tranexamique administré en dehors de l'hôpital à des patients souffrant d'un traumatisme cérébral modéré/sévère et d'une hémorragie intracrânienne a permis de réduire la mortalité à 28 jours et l'échelle d'évaluation du handicap à 6 mois par rapport au placebo et à la posologie standard d'acide tranexamique.