Emergency medicine updates: Evaluation and diagnosis of sepsis and septic shock.
Long B, Gottlieb M. | Am J Emerg Med.  2025 Apr;90:169-178
DOI: https://doi.org/10.1016/j.ajem.2025.01.055
Keywords: Abscess; CRP; Cellulitis; Computed tomography; Lactate; Necrotizing infection; POCUS; Pneumonia; Procalcitonin; SIRS; SOFA; Sepsis; Septic shock; Ultrasound; Urinary tract infection; qSOFA.

Article

Introduction : Sepsis and septic shock are common conditions evaluated and managed in the emergency department (ED), and these conditions are associated with significant morbidity and mortality. There have been several recent updates in the literature, including guidelines, on the evaluation and diagnosis of sepsis and septic shock.

Méthode : This is the first paper in a two-part series that provides emergency clinicians with evidence-based updates concerning sepsis and septic shock. This first paper focuses on evaluation and diagnosis of sepsis and septic shock.

Résultats : The evaluation, diagnosis, and management of sepsis have evolved since the first definition in 1991. Current guidelines emphasize rapid diagnosis to improve patient outcomes. However, scoring systems have conflicting data for diagnosis, and sepsis should be considered in any patient with infection and abnormal vital signs, evidence of systemic inflammation (e.g., elevated white blood cell count or C-reactive protein), or evidence of end-organ dysfunction. The clinician should consider septic shock in any patient with infection and hypotension despite volume resuscitation or who require vasopressors to maintain a mean arterial pressure ≥ 65 mmHg. There are a variety of sources of sepsis but the most common include pulmonary, urinary tract, abdomen, and skin/soft tissue. Examples of other less common etiologies include the central nervous system (e.g., meningitis, encephalitis), spine (e.g., spinal epidural abscess, osteomyelitis), cardiac (e.g., endocarditis), and joints (e.g., septic arthritis). Evaluation may include biomarkers such as procalcitonin, C-reactive protein, and lactate, but these should not be used in isolation to exclude sepsis. Imaging is a key component of evaluation and should be based on the suspected source.

Conclusion : There have been several recent updates in the literature including guidelines concerning sepsis and septic shock; an understanding of these updates can assist emergency clinicians and improve the care of these patients.

Conclusion (proposition de traduction) : Il y a eu plusieurs mises à jour récentes dans la littérature, y compris des lignes directrices concernant le sepsis et le choc septique ; une compréhension de ces mises à jour peut aider les urgentistes et améliorer les soins à leurs patients.

ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review.
Ricci F, Martini C, Scordo DM, Rossi D, Gallina S, Fedorowski A, Sciarra L, Chahal CAA, Meyers HP, Herman R, Smith SW. | Ann Emerg Med.  2025 Apr;85(4):330-340
DOI: https://doi.org/10.1016/j.annemergmed.2024.11.019  | Télécharger l'article au format  
Keywords: Acute Coronary Syndrome; Acute Myocardial Infarction; NSTEMI; OMI; STEMI.

CARDIOLOGY/REVIEW ARTICLE

Editorial : The traditional management of acute coronary syndrome has relied on the identification of ST-segment elevation myocardial infarction (STEMI) as a proxy of acute coronary occlusion. This conflation of STEMI with acute coronary occlusion has historically overshadowed non-ST-segment elevation myocardial infarction (NSTEMI), despite evidence suggesting 25% to 34% of NSTEMI cases may also include acute coronary occlusion. Current limitations in the STEMI/NSTEMI binary framework underscore the need for a revised approach to chest pain and acute coronary syndrome management. The emerging paradigm distinguishing occlusion myocardial infarction from nonocclusion myocardial infarction (NOMI) seeks to enhance diagnostic accuracy and prognostic effect in acute coronary syndrome care. This approach not only emphasizes the urgency of reperfusion therapy for high-risk ECG patterns not covered by current STEMI criteria, but also emphasizes the broader transition from viewing acute coronary syndrome as a disease defined by the ECG to a disease defined by its underlying pathology, for which the ECG is an important but insufficient surrogate test. This report outlines the emerging occlusion myocardial infarction paradigm, detailing specific ECG patterns linked to acute coronary occlusion, and proposes a new framework that could enhance triage accuracy and treatment strategies for acute coronary syndrome. Although further validation is required, the occlusion myocardial infarction pathway holds promise for earlier acute coronary occlusion detection, timely cath lab activation, and improved myocardial salvage-offering potentially significant implications for both clinical practice and future research in acute coronary syndrome management.

Conclusion : Implementing the occlusion myocardial infarction pathway requires tackling these diagnostic challenges, fostering accurate recognition of occlusion myocardial infarction pattern mimics, and establishing a clear roadmap for interdisciplinary collaboration focused on timely reperfusion goals. The natural history of occlusion myocardial infarctions is not as well documented as that of STEMI, where extensive data on the evolutionary pattern of ECGs exist. Furthermore, to our knowledge, no studies have systematically collected standard 12-lead ECGs at the exact time of coronary angiography. This emphasizes the need for targeted clinical research to test the correlation between distinct ECG patterns and angiography findings during acute coronary events and after reperfusion to support the recognition of STEMI-equivalent ECG patterns and identifying reliable ECG markers of poor myocardial reperfusion. Finally, the specificity of occlusion myocardial infarction patterns in varied clinical contexts is unclear, which is crucial for their practical application, and operational challenges in using these patterns in emergency settings require further exploration. Future research should prioritize external validation of distinct occlusion myocardial infarction patterns, evaluating their diagnostic accuracy and prognostic value across diverse patient populations who have an ECG recorded. Artificial intelligence shows promise in overcoming these challenges, because it has shown high accuracy in ECG diagnosis of occlusion myocardial infarction.

Conclusion (proposition de traduction) : La mise en œuvre du protocole d’infarctus du myocarde par occlusion nécessite de relever plusieurs défis diagnostiques, notamment en favorisant la reconnaissance précise des présentations mimant ce type d’infarctus et en établissant une feuille de route claire pour une collaboration interdisciplinaire centrée sur l’objectif de reperfusion rapide. L’histoire naturelle de l’infarctus du myocarde par occlusion est moins bien documentée que celle du STEMI, pour lequel on dispose de nombreuses données sur l’évolution des tracés ECG. De plus, à notre connaissance, aucune étude n’a systématiquement recueilli d’ECG standard à 12 dérivations exactement au moment de l’angiographie coronarienne. Cela souligne la nécessité de recherches cliniques ciblées afin d’évaluer la corrélation entre les différents profils ECG et les résultats de l’angiographie pendant les événements coronariens aigus, ainsi qu’après la reperfusion, afin de favoriser l’identification des équivalents STEMI et des marqueurs ECG fiables d’une reperfusion myocardique inadéquate. Enfin, la spécificité des profils ECG d’infarctus par occlusion dans divers contextes cliniques reste mal établie, ce qui est pourtant essentiel pour leur application pratique. Les défis opérationnels liés à l’utilisation de ces profils en contexte d’urgence méritent également d’être explorés davantage. Les recherches futures devraient prioriser la validation externe des profils distincts d’infarctus du myocarde par occlusion, en évaluant leur valeur diagnostique et pronostique dans des populations de patients variées ayant un ECG enregistré. L’intelligence artificielle offre des perspectives prometteuses pour relever ces défis, ayant déjà démontré une grande précision dans le diagnostic ECG de l’infarctus par occlusion.

Commentaire :  Modèles électrocardiographiques d'infarctus du myocarde par occlusion.

La démarche dans l'infarctus du myocarde par occlusion.
*Toujours envisager une évaluation dynamique de l'ECG, comparer avec les ECG antérieurs, corréler avec les symptômes et les concentrations de troponine sérique, exclure les imitations, revérifier les modifications ST-T dans la dérivation aVL (figure E11, disponible sur http://www.annemergmed.com) et différencier l'élévation ST de la variante normale dans V2-V4 (figure E12, disponible sur http://www.annemergmed.com). Modifié d'après Aslanger et al.
ACO, occlusion coronaire aiguë ; NOMI, infarctus du myocarde sans occlusion ; OMI, infarctus du myocarde avec occlusion.

Blood Transfusion in Patients With Acute Myocardial Infarction, Anemia, and Heart Failure: Lessons From MINT.
Goldsweig AM, Kostis WJ, Herbert BM, Bouleti C, Potter BJ, Strom JB, Benatar J, Huynh T, Vallurupalli S, Figueiredo EL, Abbott JD, Cooper HA, DeFilippis AP, Fergusson DA, Goodman SG, Hébert PC, Lopes RD, Rao SV, Simon T, Carson JL, Brooks MM, Alexander JH; MINT Investigators. | Circ Heart Fail.  2025 Apr;18(4):e012495
DOI: https://doi.org/10.1161/circheartfailure.124.012495
Keywords: anemia; heart failure; hemoglobin; myocardial infarction.

RESEARCH ARTICLE

Introduction : Blood transfusion may precipitate adverse outcomes, including heart failure (HF), among patients with acute myocardial infarction (MI). This study characterizes the effects of a restrictive or liberal transfusion strategy on outcomes in patients with MI and anemia with and without baseline HF.

Méthode : In the MINT trial (Myocardial Ischemia and Transfusion), 3504 patients with MI and anemia (hemoglobin <10 g/dL) were randomized to a restrictive (hemoglobin <8 g/dL) or liberal (hemoglobin <10 g/dL) transfusion strategy. We compared the effects of transfusion strategy on outcomes among patients with and without baseline HF. The primary outcome was death or HF at 30 days.

Résultats : Compared with patients without baseline HF (n=1633), those with baseline HF (n=1871) had higher rates of death or HF (18.0% versus 10.0%) at 30 days. Restrictive transfusion resulted in numerically higher rates of death or HF (rate ratio, 1.20 [95% CI, 0.99-1.45] versus 0.94 [95% CI, 0.70-1.26]; P_interaction=0.18) in patients with than in those without baseline HF. Among secondary outcomes, death or recurrent MI and death were more frequent among those with baseline HF. Restrictive transfusion resulted in numerically higher rates of death or MI and death in patients with than in those without baseline HF. Rates of HF were similar between restrictive and liberal transfusion in patients with baseline HF but lower with restrictive transfusion (rate ratio, 0.51 [95% CI, 0.29-0.92]; P_interaction=0.02) in patients without baseline HF.

Conclusion : A liberal transfusion strategy is safe for patients with MI and anemia, including those with baseline HF. Restrictive transfusion tended to result in worse outcomes, particularly in patients with baseline HF.

Conclusion (proposition de traduction) : Une stratégie de transfusion libérale est sûre pour les patients présentant un infarctus du myocarde et une anémie, y compris ceux souffrant d'insuffisance cardiaque initiale. Une transfusion restrictive a tendance à entraîner une aggravation des résultats, en particulier chez les patients souffrant d'une insuffisance cardiaque initiale.

Commentaire : • Carson JL and al. Restrictive versus Liberal Transfusion in Myocardial Infarction - A Patient-Level Meta-Analysis. NEJM Evid. 2025 Feb;4(2):EVIDoa2400223  
• Gurugubelli S and al. Efficacy and Safety of Blood Transfusion Protocols in the Treatment of Myocardial Infarction: A Review of Restrictive and Liberal Approaches. Cureus. 2025 Jan 31;17(1):e78307  .
• Simon T and al.; MINT Trial Investigators. Restrictive or Liberal Transfusion Strategy in Patients With Acute Myocardial Infarction and Anemia: 6-Month Mortality in the MINT Trial. Circulation. 2024 Sep 24;150(13):1064-1066  .
• Carson JL and al.; MINT Investigators. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. N Engl J Med. 2023 Dec 28;389(26):2446-2456  .

Electrocardiographic patterns of accidental hypothermia.
Okumura H, Okada N, Hamanaka K, Okada Y, Kitamura T, Matsuyama T. | Am J Emerg Med.  2025 Apr;90:210-213
DOI: https://doi.org/10.1016/j.ajem.2025.01.079  | Télécharger l'article au format  
Keywords: Accidental hypothermia; Arrhythmia.

Article

Introduction : Accidental hypothermia impacts the cardiovascular system, complicating patient management and prognosis. While previous studies have reported an association between hypothermia and ECG patterns, these findings are largely based on case reports or small-scale observational studies with limited sample sizes, underscoring the need for a more comprehensive analysis.

Méthode : We conducted a retrospective analysis using the J-POINT registry, which included patients with body temperatures ≤35 °C who visited the emergency departments of 12 Japanese institutions between April 1, 2011, and March 31, 2016. A total of 463 hypothermic patients were analyzed. All electrocardiographics were interpreted by two emergency medicine specialists blinded to body temperature and subsequently reviewed by an experienced cardiologist.

Résultats : Sinus rhythm was most common (66.7 %), followed by atrial fibrillation (AF) (21.2 %). QT prolongation and Osborn wave were observed in 48.8 % and 53.1 % of patients, respectively, both increasing with hypothermia severity. Ventricular fibrillation or pulseless ventricular tachycardia occurred in 2.4 % of all cases.

Conclusion : AF, PR prolongation, QT prolongation, and Osborn wave were observed to some extent even in mild hypothermia, and the frequency of these ECG patterns increased with severity increasing.

Conclusion (proposition de traduction) : La fibrillation auriculaire, l'allongement du rythme cardiaque, l'allongement de l'intervalle QT et l'onde d'Osborn ont été observés dans une certaine mesure, même en cas d'hypothermie légère, et la fréquence de ces tracés ECG augmentait avec la gravité de la maladie.

Commentaire : Cet article souligne l'importance d'une reconnaissance rapide des anomalies ECG pour éviter des diagnostics erronés et des traitements inappropriés.