Hemostatic technique using cyanoacrylate for fingertip cut injury: A review of 21 cases.
Sasamatsu S, Ueda T. | Acute Med Surg.  2025 Apr 29;12(1):e70056
DOI: https://doi.org/10.1002/ams2.70056  | Télécharger l'article au format  
Keywords: cyanoacrylate; emergency room visits; finger injuries; hemostasis.

ORIGINAL ARTICLE

Introduction : In the emergency department, fingertip cut injuries often involve skin loss and bleeding. Traditional hemostatic methods, such as applying simple pressure or using pressure combined with alginate fibers, are sometimes insufficient and require sutures or cauterization. To address these challenges, we explored the use of cyanoacrylate for hemostasis in fingertip cut injuries.

Méthode : We retrospectively collected data from patients aged ≥ 20 years who presented to our emergency department for fingertip cut injuries between April 2023 and March 2024. Injuries were characterized by skin loss without contamination, bone exposure, or fractures. We suggest the cyanoacrylate sealing method (CASM) in most cases. CASM involved wound cleansing, a proximal tourniquet with a rubber band, a thin cyanoacrylate coating on the wound, and observation for rebleeding.

Résultats : A total of 21 patients (mean age: 46.4 years) underwent CASM, achieving successful hemostasis in all cases. Compression hemostasis was attempted in 12 patients before CASM; however, no hemostasis was achieved. Five patients reported a tolerable stinging sensation at the wound site. The cyanoacrylate coating detached naturally within 4 to10 days, and complete epithelialization was achieved within 14 days. No significant complications, such as infection or delayed wound healing, were observed.

Conclusion : CASM is a simple and minimally invasive method to achieve hemostasis in fingertip cut injuries. It significantly reduces the procedure time compared with traditional methods such as suturing or cauterization.

Conclusion (proposition de traduction) : La méthode de cicatrisation par pansement occlusif de cyanoacrylate est une méthode simple et peu invasive pour obtenir l'hémostase dans les pertes de substance de l'extrémité d'un doigt. Elle réduit considérablement la durée du traitement par rapport aux méthodes traditionnelles telles que la suture ou la cautérisation.

Commentaire :  (A) Le saignement a été observé après le rinçage avec l'eau du robinet.
(B) Après application de cyanoacrylate.
(C) Six jours après la blessure. La plaie est épithélialisée.

Lasserre G, Bakkouch S, Pauchot J, Binda D, Robin S, Humbert P, Elias BE, Tropet Y, Obert L. Reconstruction pulpaire par pansement occlusif: évaluation clinique et analyse biologique du contenu du pansement [Fingertip reconstruction with occlusive dressing: clinical results and biological analysis of the dressing content's]. Chir Main. 2010 Oct;29(5):315-20  .

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.

Midazolam and Ketamine for Convulsive Status Epilepticus in the Out-of-Hospital Setting.
Zitek T, Scheppke KA, Antevy P, Coyle C, Garay S, Scheppke E, Farcy DA. | Ann Emerg Med.  2025 Apr;85(4):305-312
DOI: https://doi.org/10.1016/j.annemergmed.2024.11.002
Keywords: Ketamine; Midazolam; Status epilepticus.

Pain Management and Sedation

Introduction : To determine if ketamine, when added to midazolam for the treatment of out-of-hospital seizures, is associated with an increase in the rate of cessation of convulsions prior to hospital arrival.

Méthode : We performed a retrospective cohort study of out-of-hospital patients with an active convulsive seizure being transported to a hospital by a large emergency medical services system in Florida, using data from August 1, 2015 and August 5, 2024. Per protocol, patients received midazolam first for their seizure. Starting in June 2017, a new protocol was developed in which patients who continued to convulse after midazolam received ketamine. We used propensity score matching and multivariable logistic regression to determine if patients who received ketamine were more likely to stop convulsing prior to hospital arrival than those who received midazolam alone.

Résultats : Overall, 479 (80.1%) of 598 actively convulsing patients who received 2 doses of midazolam (without subsequent ketamine) had resolution of their convulsions prior to hospital arrival compared with 85 (94.4%) of 90 who received ketamine after midazolam, an absolute difference between groups of 14.3% (95% CI 8.6% to 20.1%). After propensity matching, 82.0% of those in the midazolam only group had resolution of convulsions compared to 94.4% in the ketamine group, a difference of 12.4% (95% CI 3.1% to 21.7%).

Conclusion : In this retrospective study of out-of-hospital patients with active convulsive seizures, patients who received ketamine were more likely to have stopped convulsing prior to hospital arrival than those who received midazolam alone.

Conclusion (proposition de traduction) : Dans cette étude rétrospective portant sur des patients extra-hospitaliers présentant des crises convulsives aiguës, les patients ayant reçu de la kétamine étaient plus susceptibles d'avoir cessé de convulser avant leur arrivée à l'hôpital que ceux ayant reçu uniquement du midazolam.

Effectiveness and Safety of Pharmacologic Therapies for Migraine in the Emergency Department: A Systematic Review and Bayesian Network Meta-analysis.
deSouza IS, Anthony N, Thode H Jr, Allen R, Belyavskaya J, Koos J, Singer A. | Ann Emerg Med.  2025 Apr;85(4):313-329
DOI: https://doi.org/10.1016/j.annemergmed.2024.11.004
Keywords: Migraine; Migraine therapies; Pain relief.

Pain Management and Sedation

Introduction : We performed a systematic review and Bayesian network meta-analysis to determine which pharmacologic therapies are relatively more effective and safer for migraine in adult patients who present to the emergency department (ED).

Méthode : We searched MEDLINE, Embase, and Web of Science from inception to February 9, 2024. Eligible studies were randomized controlled trials that enrolled adult participants presenting to ED with migraine and compared one pharmacologic therapy to another or placebo. Outcomes were as follows: 1) adequate pain relief at 2 hours, 2) change in pain intensity at 1 hour, 3) need for rescue drug at 2 hours, and 4) significant adverse reaction. We extracted data according to PRISMA-network meta-analysis and appraised trials using Cochrane RoB 2. For dichotomous outcomes, we performed Bayesian network meta-analysis to calculate odds ratios with 95% credible intervals; for continuous outcomes, we performed frequentist network meta-analysis to calculate mean differences with 95% confidence intervals. We assessed confidence using Confidence in Network Meta-analysis. We used Surface under the cumulative ranking curve (SUCRA) to rank agents.

Résultats : Chlorpromazine intravenous (IV)/intramuscular (IM) (SUCRA=87.3%) was most likely to be superior for "adequate pain relief at 2 hours" (24 trials; n=2,361); metoclopramide IV-ibuprofen IV (SUCRA=94.6%) was most likely to be superior for "need for rescue drug" (not needing rescue drug) at 2 hours (27 trials; n=2,942); dexamethasone IV (SUCRA=79.5%) was most likely to be superior for "significant adverse reaction" (not causing adverse reaction) (22 trials; n=2,450). The network for change in pain intensity demonstrated statistically significant incoherence at the overall level. Confidence in network meta-analysis estimates (certainty of evidence) varied and was mostly "low" or "very low," limiting the validity of the probabilistic analyses.

Conclusion : According to Bayesian network meta-analysis, ibuprofen IV is definitely among the least effective for adequate pain relief; chlorpromazine IV/IM is definitely among the most effective; valproate IV is definitely among the least effective, and ketorolac IV/IM is possibly among the least effective as single agents. The relative safety of the pharmacologic therapies cannot be determined with sufficient certainty.

Conclusion (proposition de traduction) : Selon la méta-analyse du réseau bayésien, l'ibuprofène IV est sans aucun doute l'un des moins efficaces pour soulager adéquatement la douleur ; la chlorpromazine (Largactil^®) IV/IM est sans aucun doute l'un des plus efficaces ; le valproate (Depakine^®) IV est sans aucun doute l'un des moins efficaces, et le kétorolac (Accular^®) IV/IM est peut-être l'un des moins efficaces en tant qu'agent unique. La sécurité relative des traitements pharmacologiques ne peut être déterminée avec une certitude suffisante.

Managing Acute Respiratory Failure With Facemask Noninvasive Ventilation.
Bracey A, Wright BJ. | Ann Emerg Med.  2025 Apr;85(4):349-354
DOI: https://doi.org/10.1016/j.annemergmed.2024.10.012
Keywords: Aucun

Critical Care

Editorial : The use of noninvasive ventilation has expanded considerably revolutionizing the management of acute respiratory failure in the emergency department (ED). Noninvasive ventilation may reduce mortality and morbidity in many conditions, though proper patient selection, appropriate noninvasive ventilation titration, and troubleshooting are necessary to realize these benefits.

Conclusion : Despite its routine use in the ED, there is little guidance for emergency physicians on how to utilize noninvasive ventilation devices beyond the default settings, as titration is often performed by other services. This review will focus on masked noninvasive ventilation for the management of acute respiratory failure in the ED.

Conclusion (proposition de traduction) : Malgré son utilisation courante aux urgences, il existe peu de recommandations à l'intention des urgentistes sur la manière d'utiliser les appareils de ventilation non invasive au-delà des réglages par défaut, car le réglage est souvent effectué par d'autres services. Cette revue se concentrera sur la ventilation non invasive au masque facial pour la prise en charge de l'insuffisance respiratoire aiguë aux urgences.

Effectiveness of Point-of-Care High-Sensitivity Troponin Testing in the Emergency Department: A Randomized Controlled Trial.
Thulin VIL, Jordalen SMF, Myrmel GMS, Lekven OC, Krishnapillai J, Steiro OT, Body R, Collinson P, Apple FS, Cullen L, Norekvål TM, Wisløff T, Vikenes K, Bjørneklett RO, Omland T, Aakre KM. | Ann Emerg Med.  2025 Apr 8:S0196-0644(25)00133-7
DOI: https://doi.org/10.1016/j.annemergmed.2025.03.005  | Télécharger l'article au format  
Keywords: Accelerated diagnostic protocol; Acute coronary syndrome; Cardiac biomarkers; Chest pain; Emergency department crowding.

CARDIOLOGY/ORIGINAL RESEARCH

Introduction : To compare the effectiveness of high-sensitivity cardiac troponin (hs-cTn) point-of-care testing to central laboratory hs-cTn measurements when investigating patients presenting to the emergency department (ED) with symptoms of acute coronary syndrome.

Méthode : The WESTCOR point-of-care study was a single-center prospective randomized controlled trial where we randomized patients presenting with possible acute coronary syndrome in a 1:1 fashion to receive either 0/1-hour centralized hs-cTnT measurements (control) or 0/1-hour point-of-care hs-cTnI testing (intervention). We defined length of stay (LOS) in the ED as the primary endpoint and the minimum clinically meaningful difference as 15 minutes.

Résultats : We included 1,494 patients in the final analysis, 728 in the point-of-care group, and 766 in the control group. The median (interquartile range) age was 61 (22) years, and 635 (42.5%) were women. Median LOS in the ED was 174 (95% confidence interval [CI] 167 to 181) and 180 (95% CI 175 to 189) minutes in the point-of-care and control group, respectively, resulting in a reduction in median LOS of 6 minutes (95% CI -4 to 17). Acute myocardial infarction, death, or acute revascularization occurred in 83/728 (11.4%) of point-of-care and 72/766 (9.4%) of control patients.

Conclusion : We found that implementing point-of-care hs-cTnI testing in the ED with a 0/1-hour diagnostic algorithm did not lead to a clinically meaningful reduction in ED LOS. We observed no difference in the incidence of myocardial infarction, acute coronary revascularization, or death during 30 days follow-up.

Conclusion (proposition de traduction) : Nous avons constaté que la mise en œuvre du dosage de la hs-cTnI délocalisé dans les urgences avec un algorithme de diagnostic 0/1 heure n'a pas conduit à une réduction cliniquement significative de la durée de séjour dans les urgences. Nous n'avons observé aucune différence dans l'incidence de l'infarctus du myocarde, de la revascularisation coronarienne aiguë ou du décès au cours des 30 jours de suivi.

A Critical Issue in the Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning: Approved by the ACEP Board of Directors January 22, 2025.
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning, Shih RD, Tomaszewski CA, Kaji A, Diercks DB; Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee); Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman BW, Gemme SR, Gerardo CJ, Godwin SA, Hatten BW, Haukoos JS, Kwok H, Lo BM, Mace SE, Mattu A, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Thompson JT, Tomaszewski CA, Trent S, Valente JH, Westafer LM, Wall S. | Ann Emerg Med.  2025 Apr;85(4):e45-e59
DOI: https://doi.org/10.1016/j.annemergmed.2024.12.005  | Télécharger l'article au format  
Keywords: Aucun

CLINICAL POLICY

Editorial : This clinical policy from the American College of Emergency Physicians addresses a key issue in the evaluation and management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical question: In emergency department patients diagnosed with acute carbon monoxide poisoning, does hyperbaric oxygen therapy compared with normobaric (room pressure) oxygen therapy improve long-term neurocognitive outcomes? Evidence was graded, and recommendations were made based on the strength of the available data.

Conclusion : Since publication of the 2017 ACEP clinical policy on CO treatment with HBO2, only 4 new studies were identified that met methodological quality for inclusion in answering this critical question. Of these studies, only one had original data, but this was a retrospective propensity-matched trial and showed only modest benefit. The 3 meta-analyses included varying numbers of the same RCT studies that were graded and discussed in the previous ACEP clinical policy on addressing acute CO poisoning.14 In all but one of the RCTs (Weaver et al, 2002), patients were not blinded, but more importantly, the control NBO groups did not get standardized treatment to ensure 100% oxygen was continuously delivered. Based on this review, the Clinical Policies Committee’s conclusions are similar to those made in the 2017 clinical policy that HBO2 may provide a modest benefit, especially in memory impairment.

Conclusion (proposition de traduction) : Depuis la publication de la politique clinique 2017 de l'ACEP sur le traitement du CO par l'oxygène hyperbare, seules 4 nouvelles études ont été identifiées qui répondaient aux critères de qualité méthodologique pour être incluses dans la réponse à cette question cruciale. Parmi ces études, une seule présentait des données originales, mais il s'agissait d'un essai rétrospectif apparié en fonction de la propension, qui n'a montré qu'un avantage modeste. Les 3 méta-analyses comprenaient un nombre variable des mêmes études d'essais contrôlés randomisés qui ont été classées et discutées dans la politique clinique précédente de l'American College of Emergency Physicians (ACEP) sur le traitement de l'intoxication aiguë au CO. Dans tous les essais contrôlés randomisés sauf un (Weaver et al, 2002), les patients n'étaient pas en aveugle, mais plus important encore, les groupes de contrôle d'oxygénothérapie normobare n'ont pas reçu de traitement standardisé pour s'assurer que l'oxygène à 100 % était délivré en continu. Sur la base de cet revue, les conclusions du comité des politiques cliniques sont similaires à celles formulées dans la politique clinique de 2017, à savoir que l'oxygène hyperbare peut apporter un bénéfice modeste, en particulier dans les troubles de la mémoire.

Appropriate cardiopulmonary resuscitation duration and predictors of return of spontaneous circulation in traumatic cardiac arrest.
Seo D, Heo I, Jung K, Jung H. | BMC Emerg Med.  2025 Apr 14;25(1):61
DOI: https://doi.org/10.1186/s12873-025-01219-7  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Heart arrest; Return of spontaneous circulation; Wound and injuries.

RESEARCH

Introduction : Despite advances in trauma care, traumatic cardiac arrest (TCA) shows significantly poorer outcomes compared to non-traumatic cardiac arrest, with mortality rates exceeding 96%. However, no standardized protocol exists for appropriate cardiopulmonary resuscitation (CPR) duration in TCA. This study aimed to establish evidence-based CPR duration thresholds and identify factors associated with return of spontaneous circulation (ROSC) in TCA patients.

Méthode : We conducted a retrospective observational study using a single-centre trauma registry of adult patients with TCA between January 2021 and December 2023. Univariate analysis was used to identify differences in the baseline and outcome variables between the ROSC and no-ROSC groups. We performed multivariable logistic regression analysis to identify factors independently associated with ROSC. We also investigated the appropriate cutoff time of pre-hospital and total CPR duration for ROSC (the CPR duration that has maximum sensitivity and specificity for ROSC).

Résultats :  In total, 422 patients with TCA were included, of whom 250 were eligible for analysis. The proportion of patients with ROSC was 22.4% (n = 56), and trauma bay/emergency department mortality and in-hospital mortality rates were 80.8% (n = 202) and 97.2% (n = 243), respectively. Factors associated with ROSC included alert mental status in the field, as indicated by verbal response (adjusted odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01-1.12; p = 0.06), pain response (OR, 0.03; 95% CI, 0.01-0.43; p = 0.009), and unresponsiveness (OR, 0.04; 95% CI, 0.01-0.44; p = 0.009) and non-asystolic initial rhythms, such as pulseless electrical activity (OR, 4.26; 95% CI, 1.92-9.46; p < 0.001), shockable rhythm (OR, 14.26; 95% CI, 1.44-141.54; p = 0.023), pre-hospital CPR duration (OR, 0.90; 95% CI, 0.85-0.95), and total CPR duration (OR, 0.88; 95% CI, 0.84-0.92; p < 0.001). The upper limits of pre-hospital and total CPR durations for achieving a probability of ROSC < 1% were 23 and 30 min, respectively, whereas those for a cumulative portion of ROSC > 99% were 27 and 38 min, respectively. Among the survivors (n = 7), six had favourable functional outcomes at discharge.

Conclusion : This study provides evidence-based CPR duration thresholds in TCA, demonstrating that resuscitation efforts beyond 27 min in prehospital settings and 38 min in total were futile. Additionally, an alert mental status in the field and non-asystolic initial rhythm were identified as positive predictors of ROSC. These findings may help guide appropriate duration of resuscitation efforts in TCA.

Conclusion (proposition de traduction) : Cette étude fournit des seuils de durée de RCP fondés sur des preuves dans les cas d'arrêt cardiaque traumatique, démontrant que les efforts de réanimation au-delà de 27 minutes en milieu préhospitalier et de 38 minutes au total sont vains. De plus, des signes de vie (mouvements spontanés, activité ECG, réaction pupillaire) sur le terrain et un rythme initial non asystolique ont été identifiés comme des facteurs prédictifs positifs du retour à une circulation spontanée. Ces résultats peuvent aider à déterminer la durée appropriée des efforts de réanimation dans les cas d'arrêt cardiaque traumatique.

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  .

Risk factors for failure of the first intubation attempt during cardiopulmonary resuscitation in out-of-hospital emergency settings: What about chest compression?.
Galinski M, Tazi G, Wrobel M, Boyer R, Reuter PG, Ruscev M, Debaty G, Bagou G, Dehours E, Bosc J, Lorendeau JP, Goddet S, Marouf K, Simonnet B, Gil-Jardiné C. | Resuscitation.  2025 Apr 26:110623
DOI: https://doi.org/10.1016/j.resuscitation.2025.110623
Keywords: Difficult intubation; First tracheal intubation attempt; Out-of-hospital cardiac arrest; Risk factors.

Online ahead of print

Introduction : Previous studies have described interactions between the success rate of tracheal intubation (TI) and chest compression during resuscitation from cardiac arrest. However, it is not clear if chest compression increases the complexity of TI. The aim of this study was to determine the risk factors for difficulty with tracheal intubation during resuscitation of patients with out-of-hospital cardiac arrest, focusing in particular on the impact of ongoing chest compressions on the success of the first intubation attempt.

Méthode : We performed a secondary analysis of data obtained during an observational, prospective multicenter study. After each TI, the operator provided information on both the operator and the patient, and the TI environment. We included only OHCA data. The primary endpoint was failure of the first intubation attempt.

Résultats : Data on a total of 848 OHCA patients were analyzed. A total of 291 first TI attempts failed (34.3%). Multivariate analysis revealed that six variables were associated with an increased risk of failure: an operator who had performed ≤ 50 prior intubations (odds ratio [OR] [95% confidence interval] = 2.0 [1.4-2.9]), male patient gender (OR = 1.5 [1.0-2.3]), a small inter-incisor space (OR = 3.4 [2.2-5.4]), ear, nose, and throat disease (OR = 2.8 [1.8-4.4]), vomiting (OR = 2.1 [1.4-3.2]), and continued chest compression during the TI attempt (OR = 1.6 [1.1-2.3]).

Conclusion : The first intubation attempt failed in 34% of cases, and ongoing chest compressions during intubation was one of six variables associated with the risk of failure. However, this must be weighed against the need for invasive airway management and the negative effects of interrupting chest compressions.

Conclusion (proposition de traduction) : La première tentative d'intubation a échoué dans 34 % des cas, et la poursuite des compressions thoraciques pendant l'intubation était l'une des six variables associées au risque d'échec. Cependant, cela doit être mis en balance avec la nécessité d'une gestion invasive des voies aériennes et les effets négatifs de l'interruption des compressions thoraciques.

Commentaire : Robinson AE, Driver BE, Prekker ME and al. First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department. Resuscitation. 2023 May;186:109726  .

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.

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.