Diagnostic Accuracy and Application of Subarachnoid Hemorrhage Decision Rules Among Patients With Non-Traumatic Acute Headache: A Systematic Review and Meta-Analysis.
Roostaei M, Saniee N, Ahmadi SAY, Rezai M, Tehrani-Banihashemi A, Baradaran HR, Barzkar F. | Acad Emerg Med. 2025 Jul 2
DOI: https://doi.org/10.1111/acem.70087
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : The Ottawa and Emerald rules were developed to aid in the diagnosis of subarachnoid hemorrhage (SAH) and to determine whether a CT scan is necessary for patients presenting with non-traumatic acute headaches in the emergency department. Numerous studies have been conducted to validate these clinical decision rules. In this study, we aimed to investigate the pooled diagnostic accuracy of these rules and their impact on imaging utilization.

Méthode : In this PRISMA-DTA-compliant systematic review, a comprehensive search was done in databases including PubMed, Scopus, Embase, and Web of Science. Then, screening, selection of studies, and data extraction were performed and the QUADAS-2 tool was used for critical appraisal. The true positives (TP), false negatives (FN), false positives (FP), and true negatives (TN) were extracted to calculate pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, and Diagnostic Odds Ratio (DOR) with 95% CIs. The effect of Ottawa rule on CT scan utilization was assessed by calculating pooled odds ratios for the number of CT scans in SAH and non-SAH groups before and after applying the rule.

Résultats : The pooled sensitivity, specificity, negative LR, and positive LR for the Ottawa SAH rule were 99% (95% CI: 92%-100%), 23% (95% CI: 16%-32%), 0.025 (95% CI: 0.003%-0.193%), and 1.29 (95% CI: 1.16%-1.42%) respectively. Similarly, these measures for the Emerald SAH rule were 99% (95% CI: 71%-100%), 27% (95% CI: 15%-43%), 0.065 (95% CI: 0.004%-1.072%), and 1.34 (95% CI: 1.1%-1.62%), respectively. The pooled odds ratio for CT scan utilization for the Ottawa rule was 1.15 (95% CI: 0.62%-2.13%).

Conclusion : Both rules are highly sensitive for excluding SAH in patients with non-traumatic acute headaches presenting to the emergency department but have low specificity and do not significantly reduce CT scan utilization.

Conclusion (proposition de traduction) : Ces deux règles sont très sensibles pour exclure une hémorragie sous-arachnoïdienne chez les patients présentant des céphalées aiguës non traumatiques qui se présentent aux urgences, mais elles ont une faible spécificité et ne réduisent pas de manière significative le recours à la tomodensitométrie.

Association of Two Preoxygenation Approaches With Hypoxemia During Tracheal Intubation: A Secondary Analysis.
Chou CD, Palakshappa JA, Haynie H, Garcia K, Long D, Gibbs KW; Pragmatic Critical Care Research Group. | Ann Emerg Med. 2025 Jul 22:S0196-0644(25)00376-2
DOI: https://doi.org/10.1016/j.annemergmed.2025.06.003
Keywords: Critical care; Oxygen; Oxygen mask; Preoxygenation; Tracheal intubation.

AIRWAY/BRIEF RESEARCH REPORT

Introduction : Oxygen masks (bag-valve-mask device and nonrebreathing facemask oxygen) are the most common method of preoxygenation in critically ill patients undergoing emergency tracheal intubation in the emergency department and intensive care unit. Whether the type of oxygen mask used for preoxygenation alters the risk of hypoxemia during intubation is uncertain. We sought to compare the incidence of hypoxemia during intubation in patients preoxygenated with a bag-valve-mask device to the incidence of hypoxemia in patients preoxygenated with facemask oxygen.

Méthode : We conducted a secondary analysis of 2 randomized trials of emergency tracheal intubation. The primary outcome of hypoxemia was defined as a peripheral oxygen saturation <85% between induction of anesthesia and 2 minutes after tracheal intubation. We used a propensity-weighted multivariable logistic regression model to compare the incidence of hypoxemia between groups. We hypothesized that preoxygenation with a bag-valve-mask device would be associated with a lower incidence of hypoxemia compared to preoxygenation with facemask oxygen.

Résultats : We included 1,156 patients in this analysis, of whom 136 were preoxygenated with a bag-valve-mask device and 1,020 were preoxygenated with facemask oxygen. Hypoxemia occurred in 20 of 136 (14.7%) participants in the bag-valve-mask device group and 153 of 1,020 (15.0%) participants in the facemask oxygen group. In the multivariable analysis, participants preoxygenated with a bag-valve-mask device had similar odds of hypoxemia to those preoxygenated with facemask oxygen (adjusted odds ratio 1.22, 95% confidence interval 0.72 to 2.16).

Conclusion : In critically ill patients undergoing tracheal intubation, preoxygenation with a bag-valve-mask device did not reduce the risk of hypoxemia compared to preoxygenation with facemask oxygen.

Conclusion (proposition de traduction) : Chez les patients gravement malades bénéficiant d'une intubation trachéale, la préoxygénation à l'aide d'un ballon auto remplisseur à valve unidirectionnelle (BAVU) n'a pas réduit le risque d'hypoxémie par rapport à la préoxygénation à l'aide d'un masque facial à oxygène.

Biomarkers to guide sepsis management.
Bourika V, Rekoumi EA, Giamarellos-Bourboulis EJ. | Ann Intensive Care. 2025 Jul 21;15(1):10
DOI: https://doi.org/10.1186/s13613-025-01524-1  | Télécharger l'article au format  
Keywords: Antibiotics; Biomarkers; Fluids; Guidance; Sepsis; Vasopressors.

REVIEW

Introduction : Sepsis remains a major cause of morbidity and mortality. Precision therapeutics are now regarded as a novel prospective to improve outcome. This approach relies on biomarkers to identify a pathway of pathogenesis which prevails and directs the best available therapeutic option to modulate this pathway. This review provides the most recent findings on biomarkers for bacterial or viral sepsis. These biomarkers provide guidance for prompt diagnosis and management tailored to specific needs.

Discussion : Keywords relative to sepsis management (early recognition, antibiotic administration, selection of fluids, vasopressors and immunotherapy) were searched across PubMed database. Published evidence the last five years exists for heparin-binding protein (HBP), monocyte distribution width (MDW), interleukin-10 (IL-10), presepsin, procalcitonin and C-reactive protein (CRP) for early sepsis diagnosis; procalcitonin is the most well-studied biomarker for antibiotic guidance. Endothelial and cardiac biomarkers have been explored as tools to tailor circulatory support in sepsis, including fluid therapy, and the targeted use of vasopressors for vascular tone optimization.

Conclusion : This review explored how biomarkers can optimize immunomodulatory therapies, guide vasopressor initiation, inform antibiotic stewardship, and aid in fluid resuscitation decisions, ultimately improving patient outcomes.

Conclusion (proposition de traduction) : Cette revue a examiné comment les biomarqueurs peuvent optimiser les thérapies immunomodulatrices, guider l'initiation des vasopresseurs, éclairer la gestion des antibiotiques et aider à prendre des décisions en matière de réanimation liquidienne, afin d'améliorer en fin de compte les résultats pour les patients.

Vitamin C Versus Placebo in Pediatric Septic Shock (VITACiPS) - A Randomised Controlled Trial.
Sankar J, Manoharan A, Lodha R, Sharma HP, Kabra SK. | J Intensive Care Med. 2025 Jul 24:8850666251362121.
DOI: https://doi.org/10.1177/08850666251362121
Keywords: adjunctive therapy; septic shock; vitamin C.

Research article

Introduction : Intravenous vitamin C has been evaluated as an adjunctive therapy in adults with septic shock, with mixed results. In pediatric patients, evidence remains limited and its role is yet to be defined.MethodsIn this randomized, double-blind, placebo-controlled trial conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital from February 2022 to March 2024, children <17 years-old with septic shock were randomly assigned to receive either intravenous Vitamin C at 25 mg/kg every 6 h for 72 h or equal volumes of 5% dextrose as placebo. The primary outcome was change in pediatric sequential organ failure assessment (pSOFA) score at 72 h from baseline. Secondary outcome was shock resolution and 28-day mortality.

Résultats : f 262 children with septic shock, 218 were randomized [median (IQR) age: 96 months (36.5, 133); 128 male]. The adjusted mean difference for change in pSOFA score at 72 h between the Vitamin C and placebo groups was -0.51 [95% CI: (-1.76, 0.75)] (p = 0.43)] (reduction in the Vitamin C group as compared to the placebo group). The 28-day mortality was comparable [Vitamin C, 21.6% versus placebo, 22.5%, RR: 0.96 (0.58-1.58), p = 0.88]. There was no difference in shock resolution or any other outcomes. The incidence of prespecified adverse events (acute kidney injury) was similar in both groups.

Conclusion : Intravenous Vitamin C administration as adjunctive therapy in pediatric septic shock did not significantly impact organ dysfunction at 72 h. Our findings do not support the routine use of Vitamin C as adjunctive therapy in septic shock in children.

Conclusion (proposition de traduction) : L'administration intraveineuse de vitamine C en tant que traitement d'appoint dans le choc septique pédiatrique n'a pas eu d'impact significatif sur le dysfonctionnement organique à 72 heures. Nos résultats ne soutiennent pas l'utilisation systématique de la vitamine C en tant que traitement d'appoint dans le choc septique chez les enfants.

Blood-Based Biomarkers for Improved Characterization of Traumatic Brain Injury: Recommendations from the 2024 National Institute for Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Blood-Based Biomarkers Working Group.
Bazarian JJ, Zetterberg H, Buki A, Dengler BA, Diaz-Arrastia R, Korley FK, Lazarus R, Meier TB, Mondello S, Moritz K, Okonkwo DO, Papa L, Phillips JB, Posti JP, Puccio AM, Sloley S, Steyerberg E, Wang KK, Awwad HO, Dams-O'Connor K, Doperalski A, Maas AIR, McCrea MA, Umoh N, Manley GT. | J Neurotrauma. 2025 Jul;42(13-14):1065-1085
DOI: https://doi.org/10.1089/neu.2024.0581  | Télécharger l'article au format  
Keywords: S100B calcium-binding protein; brain biomarkers; concussion; glial fibrillary acidic protein; neurofilament light chain; traumatic brain injury; ubiquitin C-terminal hydrolase L1.

ORIGINAL ARTICLE

Editorial : A 2022 report by the National Academies of Sciences, Engineering, and Medicine called for a Traumatic Brain Injury (TBI) Classification Workshop by the National Institutes of Health (NIH) to develop a more precise, evidence-based classification system. The workshop aimed to revise the Glasgow Coma Scale-based system by incorporating neuroimaging and validated blood biomarker tests. In December 2022, the National Institute for Neurological Disorders and Stroke formed six working groups of TBI experts to make recommendations for this revision. This report presents the findings and recommendations from the blood-based biomarker (BBM) working group, including feedback from the workshop and subsequent public review. The application of BBMs in a TBI classification system has potential to allow for a more adaptable and nuanced approach to triage, diagnosis, prognosis, and treatment. Current evidence supports the use of glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase L1, and S100B calcium-binding protein (S100B) to assist in reclassification of TBI at acute time points (0-24 h) primarily in emergency department settings, while neurofilament light chain (NfL), GFAP, and S100B have utility at subacute time points (1-30 days) in-hospital and intensive care unit settings. Blood levels of these biomarkers reflect the extent of structural brain injury in TBI and may be useful for describing the extent of structural brain injury in a classification system.

Conclusion : While there is insufficient evidence to support a role for BBMs at chronic time points (>30 days), emerging evidence suggests that NfL and phosphorylated tau may have a potential future role in this regard. For inclusion in a revised TBI classification system, BBM assays must have appropriate age- and sex-specific reference ranges, be harmonized across platforms, and achieve high analytical precision, including accuracy, linearity, detection limits, selectivity, recovery, reproducibility, and stability. Improving transparency in BBM assay development can be achieved through large-scale data sharing of methods and results. Future research should focus on methods for promoting clinical adoption of BBM results, correlating BBMs with advanced neuroimaging, and on discovering new biomarkers for improved diagnosis and prognosis.

Conclusion (proposition de traduction) : Bien qu’il n’existe pas de données suffisantes pour soutenir l’utilisation des biomarqueurs sanguins à des stades chroniques (au-delà de 30 jours), des données récentes suggèrent que la chaîne légère des neurofilaments (NfL) et la protéine tau phosphorylée pourraient, à l’avenir, jouer un rôle dans ce contexte. Pour être intégrés à un système révisé de classification du traumatisme crânien, les dosages de biomarqueurs sanguins doivent disposer de valeurs de référence adaptées à l’âge et au sexe, être harmonisés entre les différentes plateformes, et atteindre une grande précision analytique, comprenant l’exactitude, la linéarité, les limites de détection, la sélectivité, la récupération, la reproductibilité et la stabilité. L’amélioration de la transparence dans le développement des dosages de biomarqueurs sanguins peut être obtenue grâce au partage à grande échelle des méthodes et des résultats. Les recherches futures devraient se concentrer sur les moyens de favoriser l’adoption clinique des résultats des biomarqueurs sanguins, sur la corrélation entre les biomarqueurs sanguins et l’imagerie neuro-avancée, ainsi que sur la découverte de nouveaux biomarqueurs afin d’améliorer le diagnostic et le pronostic.

Evolving role of point-of-care ultrasound in prehospital emergency care: a narrative review.
Hellenthal KEM, Porschen C, Wnent J, Lange M. | Scand J Trauma Resusc Emerg Med. 2025 Jul 14;33(1):126
DOI: https://doi.org/10.1186/s13049-025-01443-x  | Télécharger l'article au format  
Keywords: Cardiac arrest; Point-of-care ultrasound; Prehospital; Respiratory distress; Shock; Trauma.

REVIEW

Editorial : Point-of-care ultrasound is an emerging technology in prehospital emergency care, covering a wide range of medical and traumatic disease patterns. As an ad-hoc imaging modality, it is performed on-scene and during ground or aeromedical transport, enabling experienced prehospital clinicians to diagnose or rule out potentially life-threatening conditions. Rapid ultrasound assessment modulates treatment decisions and guides the choice of transport mode and appropriate hospital destination. In this narrative review, we explore the diagnostic and therapeutic utility of point-of-care ultrasound in key prehospital symptom complexes, including respiratory distress, trauma, cardiac arrest and nontraumatic shock. We provide a concise overview of relevant protocols and ultrasound findings that support the management of prehospital disease patterns and highlight both the benefits and challenges of on-scene ultrasound. In addition, we discuss potential future applications in the context of artificial intelligence. We advocate for large scale clinical trials and underscore the need for comprehensive educational programs focused at skill aquisiton and maintenance, both of which are essential for advancing prehospital emergency care and upholding high standards of quality.

Conclusion : Prehospital point-of-care ultrasound is an emerging frontline diagnostic and therapeutic tool with the potential to advance prehospital emergency medicine. Different protocols are available that may guide the well-trained practicioner in major prehospital symptom complexes, including respiratory distress, cardiac arrest, shock and trauma. Rapid assessment by prehospital point-of-care ultrasound may guide treatment decisions and improve triage to appropriate hospitals. In this regard, early diagnosis may facilitate the triage to specialty centers, for example to cardiac centers, if pericardial effusion is detected, or to trauma centers, if internal bleeding is visualized by FAST sonography or stroke centers, if stroke is suspected in transcranial doppler. Further, in an era of telemedicine, images may be trans- mitted to respective destination hospitals. To avoid the risk of prolonging preclinical procedural times, the use of ultrasound must be stringently integrated into distinct diagnostic and therapeutic algorithms. Importantly, the speed of technological advances requires curricula that define a cohesive framework for educational and training programs, resulting in competency and maintenance of operator skills. The differentiated use of Prehospital point-of-care ultrasound and the associated training concepts further emphasize the need for increasing professionalization in prehospital emergency medicine. As prehospital care is often mistaken for a one-size-fits-all therapeutic field, constant advances in Prehospital point-of-care ultrasound may significantly improve the field, moving it closer to provision of personalized medicine. There is growing evidence supporting the use of Prehospital point-of-care ultrasound, however, to date, few systematic data exist and evidence for management of certain disease patterns is currently soley based on case reports. The current lack of randomized controlled trials will hopefully soon translate into large scale clinical trials to further elucidate the real clinical impact of Prehospital point-of-care ultrasound.

Conclusion (proposition de traduction) : L’échographie préhospitalière au point d’intervention est un outil diagnostique et thérapeutique de première ligne en plein essor, avec un fort potentiel pour faire progresser la médecine d’urgence préhospitalière. Différents protocoles sont disponibles et peuvent guider le praticien bien formé dans les grands tableaux cliniques rencontrés en préhospitalier, notamment la détresse respiratoire, l’arrêt cardiaque, l’état de choc et les traumatismes. Une évaluation rapide par échographie préhospitalière peut orienter les décisions thérapeutiques et améliorer le triage vers l’établissement hospitalier le plus adapté.
Dans cette optique, un diagnostic précoce peut faciliter l’orientation vers des centres spécialisés : par exemple un centre cardiologique en cas d’épanchement péricardique détecté, un centre de traumatologie si une hémorragie interne est visualisée via l’échographie FAST, ou un centre AVC si un accident vasculaire cérébral est suspecté via un doppler transcrânien. Par ailleurs, à l’ère de la télémédecine, les images peuvent être transmises aux hôpitaux de destination pour anticiper la prise en charge. Pour éviter le risque d’allonger les délais de prise en charge sur le terrain, l’échographie doit impérativement être intégrée de manière rigoureuse dans des algorithmes diagnostiques et thérapeutiques définis. En parallèle, la rapidité des avancées technologiques impose la mise en place de programmes pédagogiques structurés, avec un cadre de formation cohérent garantissant la compétence des opérateurs et le maintien de leurs acquis.
L’usage raisonné de l’échographie préhospitalière, combiné à des approches pédagogiques adaptées, souligne l’importance croissante de la professionnalisation en médecine d’urgence préhospitalière. Ce domaine, encore souvent perçu comme un modèle thérapeutique universel, pourrait considérablement gagner en précision grâce aux progrès constants de l’échographie au point d’intervention, rapprochant ainsi la prise en charge de la médecine personnalisée. Bien que les données en faveur de cette technologie soient de plus en plus nombreuses, les études systématiques restent encore rares à ce jour. Pour plusieurs tableaux cliniques, les recommandations reposent principalement sur des séries de cas. Il est donc à espérer que l’absence actuelle d’essais contrôlés randomisés soit rapidement comblée par des études cliniques de grande ampleur, afin d’évaluer plus précisément l’impact réel de l’échographie préhospitalière dans la pratique clinique.

Commentaire : L’article propose une synthèse actualisée du rôle croissant de l’échographie au point d’intervention dans la médecine d’urgence préhospitalière. Les auteurs mettent en évidence son utilité diagnostique dans des situations critiques comme l’arrêt cardiaque, l’état de choc, le traumatisme et la détresse respiratoire. Ils insistent sur la nécessité d’une intégration rigoureuse de l’échographie dans des algorithmes protocolisés, ainsi que sur l’importance de formations structurées pour garantir la compétence des intervenants. Malgré un potentiel prometteur, ils soulignent le manque de données issues d’essais contrôlés randomisés, appelant à des recherches de plus grande ampleur pour évaluer son impact clinique réel.

Emergency medicine updates: Managing the patient with return of spontaneous circulation.
Long B, Gottlieb M. | Am J Emerg Med. 2025 Jul;93:26-36
DOI: https://doi.org/10.1016/j.ajem.2025.03.039
Keywords: Angiography; Cardiac arrest; Post-cardiac arrest syndrome; ROSC; Resuscitation; Return of spontaneous circulation; TTM; Targeted temperature management; Vasopressor.

Review

Introduction : Patients with return of spontaneous circulation (ROSC) following cardiac arrest are a critically important population requiring close monitoring and targeted interventions in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the management of this condition.

Méthode : This paper provides evidence-based updates concerning the management of the post-ROSC patient.

Discussion : The patient with ROSC following cardiac arrest is critically ill, including a post-cardiac arrest syndrome which may include hypoxic brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathophysiology. Initial priorities in the ED setting in the post-ROSC patient include supporting cardiopulmonary function, addressing and managing the underlying cause of arrest, minimizing secondary cerebral injury, and correcting physiologic derangements. Testing including laboratory assessment, electrocardiogram (ECG), and imaging are necessary, aiming to evaluate for the precipitating cause and assess end-organ injury. Computed tomography head-to-pelvis may be helpful in the post-ROSC patient, particularly when the etiology of arrest is unclear. There are several important components of management, including targeting a mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion pressure. An oxygenation target of 92-98 % is recommended using ARDSnet protocol, along with carbon dioxide partial pressure values of 35-55 mmHg. Antibiotics should be reserved for those with evidence of infection but may be considered if the patient is comatose, intubated, and undergoing hypothermic targeted temperature management (TTM). Corticosteroids should not be routinely administered. While the majority of cardiac arrests in adults are associated with cardiovascular disease, not all post-ROSC patients r

Conclusion : An understanding of literature updates can improve the ED care of patients post-ROSC.

Conclusion (proposition de traduction) : La compréhension des mises à jour de la littérature peut améliorer les soins aux urgences des patients post-RACS.

Electrocardiogram essentials: Bradycardia.
Tannenbaum L, Long B. | Am J Emerg Med. 2025 Jul 13;97:58-64
DOI: https://doi.org/10.1016/j.ajem.2025.07.030
Keywords: AV block; Arrhythmia; Block; Bradyarrhythmia; Bradycardia; Cardiology; Epinephrine; First degree; Junctional; Mobitz; Pacing; Resuscitation; Second degree; Third degree; Transcutaneous; Transvenous.

Review article

Introduction : Bradycardia is a common finding in the emergency department (ED) and presents along a clinical spectrum, ranging from asymptomatic to hemodynamic compromise and cardiac arrest.

Méthode : This manuscript evaluates the management of bradycardia through a discussion of several cases.

Résultats : Bradycardia may result in severe hemodynamic compromise and is defined as a heart rate less than 60 beats per minute (bpm). There are a variety of causes and associations, including physiologic, pathologic, and pharmacologic. Patients may present with a range of signs and symptoms, from no symptoms to hemodynamic collapse. Obtaining an electrocardiogram is essential, which will determine the severity of bradycardia and underlying rhythm, including first-degree atrioventricular (AV) block, second-degree AV block, and third-degree AV block, among others. Management is based on the underlying etiology and patient hemodynamic status, aiming to improve the heart rate and address the underlying cause. Patients who are hemodynamically unstable require resuscitation with chronotropic agents and transcutaneous or transvenous pacing.

Conclusion : Severe bradycardia requires emergent management, and a knowledge of the treatment strategies can optimize patient care.

Conclusion (proposition de traduction) : Une bradycardie sévère nécessite une prise en charge urgente, et la connaissance des stratégies thérapeutiques permet d'optimiser les soins prodigués au patient.