BACKGROUND AND IMPORTANCE:Acute heart failure (AHF) is a frequent cause of emergency department (ED) admissions, yet the prognostic impact of infection as a trigger remains insufficiently characterized. OBJECTIVE:To evaluate the impact of infection as a trigger of AHF on in-hospital mortality and postdischarge survival. DESIGN:Retrospective observational cohort study. SETTINGS AND PARTICIPANTS:All adult patients presenting with AHF to the ED of Strasbourg University Hospital in 2020 were included. Clinical and outcome data were collected from 1296 ED visits. INTERVENTION OR EXPOSURE:Infection and other AHF triggers were defined through adjudication based on clinical, imaging, and microbiological data collected throughout the hospital stay. OUTCOME MEASURES AND ANALYSIS:The primary outcome was in-hospital mortality. Analyses were performed using inverse probability weighting (IPW). Postdischarge survival was assessed using IPW-weighted Kaplan-Meier estimates and Cox models. MAIN RESULTS:Infection was identified in 119 ED visits [9.2%, 95% confidence interval (CI): 7.7-10.9]. Patients with infection had higher in-hospital mortality than those without infection (30.3% vs. 9.0%, P  < 0.001). In IPW-weighted analyses, infection was independently associated with in-hospital mortality [odds ratio (OR) = 2.76, 95% CI: 1.64-4.66]. In contrast, atrial fibrillation (OR = 0.45, 95% CI: 0.23-0.87) and acute coronary syndrome (OR = 0.08, 95% CI 0.01-0.58) were associated with lower in-hospital mortality. Infection was also associated with reduced postdischarge survival (hazard ratio = 1.64, 95% CI: 1.14-2.37, P  = 0.008). CONCLUSION:Infection is a strong and independent predictor of short- and long-term mortality in patients presenting with AHF in the ED.

Forty-two questions were evaluated concerning management of emergencies and critical illnesses in paediatric and adult patients with sickle cell disease. The assessment covered the following areas: patient referral, vaso-occlusive crisis, acute chest syndrome, transfusion therapy, and priapism. The patient referral category included guidelines for admission to intensive care unit and management at specialized reference centers. The vaso-occlusive crisis topic encompassed pain management, hydration, incentive spirometry, and target oxygen saturation levels. For acute chest syndrome, the focus areas included imaging techniques such as lung ultrasound, computed tomography scans, and echocardiography; treatment with systemic corticosteroids; non-invasive ventilation; prophylactic and therapeutic anticoagulation; and procalcitonin and antibiotic therapy. The section on transfusion therapy addressed indications and methods of transfusion, as well as the diagnosis and prediction of delayed hemolytic transfusion reactions. A total of 45 recommendations were proposed, including 14 specific to adults, 13 specific to pediatrics, and 18 applicable to both adults and children, along with three therapeutic algorithms. The Grade of Recommendation Assessment, Development, and Evaluation (GRADE) methodology was adhered to throughout the process. Sixteen recommendations were based on a low level of evidence (GRADE 2+ or 2−), while 26 were based on evidence that could not be classified under the GRADE system and were therefore considered expert opinions. Finally, for three aspects of sickle cell disease management, the experts concluded that no reliable recommendations could be made based on the current state of knowledge. The recommendations and therapeutic algorithms received strong agreement from the experts.

BACKGROUND:The assessment of acute heart failure (AHF) prognosis is primordial in emergency setting. Although AHF management is exhaustively codified using mortality predictors, there is currently no recommended scoring system for assessing prognosis. The European Society of Cardiology (ESC) recommends a comprehensive assessment of global AHF prognosis, considering in-hospital mortality, early rehospitalization rates and the length of hospital stay. OBJECTIVE:We aimed to prospectively evaluate the performance of the Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF (MEESSI-AHF) score in estimating short prognosis according to the ESC guidelines. DESIGN, SETTINGS AND PATIENTS:A multicenter study was conducted between November 2020, and June 2021. Adult patients who presented to eleven French hospitals for AHF were prospectively included. OUTCOME MEASURES AND ANALYSIS:According to MEESSI-AHF score, patients were stratified in four categories corresponding to mortality risk: low-, intermediate-, high- and very high-risk groups. The primary outcome was the number of days alive and out of the hospital during the 30-day period following admission to the Emergency Department (ED). RESULTS:In total, 390 patients were included. The number of days alive and out of the hospital decreased significatively with increasing MEESSI-AHF risk groups, ranging from 21.2 days (20.3-22.3 days) for the low-risk, 20 days (19.3-20.5 days) for intermediate risk,18.6 days (17.6-19.6 days) for the high-risk and 17.9 days (16.9-18.9 days) very high-risk category. CONCLUSION:Among patients admitted to ED for an episode of AHF, the MEESSI-AHF score estimates with good performance the number of days alive and out of the hospital.

Abstract Introduction Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. Methods Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected. Results A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described. Conclusion These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Les syndromes d’Ehlers-Danlos (SED) sont un groupe hétérogène de maladies héréditaires rares du tissu conjonctif caractérisées par la triade clinique hyperlaxité articulaire, hyperélasticité cutanée et fragilité tissulaire. Les manifestations respiratoires associées aux SED sont fréquentes et variées. Elles dépendent principalement du type de SED. Dans les SED non vasculaires (SEDnv), hypermobile et classique, la dyspnée est un symptôme fréquent. Ses étiologies sont larges et peuvent être associées chez un même patient : asthme, faiblesse des muscles respiratoires, déformation de la cage thoracique, collapsus des voies aériennes supérieures et inférieures. La prévalence du syndrome d’apnées obstructives du sommeil est élevée dans les SEDnv. Dans le SED vasculaire (SEDv), les complications pulmonaires sont dominées par le pneumothorax, l’hémothorax et les hémoptysies. Elles précèdent souvent le diagnostic de SEDv de plusieurs années. Il est donc impératif de rechercher des arguments en faveur d’un SEDv devant tout pneumothorax ou hémothorax spontané chez un jeune patient. La présence d’anomalies scanographiques parenchymateuses évocatrices (emphysème, clusters de nodules calcifiés, nodule excavé) peut être une aide au diagnostic. Une meilleure connaissance des atteintes pulmonaires des SED par la communauté pneumologique permettrait d’améliorer la prise en charge des malades et d’ouvrir la voie à des travaux de recherche.Ehlers-Danlos syndromes (EDS) represent a heterogeneous group of heritable connective tissue disorders characterized by the clinical “triad” consisting in joint hypermobility, skin hyperextensibility and tissue fragility. Respiratory manifestations associated with EDS are frequent and variable. They vary mainly according to the type of EDS. In hypermobile and classical EDS, the most frequent non-vascular types, dyspnea is a common symptom. Its etiologies are wide-ranging and can coexist in the same patient: asthma, respiratory muscle weakness, chest wall abnormalities, upper and lower airway collapse. The prevalence of obstructive sleep apnea syndrome in nvEDS is high. Identification of the relevant dyspnea mechanism is essential to providing appropriate therapeutic measures. In vascular EDS (vEDS), the main pulmonary complications are pneumothorax, hemothorax and hemoptysis. As they frequently precede the diagnosis of vEDS by several years, it is imperative to raise the possibility of vEDS in a young patient with spontaneous pneumothorax or hemothorax. The presence of suggestive computed tomography parenchymal abnormalities (emphysema, clusters of calcified nodules, cavitated nodule) can be an aid to diagnosis. Treatment is based on the usual approaches, which must be carried out with caution by an experienced operator fully informed of the diagnosis. Better knowledge of respiratory manifestations of EDS by the pneumological community would improve patient care and pave the way for further research.

Introduction: Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. Methods: Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected. Results: A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and & GE;2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative manage-ment (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described. Conclusion: These guidelines are a step towards PSP treatment and follow-up strategy optimization in France. & COPY; 2023 SPLF and Elsevier Masson SAS. All rights reserved.

Introduction: Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. Methods: Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected. Results: A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and superior or equal to 2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for ten- sion PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking ces- sation, are described. Conclusion: These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Anaphylaxis is the most severe of the allergic hypersensitivity reactions. It is caused by the release of mediators from blood components such as mast cells and basophils into the bloodstream. Anaphylaxis is a common disease, its diagnosis is clinical and, given its pathophysiology, the treatment of choice is adrenaline.

Purpose: To provide recommendations for the appropriate choice of fluid therapy for resuscitation of critically ill patients. Design: A consensus committee of 24 experts from the French Society of Anaesthesia and Intensive Care Medicine (Societe francaise d'anesthesie et de reanimation, SFAR) and the French Society of Emergency Medicine (Societe francise de medecine d'urgence, SFMU) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were left ungraded. Methods: Four fields were defined: patients with sepsis or septic shock, patients with haemorrhagic shock, patients with acute brain failure, and patients during the peripartum period. For each field, the panel focused on two questions: (1) Does the use of colloids, as compared to crystalloids, reduce morbidity and mortality, and (2) Does the use of some specific crystalloids effectively reduce morbidity and mortality. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE methodology. Results: The SFAR/SFMU guideline panel provided nine statements on the appropriate choice of fluid therapy for resuscitation of critically ill patients. After two rounds of rating and various amendments, strong agreement was reached for 100% of the recommendations. Out of these recommendations, two have a high level of evidence (Grade 1 +/-), six have a moderate level of evidence (Grade 2 +/-), and one is based on expert opinion. Finally, no recommendation was formulated for two questions. Conclusions: Substantial agreement among experts has been obtained to provide a sizable number of recommendations aimed at optimising the choice of fluid therapy for resuscitation of critically ill patients. (C) 2022 The Authors. Published by Elsevier Masson SAS on behalf of Societe francaise d'anesthesie et de reanimation (Sfar). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Anaphylaxis is the most severe of the allergic hypersensitivity reactions. It is caused by the release of mediators from blood components such as mast cells and basophils into the bloodstream. Anaphylaxis is a common disease, its diagnosis is clinical and, given its pathophysiology, the treatment of choice is adrenaline.

Fournir des recommandations sur le choix du soluté pour le remplissage vasculaire en situation critique. Un groupe composé de 24 experts des Sociétés Françaises d’Anesthésie-Réanimation (SFAR), de Médecine d’Urgence (SFMU) a été réuni. D’éventuels conflits d’intérêts ont été officiellement déclarés dès le début du processus d’élaboration des recommandations et ce dernier a été conduit indépendamment de tout financement de l’industrie. Les auteurs ont suivi la méthode GRADE ( Grading of Recommendations Assessment, Development and Evaluation ) pour évaluer le niveau de preuve de la littérature. Les inconvénients potentiels de la formulation de recommandations fortes en présence de données de faible niveau de preuve ont été soulignés. Certaines recommandations dont le niveau de preuve était insuffisant n’ont pas été gradées. Quatre champs ont été définis, les patients atteints de sepsis ou de choc septique, les patients atteints de choc hémorragique, les patients cérébrolésés et les patientes en péripartum. Pour chacun des champs, le panel d’expert a formulé des recommandations répondant à deux questions : 1) l’utilisation d’un soluté colloïde, comparativement aux cristalloïdes, permet-elle de diminuer la morbi-mortalité ? et 2) l’utilisation d’un type de cristalloïdes permet-elle de diminuer la morbi-mortalité ? Les questions ont été formulées selon le modèle PICO (population, intervention, comparaison, et outcomes) et une recherche bibliographique extensive a été réalisée. L’analyse de la littérature et la formulation des recommandations ont été conduites selon la méthode GRADE. Neuf recommandations sur le choix du soluté de remplissage en situation critique ont été fournies par le panel d’experts SFAR/SFMU. Après deux tours de votes et plusieurs amendements, un accord fort a été obtenu pour toutes les recommandations. Parmi ces recommandations, deux ont un niveau de preuve élevé (Grade 1 + -), six ont un niveau de preuve faible (Grade 2 + -) et une est un avis d’experts. Enfin, pour deux questions, aucune recommandation n’a pu être formulée. Un accord fort a été obtenu parmi les experts afin de fournir plusieurs recommandations visant à optimiser le choix du soluté de remplissage vasculaire en situation critique. To provide recommendations for the appropriate choice of fluid therapy for resuscitation of critically ill patients. A consensus committee of 24 experts from the French societies of anesthesiology and critical care medicine (Société Française d’Anesthésie-Réanimation, SFAR) and emergency medicine (Société Française de Médecine d’Urgence, SFMU) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded. Four fields were defined: patients with sepsis or septic shock, patients with haemorrhagic shock, patients with acute brain failure, and patients during the peripartum period. For each field, the panel focused on two questions for diagnostic strategy: 1) Does the use of colloids, as compared to crystalloids, reduce morbidity and mortality, and 2) Does the use of some specific crystalloids reduce morbidity and mortality. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE methodology. The SFAR/SFMU guideline panel provided nine statements on the appropriate choice of fluid therapy for resuscitation of critically ill patients. After two rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, two have a high level of evidence (Grade 1 + -), six have a low level of evidence (Grade 2 + -), and one is based on expert judgement. Finally, no recommendation was formulated for two questions. Substantial agreement exists among experts for many strong recommendations aiming at optimizing the choice of fluid therapy for resuscitation of critically ill patients.

Purpose > To provide recommendations for the appropriate choice of fluid therapy for resuscita-tion of critically ill patients.Design > A consensus committee of 24 experts from the French societies of anesthesiology and critical care medicine (Societe Francaise d'Anesthesie-Reanimation, SFAR) and emergency medi-cine (Societe Francaise de Medecine d'Urgence, SFMU) was convened. A formal conflict-of -interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded.Methods > Four fields were defined: patients with sepsis or septic shock, patients with haemor-rhagic shock, patients with acute brain failure, and patients during the peripartum period. For each field, the panel focused on two questions for diagnostic strategy: 1) Does the use of colloids, as compared to crystalloids, reduce morbidity and mortality, and 2) Does the use of some specific crystalloids reduce morbidity and mortality. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE methodology.Results > The SFAR/SFMU guideline panel provided nine statements on the appropriate choice of fluid therapy for resuscitation of critically ill patients. After two rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, two have a high level of evidence (Grade 1 +-), six have a low level of evidence (Grade 2 +-), and one is based on expert judgement. Finally, no recommendation was formulated for two questions.Conclusions > Substantial agreement exists among experts for many strong recommendations aiming at optimizing the choice of fluid therapy for resuscitation of critically ill patients. Recommandations Formalisees

Introduction : La prise en charge de l’épidémie de Covid-19 dans un service d’urgences (SU) requiert une évaluation de ses critères de gravité. La Covid-19 est évolutive et l’aggravation respiratoire détermine le pronostic. Notre objectif était de rechercher les facteurs prédictifs de gravité en fonction du délai d’initiation d’une oxygénothérapie dans une population française atteinte de Covid-19 au sein d’un SU.Matériels et méthode : L’étude observationnelle rétrospective aux Hôpitaux Universitaires de Strasbourg, durant la première vague de la pandémie, incluait les patients hospitalisés depuis le SU en 2020 pour infection au SARS-CoV-2. Elle évaluait les délais entre le début des symptômes (J0) et l’initiation d’une oxygénothérapie, et entre J0 et l’apparition des complications hospitalières. L’analyse multivariée recherchait les facteurs associés à l’oxygénothérapie précoce et à la mortalité intra-hospitalière.Résultats : 699 patients ont été inclus. L’oxygénothérapie était initiée le 7 ± 4e jour, la ventilation mécanique le 9 ± 4e jour. L’initiation précoce d’oxygénothérapie (avant le 6e jour) était significativement et indépendamment associée à l’immunosuppression, à l’âge ≥ 75 ans, à l’hypertension artérielle, et au sexe féminin. La mortalité intra-hospitalière était significativement et indépendamment associée à un âge ≥ 75 ans, une immunosuppression, une cardiopathie ischémique, et une oxygénothérapie précoce.Conclusion : Parmi les patients hospitalisés pour la Covid-19 durant la première vague, le jour moyen d’initiation d’oxygénothérapie était le septie jour. Une oxygénothérapie précoce, un âge ≥ 75 ans, une immunosuppression et une cardiopathie ischémique étaient associés à une forme grave de la Covid-19.