Managing Awake Intubation.
Sandefur BJ, Driver BE, Long B.. | Ann Emerg Med. 2025 Jan;85(1):21-30
DOI: https://doi.org/10.1016/j.annemergmed.2024.07.017  | Télécharger l'article au format  
Keywords: Aucun

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Editorial : In the emergency department (ED), awake tracheal intubation is an important yet rarely utilized airway management technique. Awake intubation involves using meticulous topical anesthesia, with or without sedative medications, to perform tracheal intubation. The goal is to maintain airway reflexes and spontaneous breathing during the procedure. The procedure has its disadvantages, including the time it takes to perform and the challenge of managing an awake patient’s experience and movements. Awake intubation contrasts with rapid sequence intubation. Rapid sequence intubation uses induction and neuromuscular blocking agents to rapidly induce sedation and paralysis, facilitating endotracheal tube placement. Emergency physicians should consider awake intubation in patients with difficult airways or challenging physiologic characteristics, with a primary goal of avoiding cannot oxygenate/cannot ventilate scenarios. A clinician may perform awake intubation using a flexible endoscope, either nasally or orally, or an oral rigid video laryngoscope. A 2018 systematic review and meta-analysis demonstrated no difference in success between awake endoscopic and awake video laryngoscopic approaches in the operating room setting.

Conclusion : Although this procedure is rare in ED settings, the compelling potential benefits in certain patients highlight the importance of emergency physicians being familiar with the indications for and approach to awake intubation. However, emergency physicians currently report widely varying levels of confidence with awake intubation techniques. We will discuss key tenets of managing awake intubation in the ED, drawing on established literature and years of combined practice, with a focus on the awake aspect of the procedure rather than specific intubation techniques.

Conclusion (proposition de traduction) : Bien que cette procédure soit rare dans les services d'urgence, les avantages potentiels convaincants pour certains patients soulignent l'importance pour les médecins urgentistes de connaître les indications et l'approche de l'intubation chez le patient éveillé. Cependant, les médecins urgentistes font actuellement état de niveaux de confiance très variables dans les techniques d'intubation chez le patient éveillé. Nous discuterons des principes clés de la gestion de l'intubation chez le patient éveillé aux urgences, en nous appuyant sur la littérature établie et sur des années de pratique combinée, en mettant l'accent sur l'aspect éveillé de la procédure plutôt que sur des techniques d'intubation spécifiques.

Managing Emergency Endotracheal Intubation Utilizing a Bougie.
Barnicle RN, Bracey A, Weingart SD. | Ann Emerg Med. 2025 Jan;85(1):14-20
DOI: https://doi.org/10.1016/j.annemergmed.2024.04.021
Keywords: Aucun

AIRWAY/EXPERT CLINICAL MANAGEMENT

Editorial : The endotracheal tube (ETT) introducer, or “bougie,” is used to cannulate the trachea prior to ETT delivery using the Seldinger technique. In most emergency departments, the bougie is not incorporated into a primary intubation strategy and has historically been relegated to an adjunctive role or used as a rescue device for difficult airways. This may be due to inexperience with the optimized technique, difficulty troubleshooting bougie-related challenges, concern of procedure prolongation, or skepticism of its efficacy as a primary intubation device. However, recent literature has demonstrated the clear utility of a bougie-first strategy when combined with standard geometry laryngoscopy, while also underscoring the need for repetitive use in the pursuit of procedural mastery. In the largest trial in which operators did not have increased familiarity with the bougie, first-pass success with a bougie (80.4%) was not significantly different than with a stylet (83%). However, first-pass success for operators who predominantly utilize a bougie-first approach has been shown to be 96% when patients have difficult airway characteristics and 99% in those without difficult airways.

Conclusion : A technical overview for the effective use of bougies during endotracheal intubation is presented here and serves as a foundational guide for trainees, educators, and physicians aiming to optimize bougie-related skill and strategy. Our intent is to provide a level of detail not explained in the literature previously, while recognizing that operators may still modify this foundational procedure and incorporate the bougie into various other advanced airway techniques. The following recommendations, when not specifically referenced, are based on our informed practice because there is a dearth of evidence regarding the specific microskills of bougie-assisted intubation.

Conclusion (proposition de traduction) : Nous présentons ici un aperçu technique de l'utilisation optimale des mandrins pendant l'intubation endotrachéale. Il s'agit d'un guide de base pour les étudiants, les enseignant(e)s et les médecins qui souhaitent optimiser leurs compétences et leur stratégie en matière de mandrins. Notre intention est de fournir un niveau de détail qui n'a pas été expliqué dans la littérature auparavant, tout en reconnaissant que les opérateurs peuvent encore modifier cette procédure de base et incorporer les mandrins dans diverses autres techniques avancées des voies aériennes. Les recommandations suivantes, lorsqu'elles ne sont pas spécifiquement référencées, sont basées sur notre pratique, car il y a un manque de preuves concernant les micro-compétences spécifiques de l'intubation assistée à l'aide des mandrins.

Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding.
Thiebaud PC, Wassermann E, de Caluwe M, Prebin C, Noel F, Dechartres A, Raynal PA, Leblanc J, Yordanov Y. | Ann Emerg Med. 2025 Jan;85(1):31-42
DOI: https://doi.org/10.1016/j.annemergmed.2024.06.024  | Télécharger l'article au format  
Keywords: Aucun

GENERAL MEDICINE/ORIGINAL RESEARCH

Introduction : Early prognostic stratification could optimize the management of patients with upper gastrointestinal bleeding and reduce unnecessary hospitalizations. The aim of this study was to assess and compare the performance of existing prognostic scores in predicting therapeutic intervention and death.

Méthode : A systematic search of the literature identified existing prognostic scores. A multicenter retrospective cohort study included adult patients hospitalized for upper gastrointestinal bleeding from January 1, 2019, to December 31, 2020. The primary outcome was a composite including therapeutic intervention within 7 days (blood transfusion, endoscopic, surgical, or interventional radiology hemostasis) and/or 30-day death. Discrimination performance was estimated by the area under the curve (AUC). The ability to identify low-risk patients was analyzed using sensitivity and negative predictive value (NPV) for defined thresholds.

Résultats : The systematic search identified 39 prognostic scores, 12 of which could be analyzed. Among the 990 patients included, therapeutic intervention and/or death occurred in 755 (76.4%) patients. Scores with the highest discriminative performance to predict the primary composite outcome were Glasgow-Blatchford score (GBS) (AUC 0.869 [0.842 to 0.895]), modified GBS (AUC 0.872 [0.847 to 0.898]) and modified GBS 2 (AUC 0.855 [0.827 to 0.884]). The best performance to identify low-risk patients was for GBS≤1 (sensitivity 0.99 [0.99 to 1.00], NPV 0.89 [0.75 to 0.97]) and modified GBS=0 (sensitivity 0.99 [0.98 to 1.00], NPV 0.84 [0.71 to 0.94]).

Conclusion : The GBS and the modified GBS are the 2 best performing scores because they achieve both key objectives: stratifying patients based on their risk of therapeutic intervention and/or death and identifying low-risk patients who may qualify for outpatient management.

Conclusion (proposition de traduction) : Le score de Glasgow-Blatchford et le score de Glasgow-Blatchford modifié sont les deux scores les plus performants car ils atteignent les deux objectifs clés : stratifier les patients en fonction de leur risque d'intervention thérapeutique et/ou de décès et identifier les patients à faible risque qui peuvent bénéficier d'une prise en charge ambulatoire.

Commentaire : Score de Glasgow-Blatchford    en ligne.

Clinical characteristics, management, diagnostic findings, and various etiologies of patients with Kounis syndrome. A systematic review.
Cahuapaza-Gutierrez NL, Calderon-Hernandez CC, Chambergo-Michilot D, De Arruda-Chaves E, Zamora A, Runzer-Colmenares FM. | Int J Cardiol. 2025 Jan 1;418:132606
DOI: https://doi.org/10.1016/j.ijcard.2024.132606
Keywords: Allergic acute coronary syndrome; Kounis syndrome; Myocardial infarction, allergic; Systematic review (source: MeSH NLM).

Article

Introduction : Kounis syndrome (KS) is defined by the association of acute coronary syndrome secondary to an anaphylactic reaction. KS is often underdiagnosed, and new etiologies have been proposed.

Méthode : To synthesize the available evidence on clinical profile, management, diagnosis, and etiologies in patients with KS.
Methods: A search was conducted in the following databases: PubMed, Scopus, EMBASE and Web of Science from inception to March 19th, 2024. Case reports, case series, and observational studies were included. Letters to the editor, editorials, comments, notes, narrative reviews, and systematic reviews were excluded.

Résultats : A total of 190 studies were included (174 case reports, 13 case series, and 3 observational studies, 214 patients). A predominance of male gender was observed (69.63 %). Mean age was 54.4 ± 16.5 years. The most common comorbidities were hypertension (33.64 %), diabetes (16.82 %), and dyslipidemia (16.35 %). The most frequent clinical manifestations were chest pain (66.35 %) and difficulty breathing (34.11 %). Three variants of KS were identified: type I or allergic coronary vasospasm was the most frequent (43.46 %), and type III, the least common (8.88 %). The most frequent etiology was drug use (38.32 %), primarily antibiotics (42.68 %), followed by animal stings or bites (26.17 %). The calculated KS rate was 11.12 per 1000 people. The mortality rate was 7.47 %, and the majority had a favorable outcome (86.92 %) after management.

Conclusion : KS is a complex and underdiagnosed disease that should be considered as a differential diagnosis in acute coronary syndrome associated with an allergic reaction.

Conclusion (proposition de traduction) : Le syndrome de Kounis est une maladie complexe et sous-diagnostiquée qui doit être considérée comme un diagnostic différentiel dans le cas d'un syndrome coronarien aigu associé à une réaction allergique.

Diuretics in patients with chronic kidney disease.
Agarwal R, Verma A, Georgianos PI. | Nat Rev Nephrol. 2025 Jan 7.
DOI: https://doi.org/10.1038/s41581-024-00918-x
Keywords:

Review Article

Editorial : Diuretic drugs act on electrolyte transporters in the kidney to induce diuresis and are often used in chronic kidney disease (CKD), given that nephron loss creates a deficit in the ability to excrete dietary sodium, which promotes an increase in plasma volume. This rise in plasma volume is exacerbated by CKD-induced systemic and intra-renal activation of the renin-angiotensin-aldosterone-system, which further limits urinary sodium excretion. In the absence of a compensatory decrease in systemic vascular resistance, increases in plasma volume induced by sodium retention can manifest as a rise in systemic arterial blood pressure. Management of sodium and volume overload in patients with CKD is therefore typically based on restriction of dietary sodium intake and the use of diuretic agents to enhance urinary sodium excretion. Thiazide and thiazide-type diuretics are foundational therapies for the management of hypertension, whereas loop diuretics are often needed for volume overload, which might also require combination therapies. Mineralocorticoid receptor antagonists have an important role in the management of diuretic-resistant volume overload or treatment-resistant hypertension. Additionally, diuretics can be used for the diagnosis of kidney diseases and in the management of hyperkalaemia or hypokalaemia, hyponatraemia, hypercalcaemia and hypomagnesaemia.

Commentaire : Points clés
• Le traitement diurétique des patients présentant une insuffisance rénale chronique (IRC) doit être individualisé. Il est essentiel d'adapter le type de diurétique, la dose et le schéma posologique aux besoins spécifiques et au stade de l'IRC de chaque patient.
• Chez les patients présentant une IRC traités par diurétiques, une surveillance étroite des électrolytes, de la fonction rénale et de la pression artérielle est essentielle pour assurer une diurèse sûre et efficace.
• L'association de diurétiques avec d'autres antihypertenseurs et une restriction sodée alimentaire peut optimiser le contrôle de la pression artérielle et minimiser les effets secondaires des diurétiques.
• En cas de résistance aux diurétiques, l'utilisation combinée de diurétiques de l'anse et de diurétiques thiazidiques peut être bénéfique lorsque la monothérapie s'avère inefficace.
• Pour que le traitement soit efficace, il est important de donner aux patients les moyens de comprendre leur régime diurétique, ses effets secondaires potentiels et l'importance de l'observance. Des outils simples tels qu'un tensiomètre automatique pour surveiller la tension artérielle et une balance pour détecter une éventuelle surcharge volumique peuvent être utiles.

An umbrella review of systematic reviews and meta-analyses for assessment and treatment of acute shoulder dislocation.
Gonai S, Miyoshi T, da Silva Lopes K, Gilmour S. | Am J Emerg Med. 2025 Jan;87:16-27
DOI: https://doi.org/10.1016/j.ajem.2024.09.060
Keywords: Dislocation; Meta-analysis; Reduction; Shoulder; Systematic review; Umbrella review.

Article

Introduction : This study aims to provide a comprehensive review of the current evidence on accurate and rapid diagnostic methods, effective and safe shoulder dislocation reduction techniques, pharmacological treatment, and post-reduction care for acute anterior shoulder dislocation in the emergency department (ED).

Méthode : We conducted a systematic review of the literature up to December 31, 2022, with an additional search conducted up to August 31, 2024. Databases searched included Cochrane Database of Systematic Reviews, MEDLINE, Embase, CINAHL, DARE, PROSPERO, OpenGrey, and Google Scholar. We reviewed systematic reviews and meta-analyses on assessment and intervention for acute anterior shoulder dislocation. Data extraction and quality assessment were performed independently by two reviewers. The quality of evidence was evaluated using the Cochrane Risk of Bias tool and the GRADE approach, while the methodology was assessed using AMSTAR 2.

Résultats : From an initial 1345 records, 30 studies met the inclusion criteria. These included 4 articles on point-of-care ultrasound (POCUS), 5 on analgesia and anesthesia, 3 on closed reduction techniques, 10 on surgical Bankart repair, 9 comparing external and internal rotation immobilization, and 1 on nerve injuries, including duplicates. POCUS demonstrated high diagnostic accuracy comparable to radiography for shoulder dislocations and associated fractures. Analgesia and anesthesia studies showed that intra-articular anesthesia (IAA) is as effective as intravenous sedation (IVS) with fewer adverse events and shorter ED stays. Three meta-analyses on closed reduction techniques revealed no significant differences in success rates among various methods, but the FARES method was noted for superior pain management. Ten reviews on surgical Bankart repair consistently showed reduced redislocation rates, especially in younger patients, compared to non-surgical treatments including internal and external rotation immobilization. Four recent reviews reported external rotation immobilization was more effective than internal rotation in preventing redislocations. Nerve injuries were common, with the axillary nerve most frequently affected.

Conclusion : Emergency physicians managing anterior shoulder dislocation should employ POCUS for diagnosis, prioritize intra-articular anesthesia, master various reduction techniques including the FARES method, refer patients to an orthopedic surgeon for follow-up and potential surgery to prevent redislocation, and be vigilant about nerve damage.

Conclusion (proposition de traduction) : Les médecins urgentistes qui prennent en charge une luxation antérieure de l'épaule devraient utiliser l'échographie au point de service pour le diagnostic, donner la priorité à l'anesthésie intra-articulaire, maîtriser diverses techniques de réduction, y compris la méthode FARES, adresser les patients à un chirurgien orthopédique pour un suivi et une éventuelle intervention chirurgicale afin de prévenir une nouvelle luxation, et être vigilants en ce qui concerne les lésions nerveuses.

Commentaire : La méthode FARES (rapide, fiable, sûre) utilise des oscillations de diversion antéro-postérieures, l'abduction avec traction douce, plus une rotation externe si nécessaire. Aucune contre-traction n'est utilisée. Cette technique ne nécessite qu'un seul opérateur et peut être effectuée doucement, parfois sans analgésie.

1. Demandez au patient de s'allonger sur un brancard, le bras atteint près du bord. Appliquez une traction vers vous tout en déplaçant doucement le bras de haut en bas à environ 5 cm de la position neutre, à raison de deux cycles de montée et de descente par seconde.
2. Tout en tirant le bras vers vous et en oscillant de haut en bas, commencez l'abduction lentement du bras en l'éloignant du côté du patient. Continuez cette technique jusqu'à ce que vous ayez fait osciller le bras pour atteindre 90° d'abduction de l'épaule. Cela peut prendre plus de deux minutes.
3. Tout en continuant à osciller et l'abduction du bras, effectuez une légère rotation externe de l'épaule. Vous sentirez un bruit sourd lorsque l'épaule se remettra en place.
4. La réduction se produit généralement lorsque vous atteignez 120° d'abduction, mais si elle se produit un peu plus tôt, arrêtez-vous.
5. Une fois l'épaule remise en place, effectuez une légère rotation interne de l'épaule et amenez l'avant-bras sur la poitrine, la main affectée touchant l'épaule opposée.