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.

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.

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.