Risk of Delayed Intubation After Presumed Opioid Overdose in the Emergency Department.
McCabe DJ, Gibbs H, Pratt AA, Culbreth R, Sutphin AM, Abston S, Li S, Wax P, Brent J, Campleman S, Aldy K, Falise A, Manini AF; ToxIC Fentalog Study Group. | Ann Emerg Med. 2025 Jun;85(6):498-504
DOI: https://doi.org/10.1016/j.annemergmed.2025.01.022
Keywords: Intubation; Opioid; Overdose.

TOXICOLOGY/ORIGINAL RESEARCH

Editorial : The objective of this study was to evaluate the optimal duration of monitoring for patients with presumed opioid overdoses prior to a non-ICU admission, particularly in the context of the increasing prevalence of fentanyl analogs and other potent synthetic opioids. Given the critical role of emergency physicians in managing this public health crisis, the study aims to inform clinical decisionmaking regarding patient disposition after the initial overdose treatment.

Introduction : The Fentalog Study, conducted through the American College of Medical Toxicology's Toxicology Investigators Consortium, is a prospective, multi-institutional project designed to identify patients presenting to the emergency department with acute opioid overdose, gather clinical details, and confirm substances through biologic testing. This study is a secondary analysis of the Fentalog Study that assessed the risk of "delayed intubation," defined as any intubation occurring after 4 hours of arrival to the emergency department.

Méthode : Of the 1,591 patients included, only 9 (0.6%) required delayed intubation. Eight of these patients had nonrespiratory-related conditions contributing to the need for intubation. One patient only had respiratory-related conditions, had respiratory acidosis, and received a total of 6.4 mg naloxone before intubation.

Conclusion : This study provides evidence that delayed intubation after 4 hours of monitoring in patients with presumed opioid overdose is exceedingly rare.

Conclusion (proposition de traduction) : Cette étude démontre que l'intubation retardée après 4 heures de surveillance chez les patients présentant une suspicion de surdosage aux opiacés est extrêmement rare.

Dose-dependent side effects of prehospital analgesia with ketamine for winter sports injuries - an observational study.
Steffen R, Werlen D, Huber M, Knapp J. | BMC Emerg Med. 2025 Jun 7;25(1):92
DOI: https://doi.org/10.1186/s12873-025-01252-6  | Télécharger l'article au format  
Keywords: Emergency medicine; Ketamine; Prehospital analgesia; Trauma management.

Research

Introduction : Ketamine is one of the most used drugs in trauma patients after skiing accidents. However, the environmental conditions for these patients are often rough, with numerous unpleasant sensory impressions (e.g. noise from the helicopter, cold, wind, etc.), raising concerns about the adverse psychological side effects of ketamine. Moreover, it has not yet been established whether these side effects are dose-dependent, and the supplementary administration of benzodiazepines remains controversial. We analysed the subjective perception of side effects after administration of ketamine during helicopter emergency medical service missions involving trauma patients after ski accidents.

Méthode : In this retrospective observational study, data was collected from emergency services protocols and questionnaires filled out by patients. The primary outcome was defined as the patients' subjective perceptions of ketamine-associated side effects. The subjective intensity of twelve common classes of side effects was recorded on a five-point Likert scale. In addition, we conducted a linear regression analysis, with side effect intensity as the outcome and gender, age, type of injury, use of midazolam and fentanyl, ketamine dosage and relative pain reduction as covariates.

Résultats : A total of 69 patients were identified who were treated with ketamine during the winter months of 2023/2024, after suffering trauma while doing alpine winter sports. Of these, 49 patients (71%) could be included. The side effects reported were mostly mild, with two-thirds of the patients describing them as "no [side effects]" or "mild". Only 6% described them as "barely tolerable" or "unbearable". No statistically significant association could be demonstrated between the ketamine dose and the total reported side effect score. The regression model identified the additional administration of midazolam as a significant covariate for fewer side effects. With regard to prehospital care, 85% of the patients stated that they had always felt safe, while two-thirds were satisfied with the prehospital pain therapy.

Conclusion : Ketamine seems to be a suitable option for pain therapy in the case of injuries during alpine winter sport activities. Side effects reported by patients in this study were rare, not dose-dependent and described by most patients as subjectively well tolerable. The supplementary administration of midazolam could potentially further reduce these side effects.

Conclusion (proposition de traduction) : La kétamine semble être une option appropriée pour le traitement de la douleur en cas de blessures lors de la pratique de sports d'hiver alpins. Les effets secondaires rapportés par les patients dans cette étude étaient rares, non liés à la dose et décrits par la plupart des patients comme subjectivement bien tolérés. L'administration supplémentaire de midazolam pourrait potentiellement réduire davantage ces effets secondaires.

Diuretics in critically ill patients: a narrative review of their mechanisms and applications.
Coppola S, Chiumello D, Adnan A, Pozzi T, Forni LG, Gattinoni L. | Br J Anaesth. 2025 Jun;134(6):1638-1647
DOI: https://doi.org/10.1016/j.bja.2025.02.032  | Télécharger l'article au format  
Keywords: ICU; congestive heart failure; diuretic; diuretic resistance; fluid overload; renal physiology.

CRITICAL CARE

Editorial : Diuretics remain the cornerstone therapy of critically ill patients with volume overload as a result of cardiac failure, acute kidney injury or aggressive fluid resuscitation. This review summarises the principles of applied renal physiology, describing the mechanisms of action, the clinical applications, and the adverse effects of commonly used diuretics during critical illness. Loop diuretics, and in particular furosemide, remain the most popular, despite evidence of any effect on mortality or, indeed, on the need for renal replacement therapy. The efficacy of loop diuretics after administration depends on three factors. Firstly, the tubular concentration of the diuretic: continuous infusion of furosemide seems to provide a higher and more stable tubular concentration of furosemide with respect to bolus injection. Secondly, the interaction with albumin both in the plasma and in the renal tubule: despite a strong physiological rationale supporting this approach, albumin supplementation in hypoalbuminaemic patients does not seem to result in a higher diuretic efficacy. Thirdly, diuretic resistance, which can be addressed by optimising loop diuretic dose and by using combination therapy with other agents, including thiazides or thiazide-like diuretics or carbonic anhydrase inhibitors. These drugs constitute a useful adjunct to overcome loop diuretic resistance. Other agents such as distal potassium-sparing diuretics and osmotic diuretics can also be considered. The latter have been used successfully in hypokalaemia, rhabdomyolysis-associated acute kidney injury or to prevent ischaemia-reperfusion injury in kidney transplantation. Finally, this review provides the basic concepts of the interplay between acid-base equilibrium and diuretic therapy.

Conclusion : Diuretics are among the most commonly prescribed drugs in the critically ill. Despite this, there is a relative lack of information regarding outcome data and most appropriate dosing regimens. Moreover, the use of different diuretic classes and indeed combination therapy is an area where further data are needed. We have outlined a practical approach to diuretic administration with consideration given to diuretic resistance. The effects of diuretic on acidebase balance are considerable and the reader should now be versed in the effects of diuretics to this end. Although pragmatically diuretic administration is almost universal in the ICU, there is a dearth of evidence to support not only our treatment approach, but also much of our daily practice. Starting from physiological knowledge, in the clinical practice we should aim for nephroprotection, choosing the most appropriate diuretic in the most effective dose for every clinical scenario.

Conclusion (proposition de traduction) : Les diurétiques font partie des médicaments les plus couramment prescrits aux malades en réanimation. Malgré cela, il y a un manque relatif d'informations concernant les effets et les schémas posologiques les plus appropriés. En outre, l'utilisation de différentes classes de diurétiques, voire de traitements combinés, est un domaine dans lequel des données supplémentaires sont nécessaires. Nous avons présenté une approche pratique de l'administration des diurétiques en tenant compte de la résistance aux diurétiques. Les effets des diurétiques sur l'équilibre acido-basique sont considérables et le lecteur doit maintenant être familiarisé avec les effets des diurétiques à cette fin. Bien que, de manière pragmatique, l'administration de diurétiques soit presque universelle dans les unités de soins intensifs, il y a un manque de preuves pour appuyer non seulement notre approche thérapeutique, mais aussi une grande partie de notre pratique quotidienne. En partant des connaissances physiologiques, dans la pratique clinique, nous devrions viser la néphroprotection, en choisissant le diurétique le plus approprié à la dose la plus efficace pour chaque scénario clinique.

CPR quality data collection: building the foundation for a Cardiac Arrest Quality Improvement Program.
Cheng A, Drennan IR, Lauridsen KG. | CJEM. 2025 Jun;27(6):411-413
DOI: https://doi.org/10.1007/s43678-025-00939-w  | Télécharger l'article au format  
Keywords: Aucun

Editorial

Editorial : Cardiopulmonary resuscitation (CPR) quality is a critically important variable in determining survival outcomes from cardiopulmonary arrest. Front-line acute care providers struggle to consistently adhere to American Heart Association (AHA) guidelines for cardiopulmonary arrest despite being certified in both Basic and Advanced Cardiac Life Support. Healthcare professionals in emergency departments are often ‘flying blind’—providing CPR to cardiac arrest patients and debriefing resuscitation attempts without measuring, reviewing, and discussing CPR quality during or after the event. How are we to improve CPR performance and cardiac arrest survival rates if we don’t know where to target our quality improvement efforts?

Conclusion : The path to improving CPR quality in clinical practice is complex. There is a need for multifactorial interventions focused on both frequent and contextualized training and improving clinical team performance via clinical protocols, debriefings, and organizational optimizations with a focus on continuous improvements over time. We hope emergency department leaders and quality improvement officers will look to Mok et al.’s program as an example of the critical steps required to lay the foundation for a cardiac arrest quality improvement program, and in turn, provide hope for improving cardiac arrest survival outcomes in the future.

Conclusion (proposition de traduction) : La voie à suivre pour améliorer la qualité de la RCP dans la pratique clinique est complexe. Il est nécessaire de mettre en place des interventions multifactorielles axées sur une formation régulière et contextualisée et sur l'amélioration des performances de l'équipe clinique par le biais de protocoles cliniques, de débriefings et d'optimisations organisationnelles, en mettant l'accent sur des améliorations continues au fil du temps. Nous espérons que les responsables des services d'urgence et les responsables de l'amélioration de la qualité considéreront le programme de Mok et al. comme un exemple des étapes critiques requises pour jeter les bases d'un programme d'amélioration de la qualité en matière d'arrêt cardiaque et, en retour, comme un moyen d'espérer améliorer les résultats en matière de survie à l'arrêt cardiaque à l'avenir.

Commentaire :  Boucles de rétroaction dans un programme d'amélioration de la qualité des arrêts cardiaques, comprenant la collecte de données sur la qualité de la RCP, la rétroaction sur la RCP, le coaching en RCP et le débriefing structuré dans le cadre d'une simulation et de soins d'arrêts cardiaques réels.
Mok G, Vaillancourt S, Fu M, Gray S, Chartier LB, Wong N, Allan KS, Warsi F, Callender C, McGowan M, Petrosoniak A. Implementation of a CPR quality data collection program in the emergency department: a quality improvement initiative. CJEM. 2025 Jun;27(6):451-459  .

How does use of a liberal or restrictive blood transfusion strategy influence neurological outcome in patients with acute brain injury?.
Jones C, Murphy L, Nunn J. | CJEM. 2025 Jun;27(6):438-439
DOI: https://doi.org/10.1007/s43678-025-00909-2
Keywords: Aucun

Need to Know: CJEM Journal Club

Introduction : Critically ill patients with acute brain injury are vulnerable to changes in oxygen delivery. In these patients, anemia is associated with increased morbidity and mortality; however, the optimal transfusion threshold is unknown.

Méthode : To assess the impact of different blood transfusion thresholds on neurologic outcome in patients with acute brain injury.
Multi-centre, parallel-group, pragmatic, open-label randomized control trial.
Setting: 72 intensive care units (ICU) in 22 countries.
Subjects: Adults admitted to European ICUs with acute brain injury. The lead investigators are based in Belgium. Patients with GCS 13 or less, expected ICU stay of ≥ 3 days, and hemoglobin level of ≤ 9 g/dL or were eligible.
Intervention: Patients were randomized in a 1:1 ratio to administration of one unit of packed red blood cells (pRBC) for liberal transfusion (hemoglobin < 9 g/dL) and restrictive transfusion (hemoglobin < 7 g/dL).
Outcomes: The primary outcome measure was proportion of patients with unfavourable neurologic outcome at 180 days, assessed by the Glasgow Outcome Scale Extended (GOS-E).

Résultats : A total of 806 patients were included in the primary outcome analysis. In the liberal group, patients received a median of 2 pRBC transfusions. Patients in the restrictive group received a median of 0 transfusions. At 180 days, 62.6% of patients in the liberal strategy group, and 72.6% in the restrictive strategy group had an unfavorable GOS-E score ≤ 5 (ARR 10%, 95% CI 4–17%). There were no differences in secondary outcomes including 28-day mortality, organ failure, and ICU length of stay. There were fewer cerebral ischemia events in the liberal group compared with the restrictive group (8.8% vs 13.5%, 95% CI 0.44–0.97). Results were consistent across all subgroups of brain injury that were studied.

Conclusion : In this large, multi-center RCT, the authors demonstrate lower probability of unfavorable neurological outcomes at 6-months using a liberal transfusion strategy for patients with acute brain injury and anemia.

Conclusion (proposition de traduction) : Dans cet essai clinique randomisé multicentrique de grande envergure, les auteurs ont démontré que la probabilité d'une évolution neurologique défavorable à 6 mois était plus faible en utilisant une stratégie de transfusion libérale pour les patients souffrant de lésions cérébrales aiguës et d'anémie.

The fulcrum: a novel technique for reduction of shoulder dislocations.
Carr P, Maracle J. | CJEM. 2025 Jun;27(6):491-493
DOI: https://doi.org/10.1007/s43678-025-00907-4  | Télécharger l'article au format  
Keywords: Emergency medicine; Glenohumeral dislocation; Orthopedic procedures; Shoulder dislocation.

Clinical Correspondence

Editorial : Shoulder dislocation is a common presentation to the emergency department (ED) with recent data from the United States putting the annual incidence at 23.96 per 100,000 persons [1]. In the literature, failure rates are often reported at approximately 8% with delay to treatment being associated with higher failure rates for closed reduction [2]. Many techniques have been described to achieve anatomic reduction of these injuries (Table 1), each with benefits and drawbacks. Factors including patient anatomy, habitus, and type of dislocation can provide challenges achieving reduction. Additionally, bed availability and staff requirements for sedated reductions can delay treatment for patients and impair department flow in general.

Conclusion : The fundamental concept of The Fulcrum technique is that manipulation of a deformity should be focused on the point of injury so that forces are maximal at the area of interest, thereby minimizing total force required and movement of the injured extremity. The technique is usually well tolerated and can be used as the primary approach with or without sedation. Fundamentals of the Fulcrum technique have shown promise in our practice for reduction of other injuries including distal femur fractures and metacarpal fractures. Additional research is required to determine ideal and safe application of the concepts described here.
Orthopedic surgery consultation is strongly recommended prior to attempting any reduction technique in complicated dislocations.

Conclusion (proposition de traduction) : Le concept fondamental de la technique Fulcrum est que la manipulation d'une anomalie doit être concentrée sur le centre de la lésion afin que les forces soient maximales dans la zone concernée, minimisant ainsi la force totale requise et le mouvement de l'extrémité blessée. Cette technique est généralement bien tolérée et peut être utilisée comme approche primaire avec ou sans sédation. Les principes fondamentaux de la technique Fulcrum se sont révélés prometteurs dans notre pratique pour la réduction d'autres lésions, notamment les fractures du fémur distal et les fractures du métacarpe. Des recherches supplémentaires sont nécessaires pour déterminer l'application idéale et sûre des concepts décrits ici.
Il est fortement recommandé de consulter un chirurgien orthopédique avant d'essayer une technique de réduction dans le cas de luxations compliquées.

Commentaire :  L'emboîtement des avant-bras permet au médecin d'exercer une force dans tous les axes, le bras libre étant placé dans l'aisselle comme point d'appui.

Empiric antibiotic therapy for moderate to severe community-acquired pneumonia: a systematic review and network meta-analysis.
Ghadimi M, Siemieniuk RAC, Loeb M, Lima JP, Aminaei D, Gomaa H, Wang Y, Hazzan AA, Basmaji J, Yao L, Kim WSH, Grant A, Agarwal A, Motaghi S, Tajika A, Takayama T, Alvarado-Gamarra G, Kirmayr K, Muti Schuenemann GE, Zandieh S, Das A, Manja V, Momenilandi F, Likhvantsev V, Couban R, Sadeghirad B, Brignardello-Petersen R, Guyatt G. | Clin Microbiol Infect. 2025 Jun 30:S1198-743X(25)00320-9.
DOI: https://doi.org/10.1016/j.cmi.2025.06.033  | Télécharger l'article au format  
Keywords: adverse events; all-cause mortality; community-acquired pneumonia; empiric antibiotic therapy; moderate to severe; network meta-analysis; systematic review; treatment failure.

SYSTEMATIC REVIEW

Introduction : The optimal empiric antibiotic regimen for moderate to severe community-acquired pneumonia (CAP) is uncertain.
Objectives: To compare the effects of antibiotics for empiric therapy of moderate to severe CAP using a network meta-analysis (NMA).

Méthode : Medline, EMBASE, Cochrane CENTRAL, Web of Science, and CINAHL from inception to July 03, 2024.
Study eligibility criteria: Randomized controlled trials (RCT).
Participants: Adults with moderate to severe CAP.
Interventions: Any empiric antibiotic regimen versus another, placebo, or no treatment.
Assessment of risk of bias: Paired reviewers independently assessed risk of bias using a modified Cochrane tool for assessing risk of bias in randomized trials.
Methods of data synthesis: We conducted frequentist random-effects NMAs addressing patient-important outcomes and assessed the certainty of evidence using the GRADE approach.

Résultats : 143 RCTs involving 29,157 participants proved eligible. Effects are in comparison with respiratory fluoroquinolones alone. Penicillins alone (RR 1.25, 95% CI 0.93 to 1.67; RD 33 more per 1000, 95% CI 9 fewer to 88 more), 2nd generation cephalosporins alone (RR 1.34, 95% CI 0.89 to 2.02; RD 45 more per 1000, 95% CI 15 fewer to 135 more), and 3rd generation cephalosporins alone (RR 1.32, 95% CI 0.99 to 1.77; RD 42 more per 1000, 95% CI 1 fewer to 102 more) or combined with a macrolide (RR 1.34, 95% CI 0.98 to 1.84; RD 45 more per 1000, 95% CI 3 fewer to 111 more) may be inferior in reducing treatment failure (all low certainty). The evidence among other antibiotic regimens for treatment failure and among all regimens for all-cause mortality, duration of hospitalization, and adverse events suggested little to no difference (in most cases with low certainty) or was very low certainty.

Conclusion : For empiric treatment of moderate to severe CAP, none of the antibiotic regimens provided convincing evidence of important differences in any of the outcomes.

Conclusion (proposition de traduction) : Pour le traitement probabiliste de la pneumonie communautaire modérée à sévère, aucun des schémas thérapeutiques antibiotiques n'a fourni de preuves convaincantes de différences importantes dans l'un ou l'autre des résultats.

Recognising high-pressure injection injuries to the hand: a practice review with guidance for emergency physicians.
Cornely RM, Abbott EN, Gutama B, Savitz B, Torres-Guzman R, Rogers JL, Valmadrid AC, Lineaweaver WC. | Emerg Med J. 2025 Jun 30:emermed-2024-214689
DOI: https://doi.org/10.1136/emermed-2024-214689
Keywords: emergency medicine; extremity; hand injuries; management.

Practice review

Editorial : Les pistolets pneumatiques à haute pression, couramment utilisés en milieu industriel pour des tâches telles que la peinture et le nettoyage, présentent un risque important de lésions de la main car ils peuvent générer des pressions allant jusqu'à 827.37 Bar. Malgré leur rareté, ces blessures peuvent avoir de graves conséquences, notamment une atteinte fonctionnelle permanente et un risque élevé d'amputation. Souvent sous-estimées dans le milieu de travail communautaire, les lésions par injection à haute pression (LHP) échappent fréquemment à un dépistage précoce, ce qui entraîne des conséquences dommageables. À l'aide de deux cas représentatifs, cette revue des pratiques décrit les difficultés liées à la reconnaissance et à la prise en charge de ces blessures, en soulignant la nécessité d'une sensibilisation accrue des praticiens des services d'urgence. La reconnaissance précoce est à la fois difficile et cruciale, car elle facilite l'orientation en temps utile vers des spécialistes de la main pour une prise en charge complète, améliorant ainsi les conséquences pour le patient. La standardisation des lignes directrices en matière de diagnostic est également considérée comme un sujet de travail futur susceptible d'avoir un impact. En répondant à ces priorités, nous pouvons améliorer les soins aux patients et atténuer le coût de ces lésions pour les individus et les communautés.

Conclusion : Early recognition and comprehensive management of patients with HPII of the hand are critical to optimising outcomes. In the available case scenarios, we outline the significance of injected substance and the differing outcomes associated with the composition of the material. Non-surgical healthcare workers, especially ED providers, play a critical role in this process. ED provider recognition of the signs of HPII and initiating prompt clinical workup are essential components of effective clin- ical practice. Establishing clear guidelines for communication between ED providers and hand specialists can foster impactful cross-specialty collaboration. We recognise a clear call to action for improving the recognition and management of these injuries, emphasising the need for heightened awareness, standardised diagnostic algorithms and ongoing education and training initiatives. By prioritising early intervention and comprehensive management, we can enhance patient outcomes and mitigate the burden of HPII on the hand.

Conclusion (proposition de traduction) : L'identification précoce et la prise en charge globale des patients souffrant de blessures par injection à haute pression dans la main sont essentielles pour optimiser les résultats. Dans les scénarios de cas disponibles, nous soulignons l'importance de la substance injectée et les différents résultats associés à la composition du matériau. Le personnel soignant non chirurgical, en particulier les urgentistes, joue un rôle essentiel dans ce processus. L'identification par le personnel des urgences des signes de blessures par injection à haute pression et la mise en place d'un bilan clinique rapide sont des éléments essentiels d'une pratique clinique efficace. L'établissement de recommandations claires pour la communication entre les urgentistes et les spécialistes de la main peut favoriser une collaboration interspécialités efficace. Nous reconnaissons un appel clair à l'action pour améliorer la reconnaissance et la prise en charge de ces lésions, en soulignant la nécessité d'une sensibilisation accrue, d'algorithmes de diagnostic standardisés et d'initiatives d'éducation et de formation continues. En donnant la priorité à une intervention précoce et à une prise en charge globale, nous pouvons améliorer les résultats pour les patients et atténuer le coût des lésions dues aux injections à haute pression dans la main.

Ten tips for managing caustic ingestion in adult patients.
Walter T, Gosselin S, Deniau B. | Intensive Care Med. 2025 Jun;51(6):1164-1167
DOI: https://doi.org/10.1007/s00134-025-07920-2  | Télécharger l'article au format  
Keywords: Aucun

What’s New in Intensive Care

Editorial : Caustic or corrosive ingestion in adult patient is a rare but potentially life-threatening condition with a mortality of 10% among intensive care unit (ICU) patients. This narrative review outlines ten essential tips for managing patients with caustic ingestion.

Conclusion : (1) Intubate early and look for signs of hollow organ perforation
(2) Do not use activated charcoal, insert nasogastric tube, provoke vomiting or make patient drink
(3) Determine the composition of the product
(4) Carefully check for co-intoxication
(5) Call a referral center to discuss orientation and management
(6) Correct any systemic effect of the caustic substance
(7) Avoid endoscopy-based strategies for early caustic ingestion assessment
(8) Perform a CT scan 6 h post-ingestion to guide surgical decisions
(9) Bronchoscopy is mandatory before surgical treatment
(10) In the absence of surgical treatment, start rehabilitation early

Conclusion (proposition de traduction) : (1) Intubation précoce et recherche de signes de perforation des organes creux
(2) Ne pas utiliser de charbon actif, ne pas insérer de sonde gastrique, ne pas provoquer de vomissements et ne pas faire boire le patient
(3) Déterminer la composition du produit
(4) Vérifier soigneusement l'absence de coïntoxication
(5) Appeler un centre de référence pour discuter de l'orientation et de la prise en charge
(6) Corriger tout effet systémique de la substance caustique
(7) Éviter les stratégies basées sur l'endoscopie pour l'évaluation précoce de l'ingestion de substances caustiques
(8) Réaliser un scanner 6 heures après l'ingestion pour guider les décisions chirurgicales
(9) La bronchoscopie est obligatoire avant le traitement chirurgical
(10) En l'absence de traitement chirurgical, commencer la rééducation rapidement.

Commentaire :  Classement par le World Journal of Emergency Surgery des lésions caustiques de l'estomac et de l'œsophage et résumé des dix conseils pour la prise en charge de l'ingestion de produits caustiques

PENG, fascia-iliaca compartment block or femoral nerve block for pain management of patients with hip fractures.
Dolstra J, Vlieg H, Haak SL, Ter Avest E, Boerma EC, Lameijer H. | Am J Emerg Med. 2025 Jun 4;96:15-24.
DOI: https://doi.org/10.1016/j.ajem.2025.06.009  | Télécharger l'article au format  
Keywords: Anesthesia; Emergency department; Fascia iliaca compartment block; Femoral nerve block; Hip fracture; Pericapsular nerve group block; Ultrasound.

Article

Introduction : Currently three types of regional nerve blocks are commonly administered to provide analgesia to patients with hip fractures; the Fascia-Iliaca Compartment Block (FICB), Femoral Nerve Block (FNB) and Pericapsular Nerve Group Block (PENG). It is unclear which of these provides the best analgesia and the lowest number of complications.

Méthode : This systematic review aims to evaluate the literature concerning the efficacy and safety of pre-operatively placed PENG block compared to FICB and FNB for hip fractures.
Methods: The PRISMA statement guidelines were used and a systematic search of MEDLINE (via Ovid), Embase, Web of Science and Google Scholar was performed until April 8th, 2024.

Résultats : Out of 118 identified studies, 17 (14 RCTs, 3 observational) met the inclusion criteria, of which 5 exhibited a low risk of bias. Pain scores were significantly lower with the PENG block compared to FICB/FNB in 12 of 17 studies, while 5 reported no difference. Opioid use was lower in 4 of 11 studies favoring PENG, while the other 7 showed no differences with FICB/FNB. Patient satisfaction was found to be higher in PENG in 5 studies, while 2 other reported no difference. Ease of spinal positioning was better with PENG in 4 studies, with 3 reporting no difference. Adverse events showed no significant differences between blocks. None of the studies found FNB or FICB to be favorable on any of these outcomes.

Conclusion : PENG block may be a promising technique to provide analgesia to patients with hip fractures. However, there was significant heterogeneity in endpoints used and in outcomes of the various studies that compared PENG with FNB or FICB blocks. Also, only one study was conducted in the emergency department (ED). Larger randomized controlled trials with patient-centred outcomes in the ED-setting are required to definitively establish which nerve block is most effective.

Conclusion (proposition de traduction) : Le bloc PENG peut être une technique prometteuse pour fournir une analgésie aux patients souffrant de fractures de la hanche. Cependant, il existe une hétérogénéité significative dans les critères d'évaluation utilisés et dans les résultats des différentes études qui ont comparé le bloc PENG avec le bloc du nerf fémoral ou le bloc du compartiment ilio-fascial. En outre, une seule étude a été réalisée dans le service des urgences. Des essais contrôlés randomisés de plus grande envergure avec des résultats centrés sur le patient dans le contexte du service des urgences sont nécessaires pour établir définitivement quel bloc nerveux est le plus efficace.

Emergency medicine updates: Acute respiratory distress Syndrome.
Long B, Lentz S, Gottlieb M. | Am J Emerg Med. 2025 Jun 27;96:208-216
DOI: https://doi.org/10.1016/j.ajem.2025.06.066
Keywords: ARDS; Acute respiratory distress syndrome; Corticosteroids; Critical care; Fluids; Hypoxemia; Neuromuscular blocking agents; Pulmonary; Pulmonology; Recruitment maneuver; Resuscitation; Tidal volume; Ventilation.

Review article

Introduction : Acute respiratory distress syndrome (ARDS) is a critical condition associated with severe morbidity and mortality. There are several components of management, and it is important for emergency clinicians to be aware of these as they manage critically ill patients who may face extended time in the emergency department.

Méthode : This paper evaluates evidence-based updates concerning ARDS.

Discussion : ARDS is a condition associated with diffuse, severe lung inflammation resulting in hypoxemic respiratory failure. While there have been several definitions, the most recent conceptual model is based on the revised Berlin definition and incorporates risk factors, the underlying etiology, timing, chest imaging, and oxygenation. Management is primarily based on ventilation and oxygenation, with literature demonstrating that low tidal volumes (4-8 mL/kg of predicted body weight) with plateau pressure ≤30 cm H2O are associated with improved outcomes, and settings should be optimized to target driving pressure < 15 cm H2O. Resuscitation with intravenous fluids should be individualized, though overall a net neutral-to-negative fluid balance may be beneficial. Steroids should be considered in those with moderate-to-severe ARDS within 14 days of onset, but administration past 14 days after ARDS onset may worsen outcomes. Neuromuscular blocking agents may be used in those with severe ARDS and refractory hypoxemia or ventilator dyssynchrony. Prone positioning should be considered in patients with moderate-to-severe ARDS who fail to improve despite lung-protective ventilation or in those with high ventilator settings and should ideally be performed for at least 12-16 consecutive hours per day. Patients with severe ARDS refractory to low tidal volume ventilation and other adjunctive therapies may be managed with veno-venous extracorporeal membrane oxygenation (ECMO) at an ECMO center.

Conclusion : An understanding of literature updates can improve the ED care of patients with ARDS.

Conclusion (proposition de traduction) : La compréhension des mises à jour de la littérature peut améliorer la prise en charge aux urgences des patients atteints de SDRA.