Effectiveness of Point-of-Care High-Sensitivity Troponin Testing in the Emergency Department: A Randomized Controlled Trial.
Thulin VIL, Jordalen SMF, Myrmel GMS, Lekven OC, Krishnapillai J, Steiro OT, Body R, Collinson P, Apple FS, Cullen L, Norekvål TM, Wisløff T, Vikenes K, Bjørneklett RO, Omland T, Aakre KM. | Ann Emerg Med. 2025 Aug;86(2):124-135
DOI: https://doi.org/10.1016/j.annemergmed.2025.03.005
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Keywords: Accelerated diagnostic protocol; Acute coronary syndrome; Cardiac biomarkers; Chest pain; Emergency department crowding
CARDIOLOGY/ORIGINAL RESEARCH
Introduction : To compare the effectiveness of high-sensitivity cardiac troponin (hs-cTn) point-of-care testing to central laboratory hs-cTn measurements when investigating patients presenting to the emergency department (ED) with symptoms of acute coronary syndrome.
Méthode : The WESTCOR point-of-care study was a single-center prospective randomized controlled trial where we randomized patients presenting with possible acute coronary syndrome in a 1:1 fashion to receive either 0/1-hour centralized hs-cTnT measurements (control) or 0/1-hour point-of-care hs-cTnI testing (intervention). We defined length of stay (LOS) in the ED as the primary endpoint and the minimum clinically meaningful difference as 15 minutes.
Résultats : We included 1,494 patients in the final analysis, 728 in the point-of-care group, and 766 in the control group. The median (interquartile range) age was 61 (22) years, and 635 (42.5%) were women. Median LOS in the ED was 174 (95% confidence interval [CI] 167 to 181) and 180 (95% CI 175 to 189) minutes in the point-of-care and control group, respectively, resulting in a reduction in median LOS of 6 minutes (95% CI -4 to 17). Acute myocardial infarction, death, or acute revascularization occurred in 83/728 (11.4%) of point-of-care and 72/766 (9.4%) of control patients.
Conclusion : We found that implementing point-of-care hs-cTnI testing in the ED with a 0/1-hour diagnostic algorithm did not lead to a clinically meaningful reduction in ED LOS. We observed no difference in the incidence of myocardial infarction, acute coronary revascularization, or death during 30 days follow-up.
Conclusion (proposition de traduction) : Nous avons constaté que la mise en œuvre de tests hs-cTnI au point d'intervention dans les services d'urgence avec un algorithme de diagnostic 0/1 heure n'entraînait pas de réduction cliniquement significative de la durée du séjour aux urgences. Nous n'avons observé aucune différence dans l'incidence des infarctus du myocarde, des revascularisations coronariennes aiguës ou des décès au cours des 30 jours de suivi.
Intubation Practices in Community Emergency Departments.
Kei J, Eurick T, Hauck TA. | Ann Emerg Med. 2025 Aug;86(2):169-174
DOI: https://doi.org/10.1016/j.annemergmed.2024.11.021
Keywords: Airway; Endotracheal Intubation; Rapid Sequence Intubation.
AIRWAY/BRIEF RESEARCH REPORT
Introduction : This study analyzes emergency medicine airway management trends and outcomes among community emergency departments.
Méthode : A multicenter, retrospective chart review was conducted on 11,475 intubations from 15 different community emergency departments between January 1, 2015, and December 31, 2022. Data collected included patient's age, sex, rapid sequence intubation medications, use of cricoid pressure, method of intubation, number of attempts, admission diagnosis, and all-cause mortality rates.
Résultats : Active cardiopulmonary resuscitation occurred in 11.4% of intubations. When rapid sequence intubation was employed, the most frequently used induction agents were etomidate (91.6%), propofol (4.3%), and ketamine (4.1%). From 2015 to 2022, the use of rocuronium (versus succinylcholine) increased from 33.9% to 61.9%, a difference of 28% (95% confidence interval [CI] 21.1% to 34.9%). During the same period, video laryngoscopy (versus direct laryngoscopy) increased from 27.4% to 77.7%, a difference of 50.3% (95% CI 44.2% to 56.4%). Only 46% of intubations used cricoid pressure. Physicians had a first-pass success rate of 80.5% and a failure rate of 0.2%. The most common documented admission diagnoses among intubated patients were respiratory etiologies (27.8%), neurologic causes (21.4%), and sepsis (16.0%). All-cause mortality rates were high for intubated patients at 24 hours (19.7%), 7 days (29.4%), 30 days (38.4%), and 1 year (45.4%).
Conclusion : Physicians intubating in community emergency departments have similar rates of first-pass success and failure seen in academic Level-1 trauma centers despite treating medically sick patients with high all-cause mortality rates. Dramatic shifts in choice of paralytic and method for intubation were seen.
Conclusion (proposition de traduction) : Les médecins qui pratiquent des intubations dans les services d'urgence communautaires ont des taux de réussite et d'échec au premier passage similaires à ceux observés dans les centres de traumatologie universitaires de niveau 1, bien qu'ils traitent des patients atteints de maladies graves présentant des taux de mortalité tous causes confondues élevés. Des changements importants ont été observés dans le choix des curares et des méthodes d'intubation.
Clinical Policy: Critical Issues in the Management of Adult Patients Requiring Endotracheal Intubation in the Emergency Department.
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Airway Management; Godwin SA, Hahn SA, Friedman BW, Shy B, Hickey SM, Wall SP, Wolf SJ, Diercks DB; Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee); Diercks DB, Anderson JD, Byyny R, Carpenter CR, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Thompson J, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, . | Ann Emerg Med. 2025 Aug;86(2):e29-e68
DOI: https://doi.org/10.1016/j.annemergmed.2025.04.003
Keywords: Aucun
CLINICAL POLICY
Editorial : This clinical policy from the American College of Emergency Physicians is a new policy developed to identify the best evidence available to reduce peri-intubation hypoxemia and/or hypotension in emergent intubations. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) For adult patients presenting to the emergency department requiring endotracheal intubation, are there periprocedural interventions that can reduce the incidence of peri-intubation hypoxemia?; (2) For adult patients presenting to the emergency department requiring endotracheal intubation, are there peri-procedural interventions can reduce the incidence of peri-intubation hypotension? Evidence was graded and recommendations were made based on the strength of the available data.
Conclusion : Peri-intubation hypotension is associated with a higher risk of adverse events in patients undergoing emergent intubation. Methods to optimize patients’ physiology to potentially reduce this risk during intubation include uid bolus administration, induction agent selection, dosing adjustment, and the use of vasopressors, but the overall available literature to drive recommendations is limited at this time. Given the methodological criteria of this review, evidence surrounding the use of ketamine and etomidate re ects their overall safety and ef cacy in this generally critically ill patient population. Likewise, limiting the use of fentanyl during intubation when hypotension is a concern should be considered.
Conclusion (proposition de traduction) : L’hypotension péri-intubationnelle est associée à un risque accru d’événements indésirables chez les patients nécessitant une intubation en urgence. Les stratégies visant à optimiser la physiologie des patients afin de réduire ce risque comprennent l’administration de bolus de remplissage, le choix de l’agent d’induction, l’ajustement des posologies et l’utilisation de vasopresseurs. Toutefois, les données actuellement disponibles dans la littérature restent limitées pour formuler des recommandations fermes. Selon les critères méthodologiques de cette revue, les données concernant l’utilisation de la kétamine et de l’étomidate reflètent leur sécurité et leur efficacité globales dans cette population majoritairement critique. De même, la limitation de l’utilisation du fentanyl lors de l’intubation doit être envisagée lorsque le risque d’hypotension est préoccupant.
Commentaire : Cette recommandation ACEP 2025 met l’accent sur un point fondamental : la morbidité liée à l’intubation aux urgences est davantage physiologique que technique. L’optimisation de la préoxygénation, en particulier par la ventilation non invasive, apparaît comme l’intervention la plus efficace pour limiter l’hypoxémie. En revanche, les dispositifs d’intubation (vidéo-laryngoscopie, bougie, stylet) améliorent surtout le succès au premier passage sans impact démontré sur la désaturation. Concernant l’hypotension, l’étomidate et la kétamine restent les agents d’induction les plus sûrs chez les patients instables, tandis que le fentanyl, le midazolam et le propofol doivent être évités dans ce contexte. L’absence de bénéfice du remplissage systématique rappelle l’importance d’une approche individualisée. Ces recommandations confirment que la gestion des voies aériennes en urgence doit intégrer une stratégie globale d’optimisation hémodynamique et respiratoire, au-delà de la simple réussite technique de l’intubation.
La prévention des complications de l’intubation repose sur :
1. Optimisation physiologique pré-intubation
2. Préoxygénation efficace (VNI si possible)
3. Choix judicieux des agents d’induction
4. Ventilation prudente en période apnéique
Il n’existe pas d’approche universelle : l’adaptation au terrain du patient reste essentielle.
Effect of lateral versus supine positioning on hypoxaemia in sedated adults: multicentre randomised controlled trial.
Ye H, Chu LH, Xie GH, Hua YJ, Lou Y, Wang QH, Xu ZX, Tang MY, Wang BD, Hu HY, Ying J, Yu T, Wang HY, Wang Y, Ye ZJ, Bao XF, Wang MC, Chen LY, Wang XX, Zhang XB, Huang CS, Wang J, Lu YP, Luo FQ, Zhou W, Wang CG, Cheng H, Liu WJ, Luo J, Wu YQ, Li RR, Wang D, Hou LQ, Shi L, Zhang J, Wang K, Pi X, Zhou R, Yang QQ, Wan PL, Li H, Wu SJ, Song SW, Cui P, Shu L, Islam N, Fang XM. | BMJ. 2025 Aug 19;390:e084539
DOI: https://doi.org/10.1136/bmj-2025-084539
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Keywords: Aucun
RESEARCH
Introduction : To evaluate the effect of lateral versus supine positioning on incidence of hypoxaemia in sedated patients and to provide evidence based recommendations for respiratory strategies.
Méthode : Prospective, multicentre, randomised controlled trial.
Setting: 14 tertiary hospitals in China, July to November 2024.
Participants: 2159 adults (≥18 years) who underwent sedation.
Interventions: Sedated patients were randomly assigned (1:1) to receive either lateral positioning or conventional supine positioning, stratified by study centres.
Main outcome measures: The primary outcome was incidence of hypoxaemia (peripheral oxygen saturation (SpO2) ≤90%) within the first 10 minutes after positioning. Secondary outcomes included airway rescue interventions, incidence of severe hypoxaemia (SpO2 ≤85%), lowest oxygen saturation recorded, length of stay in the post-anaesthesia care unit, and safety measures (eg, bradycardia, tachycardia, hypotension, new onset arrhythmia). Analyses were performed on an intention-to-treat basis.
Résultats : Of 2159 patients randomised, 2143 were included in the primary analysis. The mean age of the patients was 53.1 years, mean body mass index was 23.9, and 53.7% (1150/2143) were women. The incidence of hypoxaemia was significantly lower in the lateral group compared with supine group (5.4% (58/1073) v 15.0% (161/1070); adjusted risk ratio 0.36, 95% confidence interval (CI) 0.27 to 0.49; P<0.001). Compared with patients in the supine group, patients in the lateral group required fewer airway rescue interventions (6.3% (68/1073) v 13.8% (148/1070); adjusted risk ratio 0.46, 0.34 to 0.61; P<0.001), had a lower incidence of severe hypoxaemia (0.7% (8/1073) v 4.8% (51/1070); adjusted risk ratio 0.16, 0.07 to 0.33; P<0.001), and had a higher mean lowest SpO2 level (96.9% v 95.7%, absolute adjusted mean difference 1.20%, 95% CI 0.87% to 1.54%; P<0.001). Additionally, length of stay in the post-anaesthesia care unit was shorter in the lateral group (38.2 v 40.5 minutes; absolute adjusted mean difference -2.22 minutes; 95% CI -3.63 to -0.80; P=0.002). Safety outcomes were comparable between the groups, but tachycardia was less frequent in the lateral group.
Conclusion : Placing sedated adults in the lateral position significantly reduces the incidence and severity of hypoxaemia and decreases the need for airway rescue interventions without compromising safety. Given its simplicity and low cost, lateral positioning could offer advantages in remote or resource constrained clinical settings. Further replication studies targeting patients with advanced age and high body mass index are needed to improve the generalisability of the findings.
Conclusion (proposition de traduction) : Le fait de placer les adultes sous sédation en position latérale réduit considérablement l'incidence et la gravité de l'hypoxémie et diminue le besoin d'interventions de secours pour dégager les voies respiratoires sans compromettre la sécurité. Compte tenu de sa simplicité et de son faible coût, le positionnement latéral pourrait offrir des avantages dans les milieux cliniques éloignés ou disposant de ressources limitées. D'autres études de reproduction ciblant les patients âgés et ayant un indice de masse corporelle élevé sont nécessaires pour améliorer la généralisation des résultats.
Inhaled or nebulised salbutamol for exacerbations of asthma and chronic obstructive pulmonary disease?.
Saidy AK, Foo B. | Emerg Med J. 2025 Aug 19;42(9):619-621
DOI: https://doi.org/10.1136/emermed-2024-214699
Keywords: Chronic Obstructive Pulmonary Disease; Emergency Medicine; asthma; management
Best Evidence Topic reports
Editorial : A short review of the literature was conducted to compare the length of emergency department (ED) stay and hospital admission rates in patients with exacerbations of asthma or chronic obstructive pulmonary disease (COPD) treated with salbutamol via a metered dose inhaler with a spacer (MDIS) versus nebulisation. Database searches were conducted using Cochrane, EMBASE, MEDLINE and Google Scholar. Six papers met our inclusion criteria and underwent analysis. Our results suggest that delivery of salbutamol via MDIS may reduce hospital admissions and ED length of stay in this patient cohort.
Conclusion : Our results suggest that delivery of salbutamol via MDIS may reduce hospital admissions and ED length of stay in this patient cohort.
Conclusion (proposition de traduction) : Nos résultats suggèrent que l’administration du salbutamol par inhalateur-doseur avec chambre d’inhalation pourrait réduire les taux d’hospitalisation et la durée de séjour aux urgences dans cette population de patients.
Commentaire : Ce Best Evidence Topic report s’inscrit dans une problématique quotidienne des services d’urgence : le choix du mode d’administration du salbutamol chez les patients présentant une exacerbation d’asthme ou de BPCO, en dehors des situations immédiatement vitales. En comparant inhalateur-doseur avec chambre d’inhalation (MDIS) et nébulisation, les auteurs interrogent une pratique encore largement ancrée, souvent plus culturelle que fondée sur des critères de gravité clairement définis.
La synthèse des six études retenues suggère que, chez des patients sélectionnés – conscients, sans désaturation et sans signe de gravité majeure –, le recours au MDIS est au moins aussi efficace que la nébulisation, avec un signal en faveur d’une réduction des admissions et de la durée de passage aux urgences. Ces résultats sont cohérents avec la pharmacodynamie du salbutamol et avec les données antérieures montrant qu’une administration répétée par MDIS permet d’atteindre des doses efficaces comparables, tout en limitant la surmédicalisation du parcours de soins.
La lecture critique met toutefois en évidence des limites importantes. L’hétérogénéité méthodologique est marquée, tant sur les critères de gravité que sur les schémas posologiques, les dispositifs de chambre d’inhalation utilisés et les critères décisionnels d’hospitalisation. Plusieurs études excluent des patients âgés, comorbides ou présentant des exacerbations sévères, ce qui réduit la portée des conclusions aux formes modérées. De plus, la distinction entre asthme et BPCO est souvent imparfaite, alors même que les mécanismes physiopathologiques et les trajectoires évolutives diffèrent.
Sur le plan pratique, ce BET ne remet pas en cause l’indication de la nébulisation dans les exacerbations sévères ou menaçantes, mais il fournit des arguments solides pour réévaluer son utilisation systématique chez des patients stables sur le plan respiratoire. Le MDIS présente des avantages organisationnels non négligeables : simplicité, rapidité de mise en œuvre, moindre exposition environnementale aux aérosols et opportunité d’éducation thérapeutique, favorisant la continuité des soins après la sortie. Dans un contexte de tension sur les flux et les ressources aux urgences, cette approche apparaît particulièrement pertinente.
En définitive, ce travail plaide pour une utilisation plus raisonnée et stratifiée des modalités d’administration du salbutamol, intégrée à une évaluation clinique fine de la gravité. Il souligne surtout le besoin d’essais randomisés pragmatiques, incluant à la fois asthme et BPCO, avec des critères de gravité standardisés, afin de guider de manière plus robuste les recommandations et d’harmoniser les pratiques en médecine d’urgence.
Revisiting Acute Respiratory Distress Syndrome ventilation management: Time for a paradigm shift focusing on tidal volume.
Merola R, Vargas M, Battaglini D. | Respir Physiol Neurobiol. 2025 Aug-Sep;336:104454.
DOI: https://doi.org/10.1016/j.resp.2025.104454
Keywords: Acute Respiratory Distress Syndrome; Driving pressure; Mechanical power; Mechanical ventilation; Tidal volume; Transpulmonary pressure.
Short communication
Editorial : Acute Respiratory Distress Syndrome (ARDS) remains a critical challenge in intensive care medicine, with persistently high mortality despite decades of research and advancements in supportive therapies. Mechanical ventilation, particularly low tidal volume (VT) strategies, has become the cornerstone of ARDS management; however, emerging evidence suggests that a uniform application of these approaches may not be universally beneficial. This viewpoint critically examines the evolution of ARDS ventilation strategies, from high VT methods to protective ventilation protocols centered on reduced VT and plateau pressures. It explores the limitations of current guidelines, highlighting how global parameters such as VT and driving pressure (ΔP) may inadequately capture the complex and heterogeneous pathophysiology of ARDS. Concepts like mechanical power, compliance-based ventilation, and transpulmonary pressure offer promising avenues for more personalized care but remain underutilized in clinical practice. Additionally, this viewpoint underscores the significance of heart-lung interactions and the impact of ventilator settings on cardiovascular function, further complicating one-size-fits-all approaches. Ultimately, this work calls for a reassessment of existing paradigms, advocating for individualized, physiology-driven strategies that move beyond population-based protocols to better address the nuanced needs of ARDS patients.
Conclusion : Over time the landscape of ARDS management has evolved but has not necessarily progressed in the way we might have hoped. The high mortality rate remains a significant problem, and while technological and methodological advancements have certainly improved some as- pects of care, they have not solved the fundamental issue of ARDS treatment. Perhaps, after decades of following the same basic principles, it is time to ask whether a fundamental shift is necessary. Should we adopt more individualized, physiologically based approaches such as transpulmonary pressure and regional ventilation, rather than focusing primarily on global parameters such as VT and ΔP? Or should we continue to refine the existing standards, exploring intermediate values of VT and ΔP that might offer a more nuanced approach to ventilation?
These questions remain open, but the time has come to re-evaluate our approach.
Conclusion (proposition de traduction) : Au fil du temps, le contexte de la prise en charge du SDRA a évolué, mais n'a pas nécessairement progressé comme nous l'aurions espéré. Le taux de mortalité élevé reste un problème important et, bien que les progrès technologiques et méthodologiques aient certainement amélioré certains aspects des soins, ils n'ont pas résolu la question fondamentale du traitement du SDRA. Après des décennies passées à suivre les mêmes principes de base, il est peut-être temps de se demander si un changement fondamental est nécessaire. Devrions-nous adopter des approches plus individualisées, basées sur la physiologie, telles que la pression transpulmonaire et la ventilation régionale, plutôt que de nous concentrer principalement sur des paramètres globaux tels que le VT et le ΔP ? Ou devrions-nous continuer à affiner les standards existants, en explorant des valeurs intermédiaires de VT et de ΔP qui pourraient offrir une approche plus nuancée de la ventilation ?
Ces questions restent ouvertes, mais le moment est venu de réévaluer notre approche.
Effectiveness of inhaled methoxyflurane in acute pain in an emergency department - A systematic review of randomized controlled trials.
Lam L, Brouwer HJ, Gupta M, Ker CJ, Jones C, Athar A, Roman C, Mitra B, Brichko L, Luckhoff C, Jennings N, Cameron P. | Am J Emerg Med. 2025 Aug;94:37-45
DOI: https://doi.org/10.1016/j.ajem.2025.04.021
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Keywords: Clinicians; Efficacy; Emergency medicine; Experience; Injuries; Methoxyflurane; Patient; Trauma; Wounds.
Article
Introduction : Inhaled Methoxyflurane has emerged as a popular analgesic agent for the management of acute traumatic pain in emergency settings. The aim of this review was to assess the analgesic efficacy of methoxyflurane compared to placebo and standard analgesics.
Méthode : We performed a systematic review of the literature with searches of seven databases (Medline Complete, CINAHL Complete, OVID Emcare, Embase Classic + Embase, Cochrane Library, Scopus and Web of Science Core Collection) for randomized controlled trials where patients presented to the emergency department with acute traumatic pain and were administered inhaled methoxyflurane compared to placebo or standard analgesics. The primary outcome was the effectiveness of analgesia. Secondary outcomes were adverse events and patient and clinician satisfaction.
Résultats : The literature search produced 250 results, of which six met the eligibility criteria. All six studies reported improved pain scores with pain reduction of up to -30.392 mm on a 100 mm VAS scale and - 5.75 on an NRS 0-10 point scale for the methoxyflurane groups. All six studies concluded a shorter time to obtain pain relief for patients in the methoxyflurane groups. Patients and clinicians reported higher satisfaction in the methoxyflurane groups and there was a low incidence of adverse events.
Conclusion : Inhaled methoxyflurane provides rapid and effective pain relief for acute trauma, consistently outperforming placebo and standard treatments and improving patient and clinician satisfaction.
Conclusion (proposition de traduction) : Le méthoxyflurane inhalé procure un soulagement rapide et efficace de la douleur en cas de traumatisme aigu, avec des performances constamment supérieures à celles du placebo et des traitements standard, ainsi qu'une meilleure satisfaction des patients et des cliniciens.
Nebulized ketamine for acute pain management in the Emergency Department: A systematic review and meta-analysis.
Cetin M, Brown CS, Bellolio F, Drapkin J, Glatter R, Motov S, E Silva LOJ. | Am J Emerg Med. 2025 Aug;94:110-118
DOI: https://doi.org/10.1016/j.ajem.2025.04.051
Keywords: Acute pain; Emergency department; Emergency room; Inhalation; Ketamine; Ketamine analgesia; Nebulization; Pain; Pre-hospital setting.
ARTICLE
Introduction : Ketamine administered in sub-dissociative doses has been effective in managing a variety of painful conditions in the emergency department (ED) and pre-hospital settings. The inhalation route of ketamine administration has gained traction over the past 5 years.
Méthode : We conducted a systematic review and meta-analysis to evaluate the analgesic efficacy and incidence of adverse effects of nebulized ketamine. We searched Ovid CENTRAL, EMBASE, and MEDLINE databases for randomized controlled trials (RCTs) and observational studies from inception to January 2025, assessing pain reduction, rescue analgesia, and occurrences of adverse effects. We used the Cochrane Collaboration tool and a modified Newcastle-Ottawa Scale to evaluate the risk of bias and the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) to evaluate the confidence in the evidence. Mean differences with 95 % confidence intervals (CI) using random effects were used for the meta-analyses.
Résultats : Thirteen studies met the inclusion criteria. Nebulized ketamine had equivalent efficacy to active controls in 8 RCT's. Four RCTs (n = 601) demonstrated no difference in pain reduction between nebulized ketamine and IV morphine with mean difference (MD) 0.28 (CI -0.18 to 0.73) at 30 min, and similar rates of rescue analgesia (16.9 % vs. 17.4 %). Eleven studies reported absence of serious events and no difference in non-serious adverse events (39.1 % ketamine and 37.8 % controls). The level of confidence for the outcomes was deemed to be very low.
Conclusion : Administration of ketamine via nebulization for patients with acute painful conditions provided equivalent analgesia with similar safety profile when compared to active controls.
Conclusion (proposition de traduction) : L'administration de kétamine par nébulisation à des patients souffrant d'affections douloureuses aiguës a fourni une analgésie équivalente avec un profil de sécurité similaire par rapport aux témoins actifs.
Commentaire : En pratique :
Utilisation d'ampoule de kétamine de 250 mg/5 mL PURE (pour maximiser la concentration dans un petit volume).
Avec une seringue de 2 mL, prélever dans l’ampoule de 250 mg/5 mL pure, le volume à administrer selon la posologie en fonction du poids (1 mg/kg. Une deuxième dose de 0,5 mg/kg à 10 min est possible, si EN 5).
Connecter l’embout nasal (MAD).
Puis pulvériser tout le volume en le fractionnant dans les deux narines : une narine ne peut absorber plus de 1 mL (préférer une pulvérisation de 0,5 mL/narine).
Diminuer la dose de moitié chez le sujet âgé.
Penser à ajouté 0,1 mL au volume de la première dose prescrite pour purger l’embout nasal 0,1 mL (qui sera donc non administré), le volume de la 2ème dose correspond au volume de la dose prescrite, sans le volume de
purge de l’embout.
Tiré de : Urg'Ara, le livret du médicament adulte (Version 1.1 - Mars 2025).
Clinical Policy: Critical Issues in the Management of Adult Patients Requiring Endotracheal Intubation in the Emergency Department.
Godwin SA, Hahn SA, Friedman BW, Shy B, Hickey SM, Wall SP, Wolf SJ, Diercks DB; Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee); Diercks DB, Anderson JD, Byyny R, Carpenter CR, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Thompson J, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, . | Ann Emerg Med. 2025 Aug;86(2):e29-e68
DOI: https://doi.org/10.1016/j.annemergmed.2025.04.003
Keywords: Aucun
Clinical policy
Editorial : This clinical policy from the American College of Emergency Physicians is a new policy developed to identify the best evidence available to reduce peri-intubation hypoxemia and/or hypotension in emergent intubations. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions:
(1) For adult patients presenting to the emergency department requiring endotracheal intubation, are there periprocedural interventions that can reduce the incidence of peri- intubation hypoxemia?;
(2) For adult patients presenting to the emergency department requiring endotracheal intubation, are there peri-procedural interventions can reduce the incidence of peri-intubation hypotension?
Evidence was graded and recommendations were made based on the strength of the available data.
Conclusion : Peri-intubation hypotension is associated with a higher risk of adverse events in patients undergoing emergent intubation. Methods to optimize patients’ physiology to potentially reduce this risk during intubation include fluid bolus administration, induction agent selection, dosing adjustment, and the use of vasopressors, but the overall available literature to drive recommendations is limited at this time. Given the methodological criteria of this review, evidence surrounding the use of ketamine and etomidate reflects their overall safety and efficacy in this generally critically ill patient population. Likewise, limiting the use of fentanyl during intubation when hypotension is a concern should be considered.
Conclusion (proposition de traduction) : L’hypotension péri-intubation est associée à un risque accru d’événements indésirables chez les patients nécessitant une intubation en situation d’urgence. Les méthodes visant à optimiser la physiologie du patient afin de réduire ce risque incluent l’administration d’un bolus de remplissage, le choix de l’agent d’induction, l’ajustement des doses, et l’utilisation de vasopresseurs. Toutefois, les données disponibles dans la littérature pour étayer des recommandations solides restent actuellement limitées. En tenant compte des critères méthodologiques de cette revue, les données concernant l’utilisation de la kétamine et de l’étomidate suggèrent une efficacité et une sécurité globalement satisfaisantes dans cette population majoritairement en état critique. De même, il convient d’envisager de limiter l’utilisation du fentanyl lors de l’intubation lorsque le risque d’hypotension est présent.