Intubation difficle: Pas qu'anatomique

Managing the Physiologically Difficult Airway in Critically Ill Adults
Jabaley CS. Crit Care. 2023 Mar 21;27(1):91. doi: 10.1186/s13054-023-04371-3.

 

Un document très intéressant qui présente de manière très claire les enjeux de l'intubation difficile qui n'est pas qu'anatomique.

 

Risks and risk prediction

Cardiovascular instability, hypoxemia, and cardiac arrest are the most common adverse events associated with tracheal intubation

Risk factors for cardiovascular collapse include age, shock, hypoxemia, advanced critical illness, and propofol administration

Hemodynamic optimization

Etomidate and ketamine may impact hemodynamics less than propofol

A crystalloid bolus prior to intubation has not been associated with improved hemodynamics, even in patients receiving positive pressure ventilation

Given the frequency of cardiovascular instability, vasopressors should be readied as part of preparation for tracheal intubation

Mitigating hypoxemia

Standard pre-oxygenation strategies are inadequate to safely extend the apneic interval in patients with moderate to severe respiratory failure

Non-invasive ventilation can be used with or without high flow nasal oxygen and is more effective than high flow nasal oxygen alone

While historically avoided, bag-mask ventilation improves oxygenation during airway management and can be employed either preemptively or for rescue

First pass success

Multiple attempts at intubation increase the risk of adverse events

Depending on the preferences and expertise of the intubating clinician, video laryngoscopy or direct laryngoscopy with adjuncts may improve first pass success

Checklists improve adherence to complex, multi-step processes and may help prompt preparation for physiologic trespass

 

Trauma: Exsufflation à l'aiguille. Pas sûr du tout

Prehospital needle thoracostomy and the need to implement objective criteria for intervention: A retrospective study

Boever JC et Al. Injury. 2025 Dec 13:112973. doi: 10.1016/j.injury.2025.112973.

 

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Ce travail montre que la décompression à l'aiguille n'est pas un geste anodin? surtout avec les catheter longs poentiellement très traumatiques. Les indications d'une décompression thoracique préhospitalières doivent être rigoureuse incluant la présence d'une détresse circulatoire avec une détresse respiratoire. Une simple asymétrie à l'auscultation ne préjuge pas du carctère compressif d'un pneumothorax. Un échographe n'est pas toujours disponible. Aussi il peut paraître sage de réaliser une décompression par thoracostomie au doigt, geste bien moins agressif que l'emploi d'une aiguille longue. Cet article confirme ce qui est déjà connu (1)

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Background: 

 

Needle thoracostomy (NT) is a frontline intervention for suspected tension pneumothorax in prehospital trauma care. The necessity for intervention in patients with relative indications is unclear, and locoregional protocols guiding NT placement by prehospital personnel vary. This study aims to identify factors associated with a positive response to NT and how often objective measures are utilized to prompt intervention, which may help better define indications for the procedure.

 

Methods: 

 

A retrospective review of adult trauma patient who received prehospital needle decompression was performed utilizing the trauma registry database from a level 1ACS accredited trauma center in Omaha, Nebraska. A positive response was defined as increased oxygen saturation by 10 %, increased systolic blood pressure by 10 mmHg, improved ventilation or breath sounds, or return of spontaneous circulation.

 

Results: 

 

A total of 214 patients were included, with an overall mortality rate of 52 % of which 144 (68 %) sustained blunt trauma and 67 (32 %) penetrating trauma. Mortality was 49 % for blunt trauma and 60 % for penetrating trauma (p = 0.182). Only 63 patients (30 %) responded to NT with an improvement in clinical parameters. The most common indication(s) for NT was documented as absent/reduced breath sounds (n = 118, 55 %), CPR (n = 79, 37 %), and hypoxia (n = 40, 19 %). After excluding patients with CPR en route (n = 135/214, 63 %), positive NT response increased to 48 % and overall mortality rate decreased to 26 %. There was no significant change in systolic blood pressure (mean difference: 0.3 mm Hg, 95 % CI:4.8-5.3, p = 0.910) or heart rate (-1.1 bpm, 95 % CI:5.8-3.6, p = 0.650) post-decompression. The incidence of hypoxia decreased from 68 % to 48 % (p < 0.001). Complications were identified in 14 % of patients and one patient did have a needle inserted into the heart, required a cardiac operation, and had subsequent anoxic brain injury.

 

Conclusions: 

 

This study highlights the low success rates of prehospital NT, with the majority of procedures being performed based on subjective indicators. Prehospital protocols should be refined by incorporating objective criteria, such as confirmed hypoxia, to better identify patients who may benefit from NT.