Résumé
Les épanchements pleuraux sont fréquemment rencontrés dans les services d’urgences. Souvent découverts fortuitement, révélant une affection chronique (insuffisance cardiaque, pathologie néoplasique, maladie de système...), ils peuvent parfois être bruyants et nécessiter, dès les urgences, une enquête étiologique spécifique ou leur évacuation. Ainsi, l’urgentiste devra-t-il être en mesure d’en évaluer la tolérance et d’initier les principales investigations étiologiques. Dans cette prise en charge, la ponction pleurale, réalisée sous échographie le cas échéant, est primordiale en permettant le plus souvent de distinguer les épanchements exsudatifs (infection à pyogènes, néoplasie, tuberculose...) et transsudatifs (anasarque, épanchement réactionnel à une pathologie de contact [embolie pulmonaire, pneumopathie...]). C’est un geste maîtrisé par l’urgentiste qui en connaîtra aussi les limites et les complications. Ainsi, au terme de cette démarche, l’urgentiste sera-t-il en mesure d’orienter au plus juste la prise en charge ultérieure du patient et d’initier les traitements urgents. Il saura aussi différer des explorations spécifiques non urgentes, dont la réalisation n’est pas compatible avec le contexte des urgences.
Abstract
Pleural effusion is a common syndrome in patients visiting the emergency department. Most of the time, pleural effusion-related conditions are poorly symptomatic and often reveal an underlying chronic comorbid condition (chronic heart failure, cancer, systemic inflammatory diseases...). However pleural effusion symptoms might be flourished and require immediate therapeutic intervention, such as pleural fluid evacuation or diagnosis workup. Therefore, emergency physicians should be able to detect life-threatening conditions within the very first minutes of patient presentation and to adequatly order urgent laboratory examinations. From this perspective, sampling of pleural fluid, eventually guided by ultrasound tomography, is often valuable in differentiating exsudative (e.g. pyogenic pleural infection, cancer, tuberculosis) and transudative effusions (e.g. anasarca, pulmonary embolism or pneumonia-related pleural effusion). Therefore, emergency physician technical should master pleural fluid puncture and drainage skills, along with their limitations and potential adverse events. At the end of the initial evaluation process, the emergency physician should be able to determine whether the patient is to be treated as an outpatient or an inpatient, and adequately determine the adequate intensity of care. Additionally, emergency physician should avoid non urgent laboratory investigation that would inappropriately delay management decision.
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Hervé, J., Santin, A. & Renaud, B. Épanchement pleural non traumatique en urgence. Ann. Fr. Med. Urgence 1, 192–199 (2011). https://doi.org/10.1007/s13341-011-0039-y
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DOI: https://doi.org/10.1007/s13341-011-0039-y