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Alte Une revue du Dr. Christiane Gagnon

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Une revue de littérature de l'ALTE

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Alte Une revue du Dr. Christiane Gagnon

  1. 1. ALTE Christiane Gagnon MD FRCPC Professeure adjointe de Pédiatrie Université de Montréal 22 Janvier 2015
  2. 2. ALTE: Définition Un épisode qui fait peur au témoin, Combinant au moins 2 des éléments suivants: •Apnée •Changement de coloration •Changement important du tonus musculaire •Étouffement ou « gagging » NIH Concensus Development Conference1986, Infantile Apnea and Home Monitoring
  3. 3. Incidence 0,6-2,46 /1000 bébés 0,6% des visites à l’urgence Garçons = Filles Âge moyen: 2 mois Pas de lien causal entre ALTE et MSN Pediatric Clinics of North America 52 (2005) 1127–1146
  4. 4. MSN Arch Dis Child 2004;90:297–300
  5. 5. Alte Arch Dis Child 2004;90:297–300
  6. 6. Facteurs de risque Prématurité Tabagisme maternel
  7. 7. Précision du questionnaire Primordiale À l’arrivée: 10%: besoin O2 ou ventilation 80%: E/P normal Pediatric Clinics of North America 52 (2005) 1127–1146
  8. 8. Diagnostic différentiel Idiopathique Gastrointestinale Neurologique Respiratoire Maltraitance Intoxication Infectieuse Métabolique Orl Cardiaque Pediatric Clinics of North America 52 (2005) 1127–1146 J Pediatr 2013;163:94-9 50% 33% 10-15% 11% 0,4-11% 8% 3% 2-5% 0,6-4% <1%
  9. 9. questionnaire Apnée centrale ou obstructive Coloration Hypotonie Étouffement ou Gagging Durée de l’épisode, manœuvres nécessaires, Activités et état précédent l’épisode Si sommeil: position Symptômes infectieux Symptômes neurologiques, hx de trauma ATCD personnels et familiaux Pediatrics in Review Vol.23 No.1 January 2002, Pediatric Clinics of North America 52 (2005) 1127–1146
  10. 10. Examen physique État général, neurologique, Hémotympan, hémorragie rétinienne, ecchymoses Signes de trauma Difficulté respiratoire Dysmorphisme
  11. 11. Bilan de base Contribution des tests au diagnostic: 2,5% des tests à l’urgence 14% des tests durant hospitalisation si Hx et E/P négatifs J Pediatr 2013;163:94-9
  12. 12. Bilan de base Fsc Rx Poumon Électrolytes, Ca, Mg, glycémie, Astrup, (ammoniac, pyruvate, lactate ) A urine CRP RSV, Coqueluche Bilan toxicologique dans l’urine Bilan septique: < 2 mois, ALTE récurrent J Pediatr 2013;163:94-9
  13. 13. Tests complémentaires EEG CT Scan, consultation en ophtalmologie, série squelettique Gorgée, repas baryté, pH Métrie Pneumogramme ECG Aminoacidémie, aminoacidurie, acides organique urinaires J Pediatr 2013;163:94-9 Clinical Pediatrics 2013;52:338-343
  14. 14. EEG J Child Neurol 2009 24: 709
  15. 15. Tests complémentaires EEG CT Scan, consultation en ophtalmologie, série squelettique Gorgée, repas baryté, pH Métrie Pneumogramme ECG Aminoacidémie, aminoacidurie, acides organique urinaires J Pediatr 2013;163:94-9 Clinical Pediatrics 2013;52:338-343
  16. 16. Reflux gastro-oesophagien J Pediatr 2000;137:321-6
  17. 17. Reflux gastro-oesophagien Résultats: 80% des apnées non reliées à reflux Apnée précède reflux 93% des cas Reflux précède l’apnée 6% des cas J Pediatr 2000;137:321-6
  18. 18. Reflux gastro-oesophagien Résultats: Parmi épisode de RGO: 18% aucun lien avec apnée 4,8% précède l’apnée 77% suit l’apnée J Pediatr 2000;137:321-6
  19. 19. Reflux gastro-oesophagien Conclusions: Le RGO est fréquent chez les bébés avec ALTE idiopathique Positionnement Rôle du traitement ? Rôle du RGO non acide? J Pediatr 2000;137:321-6
  20. 20. Reflux gastro-oesophagien Intraluminal impedance technique in the diagnosis of apparent life-threatening events (ALTE) Conclusions: RGO pas plus fréquent chez ALTE que dans population générale du même âge 1/4 des reflux sont alcalins Sur 16 pts avec ALTE idiopathique 1 seul avait RGO associé à apnée. Cir Pediatr 2008 Jan;21(1)1-4
  21. 21. Reflux gastro-oesophagien Apnées associées à RGO: phénomène normal de protection des voies respiratoires Dans la vaste majorité des cas le RGO n’est pas associé au ALTE ni à l’apnée pathologique Pharmacothérapie du RGO: pas efficace dans ALTE. Épaississement et fractionnement des boires: théoriquement bénéfique. Chirurgie? J Pediatr Gastroenterol Nutr, Vol. 49, No. 4, October 2009
  22. 22. Alte & Prématurité J Pediatr 2014;165:250-5
  23. 23. Déglutition & anciens Prématurés J Pediatr 2014;165:250-5
  24. 24. Conclusion ALTE & prématuré Editorial: The Journal of Pediatrics Vol. 165, No. 2, p 225
  25. 25. Prise en CHARGE: Hospitalisation Pour observation durant 24h minimum 7-16% des bébés auront besoin d’intervention significative Récurrence: 85% dans le premier 24 h
  26. 26. Risque augmenté de récurrence Ancien prématuré ATCD médicaux <43 semaines d’âge postconceptionnel ALTE récurrent Infection respiratoire Convulsions Maltraitance J Pediatr 2013;163:94-9
  27. 27. Où hospitaliser? •Centre où il y a soins hospitaliers pédiatriques avec capacité de monitorer avec saturomètre •Centre hospitalier avec SI pédiatriques: Plus d’un ALTE en 24 heure ou Hx de cyanose du visage ou corporelle ou HX de manœuvres de réanimation PREHOSPITAL EMERGENCY CARE 2013;17:304–311
  28. 28. Prise en charge: Congé? Pourrait être envisagé si : Bébé bien, Né à terme, aucun atcd médical, Premier épisode d’ALTE, Épisode bref et non sévère, Autorésolutif, Cause probable non évolutive. Et selon le niveau d’anxiété parentale.
  29. 29. Pronostic Mortalité après le congé ? 0 à 0,5% des enfants Morbidité la plus élevée: abus Récurrence: environ 10%, premiers soins… Follow-up quelques jours après le congé. Pediatrics 2008;122;125 American Journal of Emergency Medicine 31 (2013) 730–733
  30. 30. Guide clinique Voir section guide clinique et protocoles de notre site urgencehsj.ca Disponible printemps 2015

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