Bibliographie de Médecine d'Urgence

Mois de décembre 2023

Annals of Intensive Care

Characteristics and prognostic factors of bacterial meningitis in the intensive care unit: a prospective nationwide cohort study.
Chekrouni N, Kroon M, Drost EHGM, van Soest TM, Bijlsma MW, Brouwer MC, van de Beek D. | Ann Intensive Care. 2023 Dec 6;13(1):124
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Keywords: Admission; Bacterial meningitis; Intensive care unit; Prognostic factors; Unfavourable outcome.


Introduction : Patients with bacterial meningitis can be severely ill necessitating intensive care unit (ICU) treatment. Here, we describe clinical features and prognostic factors of adults with bacterial meningitis admitted to the ICU in a nationwide prospective cohort study.

Méthode : We prospectively assessed clinical features and outcome of adults (age > 16 years) with community-acquired bacterial meningitis included in the MeninGene study between March 1, 2006 and July 1, 2022, that were initially admitted to the ICU. We identified independent predictors for initial ICU admission and for unfavourable outcome (Glasgow Outcome Scale score between 1-4) by multivariable logistic regression.

Résultats : A total of 2709 episodes of bacterial meningitis were included, of which 1369 (51%) were initially admitted to the ICU. We observed a decrease in proportion of patients being admitted to the ICU during the Covid-19 pandemic in 2020 (decreased to 39%, p = 0.004). Median age of the 1369 patients initially admitted to the ICU was 61 years (IQR 49-69), and the rates of unfavourable outcome (47%) and mortality (22%) were high. During the Covid-19 pandemic, we observed a trend towards an increase in unfavourable outcome. Prognostic factors predictive for initial ICU admission were younger age, immunocompromised state, male sex, factors associated with pneumococcal meningitis, and those indicative of systemic compromise. Independent predictors for unfavourable outcome in the initial ICU cohort were advanced age, admittance to an academic hospital, cranial nerve palsies or seizures on admission, low leukocyte count in blood, high C-reactive protein in blood, low CSF: blood glucose ratio, listerial meningitis, need for mechanical ventilation, circulatory shock and persistent fever. 204 of 1340 episodes (15%) that were initially not admitted to the ICU were secondarily transferred to the ICU. The rates of unfavourable outcome (66%) and mortality (30%) in this group were high.

Conclusion : The majority of patients with community-acquired bacterial meningitis are admitted to the ICU, and the unfavourable outcome and mortality rates of these patients remain high. Patients that are initially admitted to non-ICU wards but secondarily transferred to the ICU also had very high rates of unfavourable outcome.

Conclusion (proposition de traduction) : La majorité des patients atteints de méningite bactérienne d'origine communautaire sont admis aux soins intensifs, et les taux d'évolution défavorable et de mortalité de ces patients restent élevés (taux d'évolution défavorable [47 %] et de mortalité [22 %]). Les patients initialement admis dans des services autres que l'USI et transférés ensuite à l'USI présentaient également des taux très élevés d'évolution défavorable (évolution défavorable [66 %] et de mortalité [30 %]).


Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study.
Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson J, Blackwood J, Wang HE. | Circulation. 2023 Dec 5;148(23):1847-1856
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Keywords: cardiography, impedance; cardiopulmonary resuscitation; heart arrest; patient outcome assessment; ventilation.


Introduction : Few studies have measured ventilation during early cardiopulmonary resuscitation (CPR) before advanced airway placement. Resuscitation guidelines recommend pauses after every 30 chest compressions to deliver ventilations. The effectiveness of bag-valve-mask ventilation delivered during the pause in chest compressions is unknown. We sought to determine: (1) the incidence of lung inflation with bag-valve-mask ventilation during 30:2 CPR; and (2) the association of ventilation with outcomes after out-of-hospital cardiac arrest.

Méthode : We studied patients with out-of-hospital cardiac arrest from 6 sites of the Resuscitation Outcomes Consortium CCC study (Trial of Continuous Compressions versus Standard CPR in Patients with Out-of-Hospital Cardiac Arrest). We analyzed patients assigned to the 30:2 CPR arm with ≥2 minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ω (corresponding to ≥250 mL VT) and a duration ≥1 s. We defined a chest compression pause as a 3- to 15-s break in chest compressions. We compared the incidence of ventilation and outcomes in 2 groups: patients with ventilation waveforms in <50% of pauses (group 1) versus those with waveforms in ≥50% of pauses (group 2).

Résultats : Among 1976 patients, the mean age was 65 years; 66% were male. From the start of chest compressions until advanced airway placement, mean±SD duration of 30:2 CPR was 9.8±4.9 minutes. During this period, we identified 26 861 pauses in chest compressions; 60% of patients had ventilation waveforms in <50% of pauses (group 1, n=1177), and 40% had waveforms in ≥50% of pauses (group 2, n=799). Group 1 had a median of 12 pauses and 2 ventilations per patient versus group 2, which had 12 pauses and 12 ventilations per patient. Group 2 had higher rates of prehospital return of spontaneous circulation (40.7% versus 25.2%; P<0.0001), survival to hospital discharge (13.5% versus 4.1%; P<0.0001), and survival with favorable neurological outcome (10.6% versus 2.4%; P<0.0001). These associations persisted after adjustment for confounders.

Conclusion : In this study, lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome.

Conclusion (proposition de traduction) : Dans cette étude, la ventilation au ballon à valve unidirectionnelle n'a pas été très fréquente au cours de la RCP 30:2. La ventilation pulmonaire dans ≥ 50% des pauses a été associée à une amélioration du retour de la circulation spontanée, de la survie et de la survie avec un résultat neurologique favorable.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.
Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, Weiner GM, Cheng A, Djärv T, Abelairas-Gómez C, Acworth J, Andersen LW, Atkins DL, Berry DC, Bhanji F, Bierens J, Bittencourt Couto T, Borra V, Böttiger BW, Bradley RN, Breckwoldt J, Cassan P, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Dassanayake V, Davis PG, Dawson JA, de Almeida MF, De Caen AR, Deakin CD, Dick. | Circulation. 2023 Dec 12;148(24):e187-e280
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Editorial : The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

JAMA Internal Medicine

Overnight Stay in the Emergency Department and Mortality in Older Patients.
Roussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, Bloom B, Catoire P, Berard L, Cachanado M, Simon T, Laribi S, Freund Y; FHU IMPEC-IRU SFMU Collaborators; FHU IMPEC−IRU SFMU Collaborators. | JAMA Intern Med. 2023 Dec 1;183(12):1378-1385
Keywords: Aucun

Original Investigation

Introduction : Patients in the emergency department (ED) who are waiting for hospital admission on a wheeled cot may be subject to harm. However, mortality and morbidity among older patients who spend the night in the ED while waiting for a bed in a medical ward are unknown.

Méthode : To assess whether older adults who spend a night in the ED waiting for admission to a hospital ward are at increased risk of in-hospital mortality. Design, settings, and participants: This was a prospective cohort study of older patients (≥75 years) who visited the ED and were admitted to the hospital on December 12 to 14, 2022, at 97 EDs across France. Two groups were defined and compared: those who stayed in the ED from midnight until 8:00 am (ED group) and those who were admitted to a ward before midnight (ward group). Main outcomes and measures: The primary end point was in-hospital mortality, truncated at 30 days. Secondary outcomes included in-hospital adverse events (ie, falls, infection, bleeding, myocardial infarction, stroke, thrombosis, bedsores, and dysnatremia) and hospital length of stay. A generalized linear-regression mixed model was used to compare end points between groups.

Résultats : The total sample comprised 1598 patients (median [IQR] age, 86 [80-90] years; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED group and 891 (56%) in the ward group. Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). They also had a higher risk of adverse events compared with the ward group (aRR, 1.24; 95% CI, 1.04-1.49) and increased median length of stay (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31). In a prespecified subgroup analysis of patients who required assistance with the activities of daily living, spending the night in the ED was associated with a higher in-hospital mortality rate (aRR, 1.81; 95% CI, 1.25-2.61).

Conclusion : The findings of this prospective cohort study indicate that for older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy. Older adults should be prioritized for admission to a ward.

Conclusion (proposition de traduction) : Les résultats de cette étude de cohorte prospective indiquent que pour les patients âgés, le fait d'attendre une nuit aux urgences pour être admis dans un service est associé à une augmentation de la mortalité et de la morbidité à l'hôpital, en particulier chez les patients ayant une autonomie limitée. Les adultes plus âgés devraient être admis en priorité dans une unité de soins.

Commentaire : C'est une étude qui a été faite en France sur 97 services d’urgence, menée par Mélanie Roussel et de Yonathan Freund. Ils se sont intéressés aux patients âgés qui dormaient dans les couloirs des urgences et ont évalué la mortalité de ces patients à un mois.
Ce sont 1 600 patients âgés qui ont été dénombrés, sur les trois jours de l'étude, chiffre important même si c’était une période particulière avec des infections (c’était la période de décembre).
Donc beaucoup de patients âgés restent dans les couloirs des services d'urgence et ce n’est pas normal. Mais le but de l’étude n’était pas de dire cela, c’était de dire que ces patients, à 39 %, vont mourir d’être restés une nuit aux urgences sans avoir pu trouver un lit…
6 études qui ont marqué la médecine d’urgence en 2023 Pr Dominique Savary. Medscape  .

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Favourable neurological outcome following paediatric out-of-hospital cardiac arrest: a retrospective observational study.
Fuchs A, Bockemuehl D, Jegerlehner S, Both CP, Cools E, Riva T, Albrecht R, Greif R, Mueller M, Pietsch U. | Scand J Trauma Resusc Emerg Med. 2023 Dec 21;31(1):106
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Keywords: Advanced life support; Chain-of-survival; Children; HEMS; Out-of-hospital Cardiac Arrest; Resuscitation.


Introduction : Out-of-hospital cardiac arrest (OHCA) in children is rare and can potentially result in severe neurological impairment. Our study aimed to identify characteristics of and factors associated with favourable neurological outcome following the resuscitation of children by the Swiss helicopter emergency medical service.

Méthode : This retrospective observational study screened the Swiss Air-Ambulance electronic database from 01-01-2011 to 31-12-2021. We included all primary missions for patients ≤ 16 years with OHCA. The primary outcome was favourable neurological outcome after 30 days (cerebral performance categories (CPC) 1 and 2). Multivariable linear regression identified potential factors associated with favourable outcome (odd ratio - OR).

Résultats : Having screened 110,331 missions, we identified 296 children with OHCA, which we included in the analysis. Patients were 5.0 [1.0; 12.0] years old and 61.5% (n = 182) male. More than two-thirds had a non-traumatic OHCA (67.2%, n = 199), while 32.8% (n = 97) had a traumatic OHCA. Thirty days after the event, 24.0% (n = 71) of patients were alive, 18.9% (n = 56) with a favourable neurological outcome (CPC 1 n = 46, CPC 2 n = 10). Bystander cardiopulmonary resuscitation (OR 10.34; 95%CI 2.29-51.42; p = 0.002) and non-traumatic aetiology (OR 11.07 2.38-51.42; p = 0.002) were the factors most strongly associated with favourable outcome. Factors associated with an unfavourable neurological outcome were initial asystole (OR 0.12; 95%CI 0.04-0.39; p < 0.001), administration of adrenaline (OR 0.14; 95%CI 0.05-0.39; p < 0.001) and ongoing chest compression at HEMS arrival (OR 0.17; 95%CI 0.04-0.65; p = 0.010).

Conclusion : In this study, 18.9% of paediatric OHCA patients survived with a favourable neurologic outcome 30 days after treatment by the Swiss helicopter emergency medical service. Immediate bystander cardiopulmonary resuscitation and non-traumatic OHCA aetiology were the factors most strongly associated with a favourable neurological outcome. These results underline the importance of effective bystander and first-responder rescue as the foundation for subsequent professional treatment of children in cardiac arrest.

Conclusion (proposition de traduction) : Dans cette étude, 18,9 % des enfants victimes d'un arrêt cardiaque extrahospitalier ont survécu avec une issue neurologique favorable 30 jours après avoir été pris en charge par le service médical d'urgence héliporté suisse. La réanimation cardio-pulmonaire immédiate et l'étiologie non traumatique de l'OHCA étaient les facteurs les plus fortement associés à une issue neurologique favorable. Ces résultats soulignent l'importance d'un secours efficace de la part des témoins et des premiers intervenants comme base du traitement professionnel ultérieur des enfants en arrêt cardiaque.

The American Journal of Emergency Medicine

Utility of end-tidal carbon dioxide to guide resuscitation termination in prolonged out-of-hospital cardiac arrest.
Hambelton C, Wu L, Smith J, Thompson K, Neth MR, Daya MR, Jui J, Lupton JR. | Am J Emerg Med. 2023 Dec 7;77:77-80
Keywords: Cardiac arrest; End-tidal carbon dioxide; Resuscitation; Termination of resuscitation

Short communication

Introduction : To evaluate if the change in end-tidal carbon dioxide (ETCO2) over time has improved discriminatory value for determining resuscitation futility compared to a single ETCO2 value in prolonged, refractory non-shockable out-of-hospital cardiac arrest (OHCA).

Méthode : This is a retrospective analysis of adult refractory non-shockable, non-traumatic OHCA patients in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry) from 2018 to 2021. We defined refractory non-shockable OHCA cases as patients with lack of a shockable rhythm at any time or return of spontaneous circulation at any time prior to 30-min of on-scene resuscitation. We abstracted ETCO2 values first recorded after advanced airway placement and nearest to the 30-min mark of on-scene resuscitation (30 min-ETCO2) from EMS charts. The primary outcome was survival to hospital discharge. We compared 30 min-ETCO2 cutoffs of 10 mmHg and 20 mmHg to the trend (increasing or not) from initial to 30 min-ETCO2 (delta-ETCO2) using sensitivity, specificity, and area under the receiver operating curves (AUROC).

Résultats : Of 3837 adult OHCA, 2850 were initially non-shockable, and there were 617 (16.1%) cases of refractory non-shockable OHCA at 30-min. We excluded 320 cases without at least two ETCO2 recordings in the EMS chart, leaving 297 cases that met inclusion criteria. Of these, 176 (59.3%) were transported and 2 (0.7%) survived to discharge. Using absolute 30 min-ETCO2 cutoffs, both survivors were in the >10 mmHg group (sensitivity 100.0%, specificity 12.5%), whereas only one survivor was identified in the >20 mmHg group (sensitivity 50.0%, specificity 32.5%). Using delta-ETCO2, both survivors were in the increasing ETCO2 group (sensitivity 100.0%, specificity 60.7%). In comparing the two tests that did not misclassify survivors, the AUROC [95% CI] was higher when using delta-ETCO2 (0.803 [0.775-0.831]) compared to an absolute cutoff of 10 mmHg (0.563 [0.544-0.582]).

Conclusion : Nearly one-sixth of EMS-treated adult OHCA patients had refractory non-shockable arrests after at least 30 min of ongoing resuscitation. In this group, the ETCO2 trend following advanced airway placement may be more accurate in guiding termination of resuscitation than an absolute ETCO2 cutoff of 10 or 20 mmHg.

Conclusion (proposition de traduction) : Près d'un sixième des adultes victimes d'un arrêt cardiaque extrahospitalier traités par les services médicaux d'urgence étaient en arrêt cardiaque réfractaire non choquable après au moins 30 minutes de réanimation. Dans ce groupe, la tendance de l'ETCO2 après la mise en place des voies aériennes avancées peut être plus précise pour guider l'arrêt de la réanimation qu'un seuil absolu d'ETCO2 de 10 ou 20 mmHg.

Mois de décembre 2023