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Azer Z, Leone M, Chatelon J, Abulfatth A, Ahmed A, Saleh R. Study of initial blood lactate and delta lactate as early predictor of morbidity and mortality in trauma patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2175871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Affiliation(s)
- Zarif Azer
- Department of Anesthesia, Intensive Care and Trauma Center, Nord University Hospital, Aix Marseille University, APHM, Marseille, France
- Department of Anesthesia and Surgical Intensive Care, Alexandria Main University Hospitals, Azarita Medical Campus, Alexandria, Egypt
| | - Marc Leone
- Department of Anesthesia, Intensive Care and Trauma Center, Nord University Hospital, Aix Marseille University, APHM, Marseille, France
| | - Jeanne Chatelon
- Department of Anesthesia, Intensive Care and Trauma Center, Nord University Hospital, Aix Marseille University, APHM, Marseille, France
| | - Amr Abulfatth
- Department of Anesthesia and Surgical Intensive Care, Alexandria Main University Hospitals, Azarita Medical Campus, Alexandria, Egypt
| | - Ahmed Ahmed
- Department of Anesthesia and Surgical Intensive Care, Alexandria Main University Hospitals, Azarita Medical Campus, Alexandria, Egypt
| | - Rabab Saleh
- Department of Anesthesia and Surgical Intensive Care, Alexandria Main University Hospitals, Azarita Medical Campus, Alexandria, Egypt
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Çeleğen M, Çeleğen K. Lactate Clearance as an Early Prognostic Marker of Mortality for Pediatric Trauma. KLINISCHE PADIATRIE 2023; 235:270-276. [PMID: 36379454 DOI: 10.1055/a-1829-6305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background While lactate clearance (LC) has already been shown as a prognostic indicator in clinical studies, its certain character needs to be defined in pediatric trauma. This research aimed to evaluate the correlation between early lactate clearance and mortality in pediatric trauma.Patients and methods A retrospective cohort study was conducted in a university hospital. Repeated LC was measured at admission, at the 2nd, 6th, and 12th hours post-admission. The association of lactate clearance with mortality was analyzed and using receiver operating characteristic (ROC) to determine the threshold levels of lactate clearance and also logistic regression analysis was performed to determine whether LC was an independent risk factor.Results Seventy-eight patients were included and overall mortality was 13%. LC values of the non-survivors was significantly lower than survivors for LC0-2 h (28.60±14.26 vs 4.64±15.90), LC0-6 h (46.63±15.23 vs 3.33±18.07), LC0-12 h (56.97±15.53 vs 4.82±22.59) (p:<0.001, p:<0.001 and p:<0.001, respectively). Areas under the curve of lactate clearance at the 2nd, 6th, and 12th hours after therapy start were a significant predictor for mortality (p:<0.001, p:<0.001, and p:<0.001, respectively). Threshold values of LC were 12.9, 19.5 and 29.3%, respectively.Conclusion Lactate clearance was a beneficial tool to estimate outcomes of pediatric trauma. Poor lactate clearance was a significant marker for poor prognosis.
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Affiliation(s)
- Mehmet Çeleğen
- Department of Pediatrics, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Kübra Çeleğen
- Division of Pediatric Nephrology, Department of Pediatrics, Afyonkarahisar Health Sciences University Faculty of Medicine, Afyonkarahisar, Turkey
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Boye M, Py N, Libert N, Chrisment A, Pissot M, Dedome E, Martinaud C, Ausset S, Boutonnet M, De Rudnicki S, Pasquier P, Martinez T. Step by step transfusion timeline and its challenges in trauma: A retrospective study in a level one trauma center. Transfusion 2022; 62 Suppl 1:S30-S42. [PMID: 35781713 DOI: 10.1111/trf.16953] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemorrhagic shock is the leading cause of preventable early death in trauma patients. Transfusion management is guided by international guidelines promoting early and aggressive transfusion strategies. This study aimed to describe transfusion timelines in a trauma center and to identify key points to performing early and efficient transfusions. METHODS This is a monocentric retrospective study of 108 severe trauma patients, transfused within the first 48 h and hospitalized in an intensive care unit between January 2017 and May 2019. RESULTS One hundred and eight patients were transfused with 1250 labile blood products. Half of these labile blood products were transfused within 3 h of admission and consumed by 26 patients requiring massive transfusion (≥4 red blood cells [RBC] within 1 h). Among these, the median delay from patient's admission to labile blood products prescription was -11 min (-34 to -1); from admission to delivery of labile blood products was 1 min (-20 to 16); and from admission to first transfusion was 20 min (7-37) for RBC, 26 min (13-38) for plasma, and 72 min (51-103) for platelet concentrates. The anticipated prescription of labile blood products and the use of massive transfusion packs and lyophilized plasma units were associated with earlier achievement of high transfusion ratios. CONCLUSION This study provides detailed data on the transfusion timelines and composition, from prescription to initial transfusion. Transfusion anticipation, use of preconditioned transfusion packs including platelets, and lyophilized plasma allow rapid and high-ratio transfusion practices in severe trauma patients.
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Affiliation(s)
- Matthieu Boye
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Nicolas Py
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Nicolas Libert
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Anne Chrisment
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Mathieu Pissot
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | | | - Christophe Martinaud
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,FMBI, French Military Blood Institute, Clamart, France
| | - Sylvain Ausset
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,FMHSS, French Military Health Service Schools, Lyon, France
| | - Mathieu Boutonnet
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Stéphane De Rudnicki
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Pierre Pasquier
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,1ère Chefferie du Service de Santé, French Military Medical Service, Villacoublay, France
| | - Thibault Martinez
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
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James A, Yordanov Y, Ausset S, Langlois M, Tourtier JP, Carli P, Riou B, Raux M. Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule. Eur J Emerg Med 2021; 28:136-143. [PMID: 33252375 DOI: 10.1097/mej.0000000000000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKROUND Triage is key in the management of mass casualty incidents. OBJECTIVE The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack. DESIGN SETTING AND PARTICIPANT This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files. OUTCOMES MEASURES AND ANALYSIS The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category. MAIN RESULT Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged. CONCLUSION A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.
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Affiliation(s)
- Arthur James
- Sorbonne Université
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
| | - Youri Yordanov
- Sorbonne Université
- UMRS Inserm 1136
- Department of Emergency Medicine and Surgery, Hôpital Saint-Antoine
- Department of Emergency, APHP
| | - Sylvain Ausset
- Department of Anesthesiology and Critical Care, Hôpital d'Instruction des armées (HIA), Clamart
| | - Matthieu Langlois
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
- Service Médical du RAID, Bièvres
| | | | - Pierre Carli
- Service d'Aide Médicale Urgente 75, Hôpital Necker-Enfants Malades, APHP
- Université de Paris
| | - Bruno Riou
- Sorbonne Université
- Department of Emergency Medicine and Surgery, Hôpital Saint-Antoine
- UMRS Inserm 1166, IHU ICAN
- Department of Emergency Medicine and Surgery, Hôpital Pitié-Salpêtrière
| | - Mathieu Raux
- Sorbonne Université
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
- UMRS Inserm 1158, Paris, France
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5
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Pottecher J, Noll E, Borel M, Audibert G, Gette S, Meyer C, Gaertner E, Legros V, Carapito R, Uring-Lambert B, Sauleau E, Land WG, Bahram S, Meyer A, Geny B, Diemunsch P. Protocol for TRAUMADORNASE: a prospective, randomized, multicentre, double-blinded, placebo-controlled clinical trial of aerosolized dornase alfa to reduce the incidence of moderate-to-severe hypoxaemia in ventilated trauma patients. Trials 2020; 21:274. [PMID: 32183886 PMCID: PMC7079402 DOI: 10.1186/s13063-020-4141-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/04/2020] [Indexed: 01/01/2023] Open
Abstract
Background Acute respiratory distress syndrome continues to drive significant morbidity and mortality after severe trauma. The incidence of trauma-induced, moderate-to-severe hypoxaemia, according to the Berlin definition, could be as high as 45%. Its pathophysiology includes the release of damage-associated molecular patterns (DAMPs), which propagate tissue injuries by triggering neutrophil extracellular traps (NETs). NETs include a DNA backbone coated with cytoplasmic proteins, which drive pulmonary cytotoxic effects. The structure of NETs and many DAMPs includes double-stranded DNA, which prevents their neutralization by plasma. Dornase alfa is a US Food and Drug Administration-approved recombinant DNase, which cleaves extracellular DNA and may therefore break up the backbone of NETs and DAMPs. Aerosolized dornase alfa was shown to reduce trauma-induced lung injury in experimental models and to improve arterial oxygenation in ventilated patients. Methods TRAUMADORNASE will be an institution-led, multicentre, double-blinded, placebo-controlled randomized trial in ventilated trauma patients. The primary trial objective is to demonstrate a reduction in the incidence of moderate-to-severe hypoxaemia in severe trauma patients during the first 7 days from 45% to 30% by providing aerosolized dornase alfa as compared to placebo. The secondary objectives are to demonstrate an improvement in lung function and a reduction in morbidity and mortality. Randomization of 250 patients per treatment arm will be carried out through a secure, web-based system. Statistical analyses will include a descriptive step and an inferential step using fully Bayesian techniques. The study was approved by both the Agence Nationale de la Sécurité du Médicament et des Produits de Santé (ANSM, on 5 October 2018) and a National Institutional Review Board (CPP, on 6 November 2018). Participant recruitment began in March 2019. Results will be published in international peer-reviewed medical journals. Discussion If early administration of inhaled dornase alfa actually reduces the incidence of moderate-to-severe hypoxaemia in patients with severe trauma, this new therapeutic strategy may be easily implemented in many clinical trauma care settings. This treatment may facilitate ventilator weaning, reduce the burden of trauma-induced lung inflammation and facilitate recovery and rehabilitation in severe trauma patients. Trial registration ClinicalTrials.gov, NCT03368092. Registered on 11 December 2017.
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Affiliation(s)
- Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d'Anesthésie-Réanimation Chirurgicale, 1 Avenue Molière, 67098, Strasbourg, France. .,Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), EA3072, 4 Rue Kirschleger, 67085, Strasbourg, France. .,Fédération Hospitalo-Universitaire OMICARE, Centre de Recherche d'Immunologie et d'Hématologie, 4 rue Kirschleger, 67085, Strasbourg Cedex, France.
| | - Eric Noll
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d'Anesthésie-Réanimation Chirurgicale, 1 Avenue Molière, 67098, Strasbourg, France.,Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), EA3072, 4 Rue Kirschleger, 67085, Strasbourg, France.,Fédération Hospitalo-Universitaire OMICARE, Centre de Recherche d'Immunologie et d'Hématologie, 4 rue Kirschleger, 67085, Strasbourg Cedex, France
| | - Marie Borel
- Sorbonne Universités, UPMC Université Paris 06, INSERM UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département d'Anesthésie Réanimation, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Gérard Audibert
- CHRU Nancy, Hôpital Central, Service d'Anesthésie-Réanimation, 29 Avenue de Lattre de Tassigny, 54000, Nancy, France
| | - Sébastien Gette
- CHR Metz-Thionville-Site de Mercy, Service de Réanimation Polyvalente, 1 Allée du Château, 57350, Ars-Laquenexy, France
| | - Christian Meyer
- Groupe Hospitalier de la Région de Mulhouse et Sud Alsace (GHRMSA), Pôle d'Anesthésie-Réanimation, 20 rue du Dr Laennec, 68051, Mulhouse Cedex 1, France
| | - Elisabeth Gaertner
- Hôpital Louis Pasteur, Service d'Anesthésie-Réanimation Pôle 2, 39 Avenue de la Liberté, 68024, Colmar Cedex, France
| | - Vincent Legros
- CHU de Reims, Hôpital Maison Blanche, Réanimation Chirurgicale et Traumatologique, SAMU 51, 45 rue Cognacq-Jay, 51092, Reims, France
| | - Raphaël Carapito
- Fédération Hospitalo-Universitaire OMICARE, Centre de Recherche d'Immunologie et d'Hématologie, 4 rue Kirschleger, 67085, Strasbourg Cedex, France.,Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Laboratoire Central d'Immunologie, 1 Place de l'Hôpital, 67091, Strasbourg Cedex, France.,Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM UMR_S 1109, 4 rue Kirschleger, 67085, Strasbourg Cedex, France
| | - Béatrice Uring-Lambert
- Fédération Hospitalo-Universitaire OMICARE, Centre de Recherche d'Immunologie et d'Hématologie, 4 rue Kirschleger, 67085, Strasbourg Cedex, France.,Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Laboratoire Central d'Immunologie, 1 Place de l'Hôpital, 67091, Strasbourg Cedex, France.,Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM UMR_S 1109, 4 rue Kirschleger, 67085, Strasbourg Cedex, France
| | - Erik Sauleau
- Hôpitaux Universitaires de Strasbourg, Hôpital Civil, Pôle Santé Publique, Groupe Méthode en Recherche Clinique (GMRC), 1 Place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Walter G Land
- Fédération Hospitalo-Universitaire OMICARE, Centre de Recherche d'Immunologie et d'Hématologie, 4 rue Kirschleger, 67085, Strasbourg Cedex, France.,Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM UMR_S 1109, 4 rue Kirschleger, 67085, Strasbourg Cedex, France
| | - Seiamak Bahram
- Fédération Hospitalo-Universitaire OMICARE, Centre de Recherche d'Immunologie et d'Hématologie, 4 rue Kirschleger, 67085, Strasbourg Cedex, France.,Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Laboratoire Central d'Immunologie, 1 Place de l'Hôpital, 67091, Strasbourg Cedex, France.,Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM UMR_S 1109, 4 rue Kirschleger, 67085, Strasbourg Cedex, France
| | - Alain Meyer
- Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), EA3072, 4 Rue Kirschleger, 67085, Strasbourg, France.,Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Physiologie et d'Explorations Fonctionnelles, 1 Place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Bernard Geny
- Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), EA3072, 4 Rue Kirschleger, 67085, Strasbourg, France.,Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Physiologie et d'Explorations Fonctionnelles, 1 Place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Pierre Diemunsch
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d'Anesthésie-Réanimation Chirurgicale, 1 Avenue Molière, 67098, Strasbourg, France.,Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), EA3072, 4 Rue Kirschleger, 67085, Strasbourg, France.,Fédération Hospitalo-Universitaire OMICARE, Centre de Recherche d'Immunologie et d'Hématologie, 4 rue Kirschleger, 67085, Strasbourg Cedex, France
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Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury. Intensive Care Med 2019; 45:1231-1240. [PMID: 31418059 DOI: 10.1007/s00134-019-05724-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma. METHODS This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds. RESULTS 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min]. CONCLUSION The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack. FUNDING Assistance Publique-Hôpitaux de Paris.
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7
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Deras P, Nouri J, Martinez O, Aubry E, Capdevila X, Charbit J. Diagnostic performance of prothrombin time point-of-care to detect acute traumatic coagulopathy on admission: experience of 522 cases in trauma center. Transfusion 2018; 58:1781-1791. [PMID: 29707780 DOI: 10.1111/trf.14643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Early identification of acute traumatic coagulopathy is a key challenge during initial management to determine whether to initiate early hemostatic support. We assessed the performance of prothrombin time (PT) at point-of-care in trauma patients to detect moderate and severe coagulopathy on admission. STUDY DESIGN AND METHODS All admitted consecutive trauma patients were analyzed retrospectively between April 2014 and July 2015. PT was measured on admission with both a PT point-of-care device (PTr-CGK) and a standard coagulation test (PTr-STD). The results for PTr-CGK and PTr-STD were compared using analysis of agreement, precision, and accuracy. The diagnostic performance of PTr-CGK to predict coagulopathy was established by analysis of receiver operating characteristic curves. The predictive performance of different thresholds and risk factors for misclassification were also studied. RESULTS Over a 16-month period, 522 patients were included. PTr-CGK estimated PTr-STD with a bias of 0.00 (95% confidence interval [CI], -0.48 to 0.50) and a precision of 0.25. The optimal threshold was 1.4 to predict severe coagulopathy (sensitivity 81% [95% CI, 68%-94%], negative predictive value 98% [95% CI, 97%-99%]), and 1.2 for moderate coagulopathy (sensitivity 80% [95% CI, 72%-88%], negative predictive value 94% [95% CI, 91%-96%]). A low PTr-CGK in the presence of severity criteria (Injury Severity Score ≥ 16, Trauma Associated Severe Hemorrhage score ≥ 12, hemoglobin level < 7 g/dL, fibrinogen level < 2 g/L, base deficit ≥ 6 mmol/L) was strongly associated with a false-negative risk. CONCLUSIONS The PT point-of-care device is reliable and accurate for the early identification of coagulopathic trauma patients.
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Affiliation(s)
- Pauline Deras
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Level-1 Regional Trauma Center, Montpellier, France
| | - Jibril Nouri
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Level-1 Regional Trauma Center, Montpellier, France
| | - Orianne Martinez
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Level-1 Regional Trauma Center, Montpellier, France
| | - Emmanuelle Aubry
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Level-1 Regional Trauma Center, Montpellier, France
| | - Xavier Capdevila
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Level-1 Regional Trauma Center, Montpellier, France
| | - Jonathan Charbit
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Level-1 Regional Trauma Center, Montpellier, France
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8
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Perozziello A, Gauss T, Diop A, Frank-Soltysiak M, Rufat P, Raux M, Hamada S, Riou B. La codification PMSI identifie mal les traumatismes graves. Rev Epidemiol Sante Publique 2018; 66:43-52. [DOI: 10.1016/j.respe.2017.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 10/04/2017] [Accepted: 10/17/2017] [Indexed: 11/25/2022] Open
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9
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Lactate serial measurements and predictive validity of early mortality in trauma patients admitted to the intensive care unit. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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10
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Mediciones seriadas del lactato y su validez predictiva de la mortalidad temprana en los pacientes con politrauma que ingresan a la unidad de cuidado intensivo. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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11
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Lactate serial measurements and predictive validity of early mortality in trauma patients admitted to the intensive care unit☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Comparison of the Prognostic Significance of Initial Blood Lactate and Base Deficit in Trauma Patients. Anesthesiology 2017; 126:522-533. [DOI: 10.1097/aln.0000000000001490] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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De Jong A, Deras P, Martinez O, Latry P, Jaber S, Capdevila X, Charbit J. Relationship between Obesity and Massive Transfusion Needs in Trauma Patients, and Validation of TASH Score in Obese Population: A Retrospective Study on 910 Trauma Patients. PLoS One 2016; 11:e0152109. [PMID: 27010445 PMCID: PMC4807035 DOI: 10.1371/journal.pone.0152109] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 02/29/2016] [Indexed: 11/18/2022] Open
Abstract
Background Prediction of massive transfusion (MT) is challenging in management of trauma patients. However, MT and its prediction were poorly studied in obese patients. The main objective was to assess the relationship between obesity and MT needs in trauma patients. The secondary objectives were to validate the Trauma Associated Severe Hemorrhage (TASH) score in predicting MT in obese patients and to use a grey zone approach to optimize its ability to predict MT. Methods and Findings An observational retrospective study was conducted in a Level I Regional Trauma Center Trauma in obese and non-obese patients. MT was defined as ≥10U of packed red blood cells in the first 24h and obesity as a BMI≥30kg/m². Between January 2008 and December 2012, 119 obese and 791 non-obese trauma patients were included. The rate of MT was 10% (94/910) in the whole population. The MT rate tended to be higher in obese patients than in non-obese patients: 15% (18/119, 95%CI 9‒23%) versus 10% (76/791, 95%CI 8‒12%), OR, 1.68 [95%CI 0.97‒2.92], p = 0.07. After adjusting for Injury Severity Score (ISS), obesity was significantly associated with MT rate (OR, 1.79[95%CI 1.00‒3.21], p = 0.049). The TASH score was higher in the obese group than in the non-obese group: 7(4–11) versus 5(2–10)(p<0.001). The area under the ROC curves of the TASH score in predicting MT was very high and comparable between the obese and non-obese groups: 0.93 (95%CI, 0.89‒0.98) and 0.94 (95%CI, 0.92‒0.96), respectively (p = 0.80). The grey zone ranged respectively from 10 to 13 and from 9 to 12 in obese and non obese patients, and allowed separating patients at low, intermediate or high risk of MT using the TASH score. Conclusions Obesity was associated with a higher rate of MT in trauma patients. The predictive performance of the TASH score and the grey zones were robust and comparable between obese and non-obese patients.
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Affiliation(s)
- Audrey De Jong
- Trauma Intensive Care & Critical Care Unit, Lapeyronie University Hospital, Montpellier, France.,Intensive Care Unit & Anesthesiology Department, Saint-Eloi University Hospital, Montpellier, France.,INSERM U1046 Montpellier, France
| | - Pauline Deras
- Trauma Intensive Care & Critical Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Orianne Martinez
- Trauma Intensive Care & Critical Care Unit, Lapeyronie University Hospital, Montpellier, France
| | | | - Samir Jaber
- Intensive Care Unit & Anesthesiology Department, Saint-Eloi University Hospital, Montpellier, France.,INSERM U1046 Montpellier, France
| | - Xavier Capdevila
- Trauma Intensive Care & Critical Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Jonathan Charbit
- Trauma Intensive Care & Critical Care Unit, Lapeyronie University Hospital, Montpellier, France
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Alawadi ZM, LeFebvre E, Fox EE, Del Junco DJ, Cotton BA, Wade CE, Holcomb JB. Alternative end points for trauma studies: A survey of academic trauma surgeons. Surgery 2015; 158:1291-6. [PMID: 25958063 DOI: 10.1016/j.surg.2015.03.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/06/2015] [Accepted: 03/18/2015] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Changing the epidemiology of trauma makes traditional end points like 30-day mortality less than ideal. Many alternative end points have been suggested; however, they are not yet accepted by the trauma community or regulatory bodies. This study characterizes opinions about the adequacy of accepted end points of studies of trauma and the appropriateness of several novel end points. METHODS An electronic survey was administered to all members of the American Association for the Surgery of Trauma. Questions involved demographics, research experience, appropriateness of proposed study end points, and the role of nontraditional, surrogate, and composite end points. RESULTS Response rate was 16% (141 of 873) with 74% of respondents practicing at Level 1 Trauma Centers. The respondents were very experienced, with 81% reporting >10 years of practice at the attending level and 87% actively involved in research. The majority of respondents rated the following end points favorably: 24-hour survival, 30-day survival, and time to control of acute hemorrhage with approval rates of 82%, 78%, and 76%, respectively. Six-hour survival, intensive care unit-free survival, and days free of multiorgan failure were rated as appropriate or very appropriate less than 66% of the time. Only 45% of respondents judged the currently used end points of trauma to be appropriate. More than 80% respondents disagreed or strongly disagreed that there was no role for of surrogate or composite endpoints in research of trauma resuscitation. CONCLUSION There is strong interest in finding efficient end points in trauma research that are both specific and reflect the changing epidemiology of trauma death. The alternative end points of 24-hour survival and time to control of acute hemorrhage had similar approval rates to 30-day mortality.
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Affiliation(s)
- Zeinab M Alawadi
- Department of Surgery, University of Texas Medical School, Houston, TX; University of Texas Health Science Center at Houston Center for Surgical Trials and Evidence-based Practice (C-STEP), Houston, TX.
| | - Eric LeFebvre
- Department of Emergency Medicine, University of Texas Medical School, Houston, TX
| | - Erin E Fox
- University of Texas Health Science Center at Houston Center for Translational Injury Research (CeTIR), Houston, TX
| | - Deborah J Del Junco
- University of Texas Health Science Center at Houston Center for Translational Injury Research (CeTIR), Houston, TX
| | - Bryan A Cotton
- Department of Surgery, University of Texas Medical School, Houston, TX; University of Texas Health Science Center at Houston Center for Translational Injury Research (CeTIR), Houston, TX
| | - Charles E Wade
- Department of Surgery, University of Texas Medical School, Houston, TX; University of Texas Health Science Center at Houston Center for Translational Injury Research (CeTIR), Houston, TX
| | - John B Holcomb
- Department of Surgery, University of Texas Medical School, Houston, TX; University of Texas Health Science Center at Houston Center for Translational Injury Research (CeTIR), Houston, TX
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Deras P, Villiet M, Manzanera J, Latry P, Schved JF, Capdevila X, Charbit J. Early coagulopathy at hospital admission predicts initial or delayed fibrinogen deficit in severe trauma patients. J Trauma Acute Care Surg 2014; 77:433-40. [DOI: 10.1097/ta.0000000000000314] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Charbit J, Millet I, Lakhal K, Brault-Noble G, Guillon F, Taourel P, Capdevila X. A haemoperitoneum does not indicate active bleeding in the peritoneum in 50% of hypotensive blunt trauma patients: a study of 110 severe trauma patients. Injury 2014; 45:88-94. [PMID: 22769979 DOI: 10.1016/j.injury.2012.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 04/05/2012] [Accepted: 05/15/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND We hypothesised that in blunt trauma patients with haemodynamic instability and haemoperitoneum on hospital admission, the haemorrhagic source may not be confined to the peritoneum. The purpose of this study was to describe the incidence and location of bleeding source in this population. METHODS The charts of trauma patients admitted consecutively between January 2005 and January 2010 to our level I Regional Trauma Centre were reviewed retrospectively. All hypotensive patients presenting a haemoperitoneum on admission were included. Hypotension was defined by a systolic blood pressure ≤ 90 mmHg. The haemoperitoneum was quantified on CT images or from operative reports as moderate (Federle score<3 or between 200 and 500 ml) or large (Federle score ≥ 3 or >500 ml). Active bleeding (AB) was defined as injury requiring a surgical or radiologic haemostatic procedure, regardless of origin (peritoneal (PAB) or extraperitoneal (EPAB)). RESULTS Of 1079 patients admitted for severe trauma, 110 patients met the inclusion criteria. Seventy-eight (71%) were male, mean age 35.3 (SD 19) years and mean ISS 36.5 (SD 20.5). Among the 91 patients who had AB, 37 patients (41%) had PAB, 34 (37%) had EPAB and 20 had both (22%). Forty-eight (53%) of them had moderate haemoperitoneum and 43 (47%) had large haemoperitoneum. A large haemoperitoneum had positive predictive value for PAB of 88% (95% CI 75-95%) and negative predictive value of 65% (95% CI 49-79%). The corresponding values in the subgroup of patients with EPAB were 65% (95% CI 38-86%) and 76% (95% CI 59-88%). CONCLUSION Haemoperitoneum was associated with PAB in only 52% of hypotensive blunt trauma patients and 63% of bleeding patients. In contrast, 59% of bleeding patients had at least one EPAB. The screening of a haemoperitoneum as a marker of active haemorrhagic source may be confusing and lead to misdiagnosis and inappropriate strategy. Clinician should exclude carefully the presence of any EPAB explaining haemorrhagic shock, before to decide haemostatic treatment.
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Affiliation(s)
- J Charbit
- Department of Anesthesiology and Critical Care, Lapeyronie University Hospital, Montpellier, F-34295 Cedex 5, France.
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δ Opioid Receptor Antagonists. Anesthesiology 2013; 119:253-5. [DOI: 10.1097/aln.0b013e31829b3853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Does the size of the hemoperitoneum help to discriminate the bleeding source and guide therapeutic decisions in blunt trauma patients with pelvic ring fracture? J Trauma Acute Care Surg 2012; 73:117-25. [PMID: 22743381 DOI: 10.1097/ta.0b013e31824ac38b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND In blunt trauma patients with a hemoperitoneum and a pelvic injury, multiple sources of active bleeding may exist. The purpose of this study was to determine whether the size of the hemoperitoneum helps to establish the bleeding source and guide therapeutic decisions in patients with pelvic fractures. METHODS The charts of patients with pelvic fractures admitted to a trauma intensive care unit from January 2005 to December 2009 were reviewed retrospectively. The hemoperitoneum size was defined by semiquantitative analysis (minimal/none, moderate, and large) using the Federle score on computed tomographic scan or during laparotomy. Active peritoneal hemorrhages requiring immediate laparotomy were compared according to hemoperitoneum size. RESULTS Of 185 patients, hemoperitoneum did not occur in 116 patients, moderate in 43, and large in 26. Among 102 patients (55%) who were hypotensive (systolic blood pressure <90 mm Hg) on admission, 27 needed therapeutic laparotomy and 15 needed pelvic embolization. Laparotomy (39% vs. 2%) and pelvic embolization (22% vs. 4%) were required significantly more often in patients with hemoperitoneum (moderate or large) than those without hemoperitoneum. The positive predictive value for an active peritoneal hemorrhage derived from qualitative analysis of the hemoperitoneum (moderate or large) was 39% (4% in hypotensive patients and 40% in those requiring pelvic embolization). The corresponding values for large hemoperitoneum only (semiquantitative analysis) were 62%, 70%, and 67%, respectively. CONCLUSION In patients with pelvic fractures, hemoperitoneum does not mean peritoneal injury requiring hemostatic procedure. Semiquantitative analysis of the hemoperitoneum improves predictability of peritoneal hemorrhage than qualitative analysis of hemoperitoneum. However, there remains numerous false-positives even in presence of large hemoperitoneum associated with hypotension.
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Charbit J, Mahul M, Roustan JP, Latry P, Millet I, Taourel P, Capdevila X. Hemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion. Am J Emerg Med 2012; 31:130-6. [PMID: 22980362 DOI: 10.1016/j.ajem.2012.06.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 06/09/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The purpose of this study was to define whether the semiquantitative analysis of hemoperitoneum increases the accuracy of early prediction of massive transfusion (MT). METHODS A retrospective review of severe trauma patients consecutively admitted to our trauma intensive care unit between January 2005 and December 2009 was conducted. Patients diagnosed with blunt abdominal trauma who had a computed tomography scan on admission were included. The hemoperitoneum size was defined using the Federle score on computed tomography as large, moderate, or minimal/none. The association between MT (≥10 U of packed red blood cells in the first 24 h) and moderate and large sizes of hemoperitoneum was assessed using a multiple logistic model. RESULTS Of the 381 patients meeting the inclusion criteria, 270 (71%) were male; the mean age was 35.5 ± 18.2 years and mean injury severity score was 23.4 ± 17. Ninety-seven (26%) had large hemoperitoneum, 107 (28%) had moderate hemoperitoneum, and 177 (46%) had minimal/no hemoperitoneum. Eighty-three patients (22%) required MT. The positive predictive value for MT of a large hemoperitoneum was 41%, 23% for a moderate hemoperitoneum, and 10% for minimal/no hemoperitoneum (P < .001). The corresponding values for hypotensive patients were 61%, 32%, and 25%, respectively (P < .001). In the multivariate analysis model, only the large size of hemoperitoneum was significantly associated with MT (OR 6.4, 95% CI 2.9-14, P < .001, r(2) = 0.47). CONCLUSION The assessment of the size of hemoperitoneum on admission substantially improves the prediction of MT in trauma patients and should be used to trigger and guide initial haemostatic resuscitation.
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Affiliation(s)
- Jonathan Charbit
- Department of Anesthesiology and Critical Care, Lapeyronie University Hospital, Montpellier, F-34295 Cedex 5, France.
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The use of the Revised Trauma Score as an entry criterion in traumatic hemorrhagic shock studies: data from the DCLHb clinical trials. Prehosp Disaster Med 2012; 27:330-44. [PMID: 22840198 DOI: 10.1017/s1049023x12000970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The Revised Trauma Score (RTS) has been proposed as an entry criterion to identify patients with mid-range survival probability for traumatic hemorrhagic shock studies. HYPOTHESIS/PROBLEM Determination of which of four RTS strata (1-3.99, 2-4.99, 1-4.99, and 2-5.99) identifies patients with predicted and actual mortality rates near 50% for use as an entry criterion in traumatic hemorrhagic shock clinical trials. METHODS Existing database analysis in which demographic and injury severity data from two prior international Diaspirin Cross-Linked Hemoglobin (DCLHb) clinical trials were used to identify an RTS range that could be an optimal entry criterion in order to find the population of trauma patients with mid-range predicted and actual mortality rates. RESULTS Of 208 study patients, the mean age was 37 years, 65% sustained blunt trauma, 49% received DCLHb, and 57% came from the European Union study arm. The mean values were: ISS, 31 (SD = 18); RTS, 5.6 (SD = 1.8); and Glasgow Coma Scale (GCS), 10.4 (SD = 4.8). The mean TRISS-predicted mortality was 34% and the actual 28-day mortality was 35%. The initially proposed 1-3.99 RTS range (n = 41) had the highest predicted (79%) and actual (71%) mortality rates. The 2-5.99 RTS range (n = 79) had a 62% predicted and 53% actual mortality, and included 76% blunt trauma patients. Removal of GCS <5 patients from this RTS 2-5.99 subgroup caused a 48% further reduction in eligible patients, leaving 41 patients (20% of 208 total patients), 66% of whom sustained a blunt trauma injury. This subgroup had 54% predicted and 49% actual mortality rates. Receiver operator curve (ROC) analysis found the GCS to be as predictive of mortality as the RTS, both in the total patient population and in the RTS 2-5.99 subgroup. CONCLUSION The use of an RTS 2-5.99 inclusion criterion range identifies a traumatic hemorrhagic shock patient subgroup with predicted and actual mortality that approach the desired 50% rate. The exclusion of GCS <5 from this RTS 2-5.99 subgroup patients yields a smaller, more uniform patient subgroup whose mortality is more likely related to hemorrhagic shock than traumatic brain injury. Future studies should examine whether the RTS or other physiologic criteria such as the GCS score are most useful as traumatic hemorrhagic shock study entry criteria.
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Yeguiayan JM, Yap A, Freysz M, Garrigue D, Jacquot C, Martin C, Binquet C, Riou B, Bonithon-Kopp C. Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R101. [PMID: 22687140 PMCID: PMC3580653 DOI: 10.1186/cc11375] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 06/11/2012] [Indexed: 01/24/2023]
Abstract
Introduction The mortality benefit of whole-body computed tomography (CT) in early trauma management remains controversial and poorly understood. The objective of this study was to assess the impact of whole-body CT compared with selective CT on mortality and management of patients with severe blunt trauma. Methods The FIRST (French Intensive care Recorded in Severe Trauma) study is a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to intensive care units from university hospital trauma centers within the first 72 hours. Initial data were combined to construct a propensity score to receive whole-body CT and selective CT used in multivariable logistic regression models, and to calculate the probability of survival according to the Trauma and Injury Severity Score (TRISS) for 1,950 patients. The main endpoint was 30-day mortality. Results In total, 1,696 patients out of 1,950 (87%) were given whole-body CT. The crude 30-day mortality rates were 16% among whole-body CT patients and 22% among selective CT patients (p = 0.02). A significant reduction in the mortality risk was observed among whole-body CT patients whatever the adjustment method (OR = 0.58, 95% CI: 0.34-0.99 after adjustment for baseline characteristics and post-CT treatment). Compared to the TRISS predicted survival, survival significantly improved for whole-body CT patients but not for selective CT patients. The pattern of early surgical and medical procedures significantly differed between the two groups. Conclusions Diagnostic whole-body CT was associated with a significant reduction in 30-day mortality among patients with severe blunt trauma. Its use may be a global indicator of better management.
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Prise en charge actuelle du traumatisé grave en France : premier bilan de l’étude FIRST (French Intensive care Recorded in Severe Trauma). ANNALES FRANCAISES DE MEDECINE D URGENCE 2012. [DOI: 10.1007/s13341-012-0181-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
BACKGROUND Little information is available concerning the ability of prehospital triage scores to predict endpoints other than mortality. METHODS We evaluated two cohorts (a national cohort of 1,360 patients during 2002 and a single center cohort of 1,003 patients in 2003-2005) of trauma patients receiving care from a prehospital mobile intensive care unit (ICU). We tested the ability of prehospital triage scores (MGAP, Revised Trauma Score [RTS], and triage RTS [T-RTS]) to predict a severe injury, the need for a prolonged ICU period, the occurrence of massive hemorrhage, and the need for emergency procedures, and compared them with a reference score (Trauma-Related Injury Severity Score [TRISS]). The areas under the receiver operating characteristic (AUC(ROC)) curves were measured. RESULTS The MGAP, RTS, and T-RTS scores were able to predict an Injury Severity Score >15 (AUC(ROC): 0.75, 0.75, and 0.74, respectively), the need for a stay in ICU >2 days or death (AUC(ROC) of 0.85, 0.83, and 0.83, respectively), and the massive hemorrhage (AUC(ROC): 0.70, 0.72, and 0.73, respectively). In contrast, MGAP, RTS, T-RTS, and TRISS scores were not predictors of the need of an emergency procedure (AUC(ROC): 0.53, 0.51, and 0.52, respectively). Four independent predictors of emergency procedure were noted: penetrating trauma, intravenous colloid administration >750 mL, systolic arterial blood pressure <100 mm Hg, and heart rate >100 bpm. CONCLUSION Prehospital triage scores were predictors of Injury Severity Score >15, prolonged ICU stay, and massive hemorrhage but not of emergency procedure requirement.
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Vivien B, Yeguiayan JM, Le Manach Y, Bonithon-Kopp C, Mirek S, Garrigue D, Freysz M, Riou B. The motor component does not convey all the mortality prediction capacity of the Glasgow Coma Scale in trauma patients. Am J Emerg Med 2011; 30:1032-41. [PMID: 22035584 DOI: 10.1016/j.ajem.2011.06.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 06/25/2011] [Indexed: 10/15/2022] Open
Abstract
PURPOSE We tested the hypothesis that the motor component of the Glasgow Coma Scale (GCS) conveys most of the predictive information of triage scores (Triage Revised Trauma Score [T-RTS] and the Mechanism, GCS, Age, arterial Pressure score [MGAP]) in trauma patients. METHOD We conducted a multicenter prospective observational study and evaluated 1690 trauma patients in 14 centers. We compared the GCS, T-RTS, MGAP, and Trauma Related Injury Severity Score (reference standard) using the full GCS or its motor component only using logistic regression model, area under the receiver operating characteristic curve, and reclassification technique. RESULTS Although some changes were noted for the GCS itself and the Trauma Related Injury Severity Score, no significant change was observed using the motor component only for T-RTS and MGAP when considering (1) the odds ratio of variables included in the logistic model as well as their discrimination and calibration characteristics, (2) the area under the receiver operating characteristic curve (0.827 ± 0.014 vs 0.831 ± 0.014, P = .31 and 0.863 ± 0.011 vs 0.859 ± 0.012, P = .23, respectively), and (3) the reclassification technique. Although the mortality rate remained less than the predetermined threshold of 5% in the low-risk stratum, it slightly increased for MGAP (from 1.9% to 3.9%, P = .048). CONCLUSION The use of the motor component only of the GCS did not change the global performance of triage scores in trauma patients. However, because a subtle increase in mortality rate was observed in the low-risk stratum for MGAP, replacing the GCS by its motor component may not be recommended in every situation.
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Affiliation(s)
- Benoît Vivien
- University Paris Descartes-Paris 5, Service d'Aide Médicale Urgente (SAMU) 75 and Department of Anesthesiology and Critical Care, Centre Hospitalo-Universitaire (CHU) Necker-Enfants Malades, Paris, France
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Yeguiayan JM, Garrigue D, Binquet C, Jacquot C, Duranteau J, Martin C, Rayeh F, Riou B, Bonithon-Kopp C, Freysz M. Medical pre-hospital management reduces mortality in severe blunt trauma: a prospective epidemiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R34. [PMID: 21251331 PMCID: PMC3222071 DOI: 10.1186/cc9982] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 11/09/2010] [Accepted: 01/20/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Severe blunt trauma is a leading cause of premature death and handicap. However, the benefit for the patient of pre-hospital management by emergency physicians remains controversial because it may delay admission to hospital. This study aimed to compare the impact of medical pre-hospital management performed by SMUR (Service Mobile d'Urgences et de Réanimation) with non-medical pre-hospital management provided by fire brigades (non-SMUR) on 30-day mortality. METHODS The FIRST (French Intensive care Recorded in Severe Trauma) study is a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to university hospital intensive care units within the first 72 hours. Initial clinical status, pre-hospital life-sustaining treatments and Injury Severity Scores (ISS) were recorded. The main endpoint was 30-day mortality. RESULTS Among 2,703 patients, 2,513 received medical pre-hospital management from SMUR, and 190 received basic pre-hospital management provided by fire brigades. SMUR patients presented a poorer initial clinical status and higher ISS and were admitted to hospital after a longer delay than non-SMUR patients. The crude 30-day mortality rate was comparable for SMUR and non-SMUR patients (17% and 15% respectively; P = 0.61). After adjustment for initial clinical status and ISS, SMUR care significantly reduced the risk of 30-day mortality (odds ratio (OR): 0.55, 95% CI: 0.32 to 0.94, P = 0.03). Further adjustments for the delay to hospital admission only marginally affected these results. CONCLUSIONS This study suggests that SMUR management is associated with a significant reduction in 30-day mortality. The role of careful medical assessment and intensive pre-hospital life-sustaining treatments needs to be assessed in further studies.
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Affiliation(s)
- Jean-Michel Yeguiayan
- Université de Bourgogne, Service d'Anesthésie et Réanimation - SAMU 21, Hôpital Général, 3 Rue Faubourg Raines, Centre Hospitalier Universitaire de Dijon, Faculté de médecine, 21033 Dijon Cedex, France.
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Raab H, Lindner KH, Wenzel V. Preventing cardiac arrest during hemorrhagic shock with vasopressin. Crit Care Med 2010; 36:S474-80. [PMID: 20449913 DOI: 10.1097/ccm.0b013e31818a8d7e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The optimal strategy of stabilizing hemodynamic function in uncontrolled traumatic hemorrhagic shock states is unclear. Although fluid replacement is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is controversial, because it may worsen bleeding. In the refractory phase of severe hemorrhagic shock, arginine vasopressin has been shown to be beneficial in selected cases due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site toward the heart and brain, and decrease in fluid-resuscitation requirements. Especially in patients with severe traumatic brain injury, rapid stabilization of cardiocirculatory function is essential to ensure adequate brain perfusion, thus, to prevent neurologic damage and to improve outcome. In addition, despite wide distribution of highly developed and professional emergency medical systems in western industrialized countries, survival chances of patients with uncontrolled traumatic hemorrhagic shock in the preclinical setting are still poor.
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Affiliation(s)
- Helmut Raab
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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Kreutziger J, Ellmauer PP, Lindner K, Wenzel V. Vasopressoren bei der kardiopulmonalen Reanimation. Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Mechanism, glasgow coma scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in trauma patients. Crit Care Med 2010; 38:831-7. [PMID: 20068467 DOI: 10.1097/ccm.0b013e3181cc4a67] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Prehospital triage of trauma patients is of paramount importance because adequate trauma center referral improves survival. We developed a simple score that is easy to calculate in the prehospital phase. DESIGN Multicenter prospective observational study. SETTING Prehospital physician-staffed emergency system in university and nonuniversity hospitals. INTERVENTIONS We evaluated 1360 trauma patients receiving care from a prehospital mobile intensive care unit in 22 centers in France during 2002. The association of prehospital variables with in-hospital death was tested using logistic regression, and a simple score (the Mechanism, Glasgow coma scale, Age, and Arterial Pressure [MGAP] score) was created and compared with the triage Revised Trauma Score, Revised Trauma Score, and Trauma Related Injury Severity Score. The model was validated in 1003 patients from 2003 through 2005. MEASUREMENTS AND MAIN RESULTS Four independent variables were identified, and each was assigned a number of points proportional to its regression coefficient to provide the MGAP score: Glasgow Coma Scale (from 3-15 points), blunt trauma (4 points), systolic arterial blood pressure (>120 mm Hg: 5 points, 60 to 120 mm Hg: 3 points), and age <60 yrs (5 points). The area under the receiver operating characteristic curve of MGAP was not significantly different from that of the triage Revised Trauma Score or Revised Trauma Score, but when sensitivity was fixed >0.95 (undertriage of 0.05), the MGAP score was more specific and accurate than triage Revised Trauma Score and Revised Trauma Score, approaching those of Trauma Related Injury Severity Score. We defined three risk groups: low (23-29 points), intermediate (18-22 points), and high risk (<18 points). In the derivation cohort, the mortality was 2.8%, 15%, and 48%, respectively. Comparable characteristics of the MGAP score were observed in the validation cohort. CONCLUSION The MGAP score can accurately predict in-hospital death in trauma patients.
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Meisler R, Thomsen AB, Abildstrøm H, Guldstad N, Borge P, Rasmussen SW, Rasmussen LS. Triage and mortality in 2875 consecutive trauma patients. Acta Anaesthesiol Scand 2010; 54:218-23. [PMID: 19817720 DOI: 10.1111/j.1399-6576.2009.02075.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Most studies on trauma and trauma systems have been conducted in the United States. We aimed to describe the factors predicting mortality in European trauma patients, with focus on triage. METHODS We prospectively registered all trauma patients in Eastern Denmark over 12 consecutive months. We analysed the flow of trauma patients through the system, the time spent at different locations, and we assessed the risk factors of mortality. RESULTS We included 2875 trauma patients, of whom 158 (5.5%) died before arrival at the hospital. Most patients (75.3%) were brought to local hospitals and patients primarily (n=82) or secondarily triaged (n=203) to the level I trauma centre were the most severely injured. Secondarily transferred patients spent a median of 150 min in the local hospital before transfer to the level I trauma centre and 48 min on transportation. Severe injury with an injury severity score >15 was seen in 345 patients, of whom 118 stayed at the local hospital. They had a significantly higher mortality than 116 of those secondarily transferred [45/118, 38.1% vs. 11/116, 9.7% (P<0.0001)]. Mortality within 30 days was 4.3% in admitted patients, and significant risk factors of death were violence [odds ratio (OR)=5.72], unconsciousness (OR=4.87), hypotension (OR=4.96), injury severity score >15 (OR=27.42), and age. CONCLUSIONS Around 50% of all trauma deaths occurred at the scene. Increased survival of severely injured patients may be achieved by early transfer to highly specialised care.
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Affiliation(s)
- R Meisler
- Department of Anaesthesia, HOC 4231, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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Boffard KD, Choong PIT, Kluger Y, Riou B, Rizoli SB, Rossaint R, Warren B. The treatment of bleeding is to stop the bleeding! Treatment of trauma-related hemorrhage. Transfusion 2009; 49 Suppl 5:240S-7S. [DOI: 10.1111/j.1537-2995.2008.01987.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kreutziger J, Wenzel V. Overcoming frustration about neutral clinical studies in cardiopulmonary resuscitation. Resuscitation 2009; 80:723-5. [DOI: 10.1016/j.resuscitation.2009.04.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 04/14/2009] [Indexed: 11/25/2022]
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Duchesne JC, Mathew KA, Marr AB, Pinsky MR, Barbeau JM, Mcswain NE. Current Evidence Based Guidelines for Factor VIIa Use in Trauma: The Good, the Bad, and the Ugly. Am Surg 2008. [DOI: 10.1177/000313480807401206] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recombinant factor VII (rFVIIa) has arisen as an option for the control of life-threatening traumatic bleeding unresponsive to other means. The timing of administration, dosage, mortality, units of blood transfusion saved, risk of thrombotic events, and risk/benefits ratio are presently poorly defined. A Medline search from 1995 through March 2008 was conducted. All English language articles containing the terms “trauma” and “factor VII” or its variants were retrieved. Letters to the editor, animal studies, and general reviews were excluded. A total of 19 articles met inclusion criteria. These articles were then reviewed and stratified into three classes of evidence according to the quality assessment instrument developed by the Brain and Trauma Foundation. Levels of recommendation were developed. A total of 118 articles were identified. Only one Class I study was identified. This study demonstrated that three doses of rFVIIa given in blunt traumatic hemorrhage yielded a significant reduction of 2.6 of red blood cells used. These findings were not statistically significant for penetrating trauma patients. There was no reduction in mortality and no increase in thromboembolic events. Four Class II studies were identified; three showed a significant decrease of blood product usage and one demonstrated significant reductions in 24-hour and 30 day death from hemorrhage in patients receiving rFVIIa. The remaining 14 studies were Class III reviews of databases, registries, case series, and case reports. No identified study specifically addressed the cost/benefit analysis of rFVIIa usage in trauma hemorrhage. Utility of rFVIIa in trauma-associated hemorrhage remains controversial. There is Level I supporting the use of rFVIIa for blunt trauma patients only. There is no Class I evidence supporting decreased mortality or differences in thromboembolic events. Minimal effective dosing regimens and cost/benefit analyses have not yet been examined.
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Affiliation(s)
- Juan C. Duchesne
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
| | - Kavitha A. Mathew
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
| | - Alan B. Marr
- Departments of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Michael R. Pinsky
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
| | - James M. Barbeau
- Departments of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Norman E. Mcswain
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
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Developing alternative strategies for the treatment of traumatic haemorrhagic shock. Curr Opin Crit Care 2008; 14:247-53. [PMID: 18467882 DOI: 10.1097/mcc.0b013e3282fce62a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW The optimal strategy of stabilizing haemodynamic function in uncontrolled traumatic haemorrhagic shock states is unclear. Although fluid replacement is established in controlled haemorrhagic shock, its use in uncontrolled haemorrhagic shock is controversial, because it may worsen bleeding. RECENT FINDINGS In the refractory phase of severe haemorrhagic shock, arginine vasopressin has been shown to be beneficial in selected cases due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain, and decrease in fluid resuscitation requirements. Especially in patients with severe traumatic brain injury, rapid stabilization of cardiocirculatory function is essential to ensure adequate brain perfusion and thus to prevent neurological damage and to improve outcome. In addition, despite wide distribution of highly developed and professional emergency medical systems in western industrialized countries, survival chances of patients with uncontrolled traumatic haemorrhagic shock in the prehospital setting are still poor. SUMMARY A multicenter, randomized, controlled, international clinical trial is being initiated to assess the effects of arginine vasopressin (10 IU) vs. saline placebo in prehospital traumatic haemorrhagic shock patients, not responding to standard shock treatment, being managed by helicopter emergency medical services [vasopressin in traumatic haemorrhagic shock (VITRIS.at) study].
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Methylprednisolone in acute spinal cord injury: is there any other ethical choice? J Neurosurg Anesthesiol 2008; 20:137-9. [PMID: 18362777 DOI: 10.1097/01.ana.0000314441.63823.b0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Regional and Local Brain Oxygenation During Hemorrhagic Shock: A Prospective Experimental Study on the Effects of Small-Volume Resuscitation With Norepinephrine. ACTA ACUST UNITED AC 2008; 64:641-8; discussion 648-9. [DOI: 10.1097/ta.0b013e3181637a6c] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE It is proposed to not resuscitate trauma patients who have a cardiac arrest outside the hospital because they are assumed to have a dismal prognosis. Our aim was to compare the outcome of patients with traumatic or nontraumatic ("medical") out-of-hospital cardiac arrest. DESIGN Cohort analysis of patients with out-of-hospital cardiac arrest included in the European Epinephrine Study Group's trial comparing high vs. standard doses of epinephrine. SETTING Nine French university hospitals. PATIENTS A total of 2,910 patients. INTERVENTIONS Patients were successively and randomly assigned to receive repeated high doses (5 mg each) or standard doses (1 mg each) of epinephrine at 3-min intervals. MEASUREMENTS AND MAIN RESULTS Return of spontaneous circulation, survival to hospital admission and discharge, and secondary outcome measures of 1-yr survival and neurologic outcome were recorded. In the trauma group, patients were younger (42 +/- 17 vs. 62 +/- 17 yrs, p < .001), presented with fewer witnessed out-of-hospital cardiac arrests (62.3% vs. 79.7%), and had fewer instances of ventricular fibrillation as the first documented pulseless rhythm (3.4% [95% confidence interval, 1.2-5.5%] vs. 17.3% [15.8-18.7%]). A return of spontaneous circulation was observed in 91 of 268 trauma patients (34.0% [28.3-39.6%]) compared with 797 of 2,642 medical patients (30.2% [28.4-31.9%]), and more trauma patients survived to be admitted to the hospital (29.9% [24.4-35.3%] vs. 23.5% [22.0-25.2%]). However, there was no significant difference between trauma and medical groups at hospital discharge (2.2% [0.5-4.0%] vs. 2.8% [2.1-3.4%]) and 1-yr survival (1.9% [0.3-3.5%] vs. 2.5% [1.9-3.1%]). Among patients who were discharged, a good neurologic status was observed in two trauma patients (33.3% [4.3-77.7%]) and 37 medical patients (50% [38.1-61.9%]). CONCLUSIONS The survival and neurologic outcome of out-of-hospital cardiac arrest were not different between trauma and medical patients. This result suggests that, under the supervision of senior physicians, active resuscitation after out-of-hospital cardiac arrest is as important in trauma as in medical patients.
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Rossaint R, Christensen MC, Choong PIT, Boffard KD, Riou B, Rizoli S, Kluger Y, Lefering R, Morris S. Cost-Effectiveness of Recombinant Activated Factor VII as Adjunctive Therapy for Bleeding Control in Severely Injured Trauma Patients in Germany. Eur J Trauma Emerg Surg 2007; 33:528-38. [DOI: 10.1007/s00068-007-6210-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Accepted: 03/25/2007] [Indexed: 11/24/2022]
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David JS, Gelas-Dore B, Inaba K, Levrat A, Riou B, Gueugniaud PY, Schott AM. Are Patients With Self-Inflicted Injuries More Likely to Die? ACTA ACUST UNITED AC 2007; 62:1495-500. [PMID: 17563673 DOI: 10.1097/01.ta.0000250495.77266.7f] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Suicide represents one of the leading causes of trauma in industrialized countries. However, when compared with unintentional injury and assault, the outcome of self-inflicted injury has not been well described. METHODS All patients admitted to a French academic trauma center from January 2002 to December 2004 and listed in a trauma data bank were included in a prospective analysis. Variables including mortality, circumstances (unintentional vs. assault vs. self-inflicted), and mechanism of injury were recorded. RESULTS About 1,004 continuous trauma patients were analyzed: 151 (15%) with self-inflicted injuries, 761 (76%) with unintentional injuries, and 91 (9%) with injuries from assault. When compared with patients suffering from unintentional injuries and assault, self-inflicted injury patients presented more frequently after a fall from height (94 of 151 vs. 133 of 759 and 0 of 91, p < 0.05) and with a severe head injury (47 of 151 vs. 172 of 752 and 10 of 91, p < 0.05). They also had a more severe injury (Injury Severity Score, 28 +/- 21 vs. 22 +/- 16 and 12 +/- 10; p < 0.05), a lower probability of survival (Trauma Related Injury Severity Score, 0.71 +/- 0.37 vs. 0.83 +/- 0.28 and 0.92 +/- 0.19; p < 0.05), and survival rate (70% vs. 85% and 93%, p < 0.05). In multivariate analysis, Trauma Related Injury Severity Score (odds ratio, 0.54; 95% confidence interval, 0.45-0.59; p < 0.001), age (odds ratio, 1.17; confidence interval, 1.02-1.34; p < 0.05), and mechanism of trauma (p = 0.01) were independently correlated with the final mortality rate. CONCLUSIONS Self-inflicted injury patients presented with a higher mortality rate that was related to increased injury severity. The circumstances surrounding the trauma were not independently associated with an increased odds ratio of death after major trauma.
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Affiliation(s)
- Jean-Stephane David
- Hospices Civils de Lyon, Department of Anesthesiology, Critical Care and EMS, Edouard Herriot Hospital, Lyon, France.
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Rizoli SB, Boffard KD, Riou B, Warren B, Iau P, Kluger Y, Rossaint R, Tillinger M. Recombinant activated factor VII as an adjunctive therapy for bleeding control in severe trauma patients with coagulopathy: subgroup analysis from two randomized trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:R178. [PMID: 17184516 PMCID: PMC1794494 DOI: 10.1186/cc5133] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Revised: 12/01/2006] [Accepted: 12/21/2006] [Indexed: 11/10/2022]
Abstract
Introduction We conducted a post-hoc analysis on the effect of recombinant factor VIIa (rFVIIa) on coagulopathic patients from two randomized, placebo-controlled, double-blind trials of rFVIIa as an adjunctive therapy for bleeding in patients with severe trauma. Methods Blunt and penetrating trauma patients were randomly assigned to rFVIIa (200 + 100 + 100 μg/kg) at 0, 1, and 3 hours after transfusion of 8 units of red blood cells (RBCs) or to placebo. Subjects were monitored for 48 hours post-dosing and followed for 30 days. Coagulopathy was retrospectively defined as transfusion of fresh frozen plasma (FFP) (>1 unit of FFP per 4 units of RBCs), FFP in addition to whole blood, and transfusion of platelets and/or cryoprecipitate. Results Sixty rFVIIa-treated and 76 placebo subjects were retrospectively identified as being coagulopathic. No significant differences were noted in baseline characteristics. The rFVIIa-treated coagulopathic subgroup consumed significantly less blood product: RBC transfusion decreased by 2.6 units for the whole study population (P = 0.02) and by 3.5 units among patients surviving more than 48 hours (P < 0.001). Transfusion of FFP (1,400 versus 660 ml, P < 0.01), platelet (300 versus 100 ml, P = 0.01), and massive transfusions (29% versus 6%, P < 0.01) also dropped significantly. rFVIIa reduced multi-organ failure and/or acute respiratory distress syndrome in the coagulopathic patients (3% versus 20%, P = 0.004), whereas thromboembolic events were equally present in both groups (3% versus 4%, P = 1.00). Conclusion Coagulopathic trauma patients appear to derive particular benefit from early adjunctive rFVIIa therapy.
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Affiliation(s)
- Sandro B Rizoli
- Department of Surgery and Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Suite H1-71, Toronto, Ontario, M4N 3M5 Canada
| | - Kenneth D Boffard
- Department of Surgery, Johannesburg Hospital, University of the Witwatersrand, 17 Pallinghurst Road, Parktown, ZA – Johannesburg 2193, South Africa
| | - Bruno Riou
- Departments of Emergency Medicine and Surgery and Anesthesiology and Critical Care, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 4 Place Jussieu, 75005, Paris, France
| | - Brian Warren
- Department of Surgery, Tygerberg Hospital, University of Stellenboch, Fransie van Zyl Avenue, Tygerberg, Bellville 7530 Cape Town, South Africa
| | - Philip Iau
- Department of Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074
| | - Yoram Kluger
- Department of General Surgery B, Rambam Medical Centre, 66 Jabotinsky St., Petach Tikvah Bat-Galim, Haifa, 49100, Israel
| | - Rolf Rossaint
- Department of Anesthesiology, University Clinics, Pauwelsstr. 30, 52057 Aachen, Germany
| | - Michael Tillinger
- Medical and Science Department, Novo Nordisk A/S, Novo Alle 2880 Bagsværd, Denmark
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Morris S, Ridley S, Munro V, Christensen MC. Cost effectiveness of recombinant activated factor VII for the control of bleeding in patients with severe blunt trauma injuries in the United Kingdom. Anaesthesia 2007; 62:43-52. [PMID: 17156226 DOI: 10.1111/j.1365-2044.2006.04896.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to assess the lifetime cost effectiveness of recombinant activated factor VII vs placebo as adjunctive therapy for control of bleeding in patients with severe blunt trauma in the UK. We developed a cost-effectiveness model based on patient level data from a 30-day international, randomised, placebo-controlled Phase II trial. The data were supplemented with secondary data from UK sources to estimate lifetime costs and benefits. The model produced a baseline estimate of the incremental cost per life year gained with recombinant activated factor VII relative to placebo of 12 613 UK pounds. The incremental cost per quality adjusted life year gained was 18 825 UK pounds. These estimates are sensitive to the choice of discount rate and health state utility values used. Preliminary results suggest that relative to placebo, recombinant activated factor VII may be a cost-effective therapy to the UK National Health Service.
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Affiliation(s)
- S Morris
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex UB8 3PH, UK
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Bloomfield R, Steel E, MacLennan G, Noble DW. Accuracy of weight and height estimation in an intensive care unit: Implications for clinical practice and research. Crit Care Med 2006; 34:2153-7. [PMID: 16763505 DOI: 10.1097/01.ccm.0000229145.04482.93] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Numerous calculations routinely used in the intensive care require the knowledge of patients' weight and height, although these measurements are not always made. Estimates by doctors or nurses are often substituted. This study sought to ascertain the accuracy of estimates of weight and height of patients made by intensive care unit (ICU) staff. DESIGN : Prospective clinical study. SETTING Sixteen-bed mixed medical and surgical ICU in a university teaching hospital. PATIENTS Fourteen patients had their height and weight estimated by 20 members of the medical and nursing staff. MEASUREMENTS After all estimates had been recorded, measurements of weight and height were obtained. Weight was measured by means of a patient hoist with a calibrated weighing facility and height using a steel tape measure. MAIN RESULTS Estimation of weight was poor, with 47% of estimates at least 10% different and 19% of estimates at least 20% different from the measured values. The majority of height estimates were within 10% of the measured values. CONCLUSIONS Individual estimates of weight and height are frequently inaccurate. These errors of estimation could compromise application of effective therapies, as well as contribute to a reduction in design sensitivity of clinical trials.
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Raux M, Thicoïpé M, Wiel E, Rancurel E, Savary D, David JS, Berthier F, Ricard-Hibon A, Birgel F, Riou B. Comparison of respiratory rate and peripheral oxygen saturation to assess severity in trauma patients. Intensive Care Med 2006; 32:405-12. [PMID: 16485093 DOI: 10.1007/s00134-005-0063-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2005] [Accepted: 12/27/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Physiological variables are important in the assessment of trauma patients. The role of respiratory rate (RR) and peripheral oxygen saturation (SpO(2)) remains a matter of debate. We therefore assessed the role of RR and SpO(2) in predicting death in trauma patients. DESIGN Prospective analysis of a multicentric cohort of trauma patients in 2002. PATIENTS A cohort of 1,481 trauma patients cared for by a prehospital mobile intensive care unit (mean age 38 +/- 17 years, 91% blunt and 9% penetrating trauma). INTERVENTION None. RESULTS Systolic arterial blood pressure, heart rate, Glasgow coma scale, RR and SpO(2) were recorded and the Injury Severity Score (ISS) and Trauma Related Injury Severity Score (TRISS) calculated. TRISSn was obtained by neutralizing RR. Systolic arterial blood pressure (99.9%), heart rate (99.9%), and Glasgow coma scale (99.3%) were recorded in most patients, but not RR (63%) and SpO(2) (67%). In patients with both RR and SpO(2) recording (n=675), the discrimination and calibration of TRISS was not significantly modified when RR was neutralized. Whatever the manner of expressing RR and SpO(2) (continuous, five classes, dichotomous), none was significant in predicting mortality with TRISSn. Initial SpO(2) was abnormal (< 90%) and recorded again at the hospital in 97 patients, and the proportion of patients with a non-measurable SpO(2) significantly decreased (8 vs. 42%, p < 0.001) and measurable SpO(2) markedly increased (median 99 vs. 85%, p < 0.001). CONCLUSION Respiratory rate and SpO(2) do not add significant value to other variables when predicting mortality in severe trauma patients.
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Affiliation(s)
- Mathieu Raux
- University Pierre et Marie Curie (Paris 6), Department of Anesthesiology and Critical Care, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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Mohr AM, Holcomb JB, Dutton RP, Duranteau J. Recombinant activated factor VIIa and hemostasis in critical care: a focus on trauma. Crit Care 2005; 9 Suppl 5:S37-42. [PMID: 16221318 PMCID: PMC3226122 DOI: 10.1186/cc3784] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In this article we describe the current use of recombinant activated factor VII (rFVIIa; NovoSeven) in trauma patients. Emphasis is placed on current uses as defined by key studies, efficacy data, and safety data. Most published studies in trauma patients are retrospective case studies and reports, although an international, double-blind, randomized, controlled, phase II study has been conducted that reported on the efficacy of rFVIIa in reducing the amount of blood products transfused in blunt trauma patients. That study demonstrated the efficacy and safety profile of this hemostatic agent as compared with placebo as adjunctive therapy in the management of severe bleeding associated with trauma. Further prospective, randomized, and placebo-controlled clinical trials will yield more information on the role of rFVIIa in the management of traumatic bleeding.
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Affiliation(s)
- Alicia M Mohr
- Department of Surgery, New Jersey Medical School, Newark, New Jersey, USA.
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Vivien B, Langeron O, Morell E, Devilliers C, Carli PA, Coriat P, Riou B. Early hypocalcemia in severe trauma*. Crit Care Med 2005; 33:1946-52. [PMID: 16148464 DOI: 10.1097/01.ccm.0000171840.01892.36] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We tested the hypothesis that colloid-induced hemodilution can induce hypocalcemia in the early phase of severe trauma resuscitation and tried to assess other potential causative factors of that hypocalcemia. DESIGN Prospective cohort. SETTING Level I academic trauma center. PATIENTS Consecutive severe trauma patients (n = 212, mean Injury Severity Score 34) resuscitated in the prehospital phase without any blood transfusion. INTERVENTIONS At admission, ionized calcium (corrected to an arterial pH = 7.40) was measured. MEASUREMENTS AND MAIN RESULTS Hypocalcemia was defined as a value <1.15 mmol/L and severe hypocalcemia as a value <0.9 mmol/L. A normal ionized calcium concentration was observed in 56 (26%) patients, a mild ionized hypocalcemia (1.05 +/- 0.06 mmol/L) in 135 (64%) patients, and a severe ionized hypocalcemia (0.77 +/- 0.10 mmol/L) in 21 (10%) patients. There were significant correlations between ionized calcium concentration with the amount of infused colloid (R = .658, p < .001) and arterial pH (R = .760, p < 0.001) but not with the amount of infused crystalloid (R = .007, not significant). Despite taking into account hemodilution, arterial pH, binding of calcium to lactates, and colloids, some patients had marked differences (>15%) between calculated and observed ionized calcium, and these patients had more severe trauma and more frequently had acidosis and/or prehospital cardiac arrest. Using the TRISS methodology, survival was not significantly different from that expected in this trauma population. CONCLUSION Hypocalcemia frequently occurs on arrival at the hospital in severe trauma patients, and colloid-induced hemodilution and severe shock and/or ischemia-reperfusion appear to be important causative factors.
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Affiliation(s)
- Benoît Vivien
- Department of Anesthesiology and Critical Care, Centre Hospitalo-Universitaire (CHU) Pitié-Salpêtrière, Paris, France
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Wade CE, Holcomb JB. Endpoints in clinical trials of fluid resuscitation of patients with traumatic injuries. Transfusion 2005; 45:4S-8S. [PMID: 15989685 DOI: 10.1111/j.0041-1132.2005.00156.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Charles E Wade
- US Army Institute of Surgical Research, Fort Sam Houston, Texas 78234-6315, USA.
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Silverman T, Aebersold P, Landow L, Lindsey K. Regulatory perspectives on clinical trials for trauma, transfusion, and hemostasis. Transfusion 2005; 45:14S-21S. [PMID: 15989687 DOI: 10.1111/j.0041-1132.2005.00157.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Toby Silverman
- Division of Hematology, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, Maryland 20857, USA.
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