How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study.

Figueiredo S, Taconet C, Harrois A, Hamada S, Gauss T, Raux M, Duranteau J; Traumabase Group.

BACKGROUND:

The diagnostic value of hemoglobin (Hb) for detecting a significant hemorrhage (SH) in the early phase of trauma remains controversial. The present study aimed to assess the abilities of Hb measurements taken at different times throughout trauma management to identify patients with SH.

METHODS:

All consecutive adult trauma patients directly admitted to six French level-1 trauma centers with at least one prehospital Hb measurement were analyzed. The abilities of the following variables to identify SH (≥ 4 units of red blood cells in the first 6 h and/or death related to uncontrolled bleeding within 24 h) were determined and compared to that of shock index (SI): Hb as measured with a point-of-care (POC) device by the prehospital team on scene (POC-Hbprehosp) and upon patient's admission to the hospital (POC-Hbhosp), the difference between POC-Hbhosp and POC-Hbprehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Labhosp).


RESULTS:

A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hbprehosp significantly predicted SH with an area under ROC curve (AUC) of 0.72 and best cutoff values of 12 g/dl for women and 13 g/dl for men. POC-Hbprehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hbhosp and Hb-Labhosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hbhosp were 10 g/dl for women and 12 g/dl for men. DeltaPOC-Hb also predicted SH with an AUC of 0.77, a best cutoff value of - 2 g/dl irrespective of the gender. For a same prehospital fluid volume infused, DeltaPOC-Hb was significantly larger in patients with significant hemorrhage than in controls.


CONCLUSIONS:

Challenging the classical idea that early Hb measurement is not meaningful in predicting SH, POC-Hbprehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hbhosp had a greater ability to predict SH when compared to shock index. For a given prehospital fluid volume infused, the magnitude of the Hb drop was significantly higher in patients with significant hemorrhage than in controls.

Ann Intensive Care. 2018 Jul 6;8(1):76.

doi: 10.1186/s13613-018-0420-8.

https://www.ncbi.nlm.nih.gov/pubmed/29980953

Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis.

Gauss T, Gayat E, Harrois A, Raux M, Follin A, Daban JL, Cook F7, Hamada S; TraumaBase Group; Prehospital Traumabase Group Ile de France, SAMU=Service d’Aide Médicale Urgente.

BACKGROUND:

The role of vasopressors in trauma-related haemorrhagic shock (HS) remains a matter of debate. They are part of the most recent European recommendations on the management of HS and are regularly used in France. We assessed the effect of early administration of noradrenaline in 24 h mortality of trauma patients in HS, using a propensity-score analysis.

METHODS:

The study included patients from a multicentre prospective regional trauma registry. HS was defined as transfusion of ≥4 erythrocyte-concentrate units during the first 6 h. Patients with a Glasgow coma scale=3 and pre-hospital traumatic cardiac arrest were excluded. The main outcome measure was in-hospital mortality. The explicative and adjustment variables for the outcome and treatment allocation were predetermined by a Delphi method. The in-hospital mortality of patients with and without early administration of noradrenaline was compared in a propensity-score model, including all predetermined variables.


RESULTS:

Of 7141 patients in the registry in the study period, 6353 were screened and 518 patients in HS (201 with early noradrenaline use and 317 without) were included and analysed. After propensity-score matching, 100 patients remained in each group, and the hazard-ratio mortality was 0.95 (95% confidence interval: 0.45-2.01; P=0.69).


CONCLUSIONS:

The results of the present study suggest that noradrenaline use in the early phase of traumatic HS does not seem to affect mortality adversely. This observation supports a rationale for equipoise in favour of a prospective trial of the use of vasopressors in HS after trauma.

Br J Anaesth. 2018 Jun;120(6):1237-1244.

doi: 10.1016/j.bja.2018.02.032.

https://www.ncbi.nlm.nih.gov/pubmed/29793591

Development and validation of a pre-hospital "Red Flag" alert for activation of intra-hospital haemorrhage control response in blunt trauma.

Hamada SR, Rosa A, Gauss T, Desclefs JP, Raux M, Harrois A, Follin A, Cook F, Boutonnet M; Traumabase® Group, Attias A, Ausset S, Boutonnet M, Dhonneur G, Duranteau J, Langeron O, Paugam-Burtz C, Pirracchio R, de St Maurice G, Vigué B, Rouquette A, Duranteau J.

BACKGROUND:

Haemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures.

METHODS:

A multicentre retrospective study of prospectively collected data from a trauma registry (Traumabase®) was performed. SH was defined as: packed red blood cell (RBC) transfusion in the trauma room, or transfusion ≥ 4 RBC in the first 6 h, or lactate ≥ 5 mmol/L, or immediate haemostatic surgery, or interventional radiology and/or death of haemorrhagic shock. Pre-hospital characteristics were selected using a multiple logistic regression model in a derivation cohort to develop a Red Flag binary alert whose performances were confirmed in a validation cohort.


RESULTS:

Among the 3675 patients of the derivation cohort, 672 (18%) had SH. The final prediction model included five pre-hospital variables: Shock Index ≥ 1, mean arterial blood pressure ≤ 70 mmHg, point of care haemoglobin ≤ 13 g/dl, unstable pelvis and pre-hospital intubation. The Red Flag alert was triggered by the presence of any combination of at least two criteria. Its predictive performances were sensitivity 75% (72-79%), specificity 79% (77-80%) and area under the receiver operating characteristic curve 0.83 (0.81-0.84) in the derivation cohort, and were not significantly different in the independent validation cohort of 2999 patients.


CONCLUSION:

The Red Flag alert developed and validated in this study has high performance to accurately predict or exclude SH.Haemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures.

Crit Care. 2018 May 5;22(1):113.

doi: 10.1186/s13054-018-2026-9.


https://www.ncbi.nlm.nih.gov/pubmed/29728151

Tranexamic acid in severe trauma patients managed in a mature trauma care system.

Boutonnet M, Abback P, Le Saché F, Harrois A, Follin A, Imbert N, Cap AP, Trichereau J, Ausset S; Traumabase Group.

BACKGROUND:

Tranexamic acid (TXA) use in severe trauma remains controversial notably because of concerns of the applicability of the CRASH-2 study findings in mature trauma systems. The aim of our study was to evaluate the outcomes of TXA administration in severely injured trauma patients managed in a mature trauma care system.

METHODS:

We performed a retrospective study of data prospectively collected in the TraumaBase registry (a regional registry collecting the prehospital and hospital data of trauma patients admitted in six Level I trauma centers in Paris Area, France). In hospital mortality was compared between patients having received TXA or not in the early phase of resuscitation among those presenting an unstable hemodynamic state. Propensity score for TXA administration was calculated and results were adjusted for this score. Hemodynamic instability was defined by the need of packed red blood cells (pRBC) transfusion and/or vasopressor administration in the emergency room (ER).


RESULTS:

Among patients meeting inclusion criteria (n = 1,476), the propensity score could be calculated in 797, and survival analysis could be achieved in 684 of 797. Four hundred seventy (59%) received TXA, and 327 (41%) did not. The overall hospital mortality rate was 25.7%. There was no effect of TXA use in the whole population but mortality was lowered by the use of TXA in patients requiring pRBC transfusion in the ER (hazard ratio, 0.3; 95% confidence interval, 0.3-0.6).


CONCLUSION:

The use of TXA in the management of severely injured trauma patients, in a mature trauma care system, was not associated with reduction in the hospital mortality. An independent association with a better survival was found in a selected population of patients requiring pRBC transfusion in the ER.

J Trauma Acute Care Surg. 2018 Jun;84(6S Suppl 1):S54-S62.

doi: 10.1097/TA.0000000000001880.

https://www.ncbi.nlm.nih.gov/pubmed/29538226

Evolution and organisation of trauma systems.

David JS, Bouzat P, Raux M.

Over the last 20 years, numerous studies have fairly consistently reported an improvement in the prognosis of patients with severe trauma after the establishment of a trauma network. These systems can be either exclusive, in which all patients are referred only to a small number of specifically designated centres that meet strict criteria, or inclusive, in which patients may be referred to any hospital of a particular area according to capacity, which is observed in France. Hospitals are classified (level 1 to level 3) according to their technical facilities and the number of patients admitted for severe trauma, knowing that studies have also shown an improvement of the outcome for the most severely injured patients (haemorrhagic shock, severe head trauma), in hospitals with the greatest technical facilities and the most important activity. The triage of the patients to a suitable centre must be done after careful prehospital evaluation, which is made on clinical criteria (mechanism, injury, medical history), measurement of vital signs, calculation of scores (RTS, MGAP) or based on classifications. According to this assessment, the patients will then be triaged to a centre that has the capacity for the optimal and definitive management of these injuries. The goal is then to avoid under triage which is synonymous of retransfer, loss of time, and probably also prognosis worsening, and to avoid over triage that may induce an inadequate use of resources, activity overload and cost increase. Thus, it seems essential to develop trauma networks to improve mortality and morbidity of patients that undergone a severe injury. These trauma networks will then have to be evaluated and a register set up.

Anaesth Crit Care Pain Med. 2018 Feb 21. pii: S2352-5568(17)30354-5

DOI: 10.1016/j.accpm.2018.01.006

https://www.ncbi.nlm.nih.gov/pubmed/29476943

Medical information system (PMSI) does not adequately identify severe trauma

Perozziello A, Gauss T, Diop A, Frank-Soltysiak M, Rufat P, Raux M, Hamada S, Riou B; Le Groupe Traumabase.

BACKGROUND:

Resource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims.

METHODS:

We studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient.


RESULTS:

During the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %).


CONCLUSION:

DCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding.

Rev Epidemiol Sante Publique. 2018 Feb;66(1):43-52.

doi: 10.1016/j.respe.2017.10.002

https://www.ncbi.nlm.nih.gov/pubmed/?term=29221606

Fibrinogen on Admission in Trauma score: Early prediction of low plasma fibrinogen concentrations in trauma patients.

Gauss T, Campion S, Kerever S, Eurin M, Raux M, Harrois A, Paugam-Burtz C, Hamada S; Traumabase Group.

BACKGROUND:

Early recognition of low fibrinogen concentrations in trauma patients is crucial for timely haemostatic treatment and laboratory testing is too slow to inform decision-making.

OBJECTIVE:

To develop a simple clinical tool to predict low fibrinogen concentrations in trauma patients on arrival.


DESIGN:

Retrospective cohort study.


SETTING:

Three designated level 1 trauma centres in the Paris Region, from January 2011 to December 2013.


PATIENTS:

Patients admitted in accordance with national triage guidelines for major trauma and plasma fibrinogen concentration testing on admission.


INTERVENTION:

Construction of a clinical score [Fibrinogen on Admission in Trauma (FibAT) score] in a derivation cohort to predict fibrinogen plasma concentration 1.5 g l or less after multiple regressions. One point was given for each predictive factor. The score was the sum of all. Validation was performed in a separate validation cohort.


MAIN OUTCOME MEASURE:

Predictive accuracy of FibAT score.


RESULTS:

In total, 2936 patients were included, 2124 in the derivation cohort and 812 in the validation cohort. In the derivation cohort, a multivariate logistic model identified the following predictive factors for plasma fibrinogen concentrations 1.5 g l or less: age less than 33 years, prehospital heart rate more than 100 beats per minute, prehospital SBP less than 100 mmHg, blood lactate concentration on admission more than 2.5 mmol l, free intraabdominal fluid on sonography, decrease in haemoglobin concentration from prehospital to admission of more than 2 g dl, capillary haemoglobin concentration on admission less than 12 g dl and temperature on admission less than 36°C. The FibAT score had an area under the receiver operating characteristic curve of 0.87 [95% confidence interval (0.86 to 0.91)] in the derivation cohort and of 0.82 (95% confidence interval (0.86 to 0.91)] in the validation cohort to predict a low plasma fibrinogen.


CONCLUSION:

The FibAT score accurately predicts plasma fibrinogen levels 1.5 g l or less on admission in trauma patients. This easy-to-use score could allow early, goal-directed therapy to trauma patients.

Eur J Anaesthesiol. 2018 Jan;35(1):25-32.

doi: 10.1097/EJA.0000000000000734.

https://www.ncbi.nlm.nih.gov/pubmed/29120938

Keep calm... and prepare,

Keep calm… and prepare.

Tobias Gauss and Fabrice Cook for The Traumabase Group.

 

On the 22nd of July 2011, a terrible attack by a single acting shooter on the Norwegian island of Utøya cost 77 young lives, injured 78 and changed the lives of hundreds forever within 73 minutes. In the current international context of increased threat, sharing experience about disaster response is crucial. With some exceptions [1][2][3], many of these studies adopt a deficit-based analysis approach and focus on dysfunctions rather than positive lessons.

 

In contrast, Brandrud et al. [4] adopted an original approach. The group used the conclusions of two official and independent commissions as starting point, namely that the medical response to the incident was particularly well managed. This allowed the authors a “positive deviance” [5][6] analysis to draw important lessons from this incident.

The authors attempted to gather crucial insights with the help of detailed group interviews and expert review: How did a rural district hospital, Ringerike, that is not a Level-1 Trauma Centre manage a major disaster effectively, despite the fact that its resources were exhausted 40 minutes after admission of the first patients? What can this outstanding performance teach health professionals in preparation for disaster in any setting, and especially in a non-specialist hospital?

 

The answers provided are very relevant to disaster preparedness and training programmes everywhere. A disaster can strike anywhere and in any form - natural, accidental, man-made. Any acute health facility is potentially involved, and the stakes are especially high if it is isolated and in “safe” distance from referral centres like the Ringerike hospital was. Terrorists may deliberately integrate this potential vulnerability into their strategy. As such, the Ringerike example is important as it shows that a well-prepared acute care facility can cope if necessary, even if it is not a tertiary centre. Moreover, this example also shows that health professionals can rise to the occasion and cope under extreme circumstances, despite the scarcity of medical disasters that are encountered perhaps only once (if that) in a professional life-time.

 

But the lessons go beyond the disaster preparedness. They indicate how any acute health care facility, no matter its size, can meet the challenge to create a shared mental model and maintain an institutional memory in order to deal with rare events and to improve care. It seems that the main drivers behind the success were empowerment and the principle of subsidiarity. Subsidiarity is the idea that no decision should be made and no function performed at a higher or more central level than can be accomplished at a more local level. How did the hospital staff achieve this?

 

As Brandrud et al. demonstrate, an important element is context. The crisis response was not conjured out of thin air. A culture of resilience existed, embedded in a favourable institutional and general context. The Ringerike hospital was able to implement the rationale of a national trauma system with national guidelines, shared triage rules, quality standards and evaluation, in association with a national Trauma Registry. The hospital administration provided doctrine, mission, objectives and necessary means, but refrained from micromanagement and a top-down approach and lent autonomy to front-line actors and teams to accomplish their mission. The principle of subsidiarity was respected; actors were empowered within a shared model and framework.

This framework formed the basis for a plan, which existed within what Brandrud et al. call the “structure”. This plan needed to be simple and concise and most importantly, it had to be known by all actors. It was internalised through a continuous institutional learning process, which allowed implementation with no discordance from the overall structural framework. A continuous learning process allowed the plan to evolve; lessons learned were communicated back to the teams. In this fashion, a shared adaptive mental model was produced. This shared mental model then created the capacity to adapt and to improvise as a group during a crisis. When we all know what we are aiming for, but the aim cannot be reached with method A, it is easier to find a method B together.

Collective learning and training was an essential pillar of success [7]. At Ringerike hospital, monthly training has been taking place for many years within the framework of a 2003 national policy (BEST: Better & Systematic Trauma Care). Such training requires institutional support: it costs time and time is money for modern health facilities. But only through repeated training could collective knowledge, competence and structure be achieved. Training tested the existing command and communication structure and furthered understanding of team members’ respective roles and needs. Training turned skill and competence into second nature and achieved confidence and trust, which turn enhanced the shared mental model. Habituation also increased resilience - as an interviewee stated: “It makes you tolerate more.” The overall plan was an integral part of the training, with no apparent plan-training gap. And again, we find the principles of empowerment and subsidiarity on a multi-professional level. These elements obviously favoured effective and legitimate leadership and active, anticipating followership. Both allowed for a robust command structure and communication, essential in any crisis management [8][9].

The importance of this study is that the authors demonstrate and summarize essential elements of a conceptual framework to create a shared mental model and maintain a collective memory through empowerment and subsidiarity based on knowledge and competence. This enables the capacity for dealing with a crisis situation or a rare catastrophic event and to improve care in any given health facility, both in regular and exceptional circumstances, no matter the available resources. We hope that the results presented by Brandrud and al. will inspire others. The work should also serve as a reminder for the European and international medical community to work towards a shared reporting structure, standardized data set and methodological approach in analogy to the Utstein trauma or cardiac arrest template. This will facilitate evaluation of disaster response and quality improvement in disaster management through comparison.

BMJ Qual Saf. 2017 Jun 26.

DOI: 10.1136/bmjqs-2017-006969

https://www.ncbi.nlm.nih.gov/pubmed/28652260

Comparison of the Prognostic Significance of Initial Blood Lactate and Base Deficit in Trauma Patients

Raux M, Le Manach Y, Gauss T, Baumgarten R, Hamada S, Harrois A, Riou B, Duranteau J, Langeron O, Mantz J, Paugam-Burtz C, Vigue B; TRAUMABASE Group.

BACKGROUND: Initial blood lactate and base deficit have been shown to be prognostic biomarkers in trauma, but their respective performances have not been compared.

METHODS: Blood lactate levels and base deficit were measured at admission in trauma patients in three level 1 trauma centers. This was a retrospective analysis of prospectively acquired data. The association of initial blood lactate and base deficit with mortality was tested using receiver operating characteristics curve, logistic regression using triage scores (Revised Trauma Score and Mechanism Glasgow scale and Arterial Pressure score), and Trauma Related Injury Severity Score as a reference standard. The authors also used a reclassification method.

RESULTS: The authors evaluated 1,075 trauma patients (mean age, 39 ± 18 yr, with 90% blunt and 10% penetrating injuries and a mortality of 13%). At admission, blood lactate was elevated in 425 (39%) patients and base deficit was elevated in 725 (67%) patients. Blood lactate was correlated with base deficit (R = 0.54; P < 0.001). Using logistic regression, blood lactate was a better predictor of death than base deficit when considering its additional predictive value to triage scores and Trauma Related Injury Severity Score. This result was confirmed using a reclassification method but only in the subgroup of normotensive patients (n = 745).

CONCLUSIONS: Initial blood lactate should be preferred to base deficit as a biologic variable in scoring systems built to assess the initial severity of trauma patients.

Anesthesiology. 2017 Mar;126(3):522-533.

doi: 10.1097

https://www.ncbi.nlm.nih.gov/pubmed/28059838

Long-term prognosis after out-of-hospital resuscitation of cardiac arrest in trauma patients

Duchateau FX, Hamada S, Raux M, Gay M, Mantz J, Paugam-Burtz C, Gauss T; Traumabase Group.


BACKGROUND:

Although prehospital cardiac arrest (CA) remains associated with poor long-term outcome, recent studies show an improvement in the survival rate after prehospital trauma associated CA (TCA). However, data on the long-term neurological outcome of TCA, particularly from physician-staffed Emergency Medical Service (EMS), are scarce, and results reported have been inconsistent. The objective of this pilot study was to evaluate the long-term outcome of patients admitted to several trauma centres after a TCA.


METHODS: 

This study is a retrospective database review of all patients from a multicentre prospective registry that experienced a TCA and had undergone successful cardiopulmonary resuscitation (CPR) prior their admission at the trauma centre. The primary end point was neurological outcome at 6 months among patients who survived to hospital discharge.


RESULTS: 

88 victims of TCA underwent successful CPR and were admitted to the hospital, 90% of whom were victims of blunt trauma. Of these 88 patients, 10 patients (11%; CI 95% 6% to 19%) survived to discharge: on discharge, 9 patients displayed a GCS of 15 and Cerebral Performance Categories (CPC) 1-2 and one patient had a GCS 7 and CPC of 3. Hypoxia was the most frequent cause of CA among survivors. 6-month follow-up was achieved for 9 patients of the 10 surviving patients. The 9 patients with a good outcome on hospital discharge had a CPC of 1 or 2 6 months post discharge. All returned to their premorbid family and social settings.


CONCLUSIONS: 

Among patients admitted to hospital after successful CPR from TCA, hypoxia as the likely aetiology of arrest carried a more favourable prognosis. Most of the patients successfully resuscitated from TCA and surviving to hospital discharge had a good neurological outcome, suggesting that prehospital resuscitation may not be futile.

Emerg Med J. 2017 Jan;34(1):34-38.

doi: 10.1136/emermed-2014-204596.

https://www.ncbi.nlm.nih.gov/pubmed/27797869

Paris terrorist attack: early lessons from the intensivists.

Traumabase Group

During the night of 13-14 November, the city of Paris was exposed, within a few hours, to three bomb explosions, four shooting scenes, and one 3-hour hostage-taking of several hundred people causing at least 130 deaths and more than 250 injured victims. Most unstable patients were transferred to the six trauma centers of the Paris area, all members of the TRAUMABASE Group. A rapid adaptation of the organization of trauma patients' admittance was required in all centers to face the particular needs of the situation. Everything went relatively well in all centers, with overall hospital mortality below 2 %. Nevertheless, most physicians nowadays agree that anticipation, teaching, and training are crucial to appropriately face such events. All of us have learned many additional issues from this experience. Following a meeting of the TRAUMABASE Group, the most relevant issues are detailed in the following.

Crit Care. 2016 Apr 8;20:88.

DOI: 10.1186/s13054-016-1246-0

https://www.ncbi.nlm.nih.gov/pubmed/27056826

Impact de l’utilisation d’un vasopresseur dans les premières heures sur la mortalité des patients en choc post-traumatique; SFAR2016/MED-2072

Sophie Hamada, Etienne Gayat, Mathieu Raux, Anatole Harrois, Fabrice Cook, Arnaud Follin, Jean-Louis Daban, Tobias Gauss

Groupe Traumabase

 

Rationnel et hypothèse

La place des vasopresseurs dans la gestion du choc hémorragique reste controversée. Les recommandations européennes et françaises proposent son utilisation à la phase initiale en cas d’échec de l’expansion volémique [1]. Deux études américaines observationnelles suggèrent que les catécholamines pourraient être un facteur indépendant de mortalité en analyse multivariée [2, 3]. En dehors des biais des études observationnelles rétrospectives, ces études ne distinguaient pas les différents types de catécholamines, ni le moment de l’introduction ou les objectifs hémodynamiques recherchés.

 

L’hypothèse du travail était que l’introduction d’un vasopresseur dès la prise en charge pré-hospitalière et pendant les premières 6 heures du choc hémorragique traumatique ne constitue pas un facteur indépendant de mortalité.

 

Méthodes

Etude rétrospective multicentrique incluant tous les patients traumatisés grave en choc hémorragique admis en primaire entre janvier 2010 et décembre 2015 dans six centres participants à un observatoire régional prospectif (accord CCTIRS, CNIL et CPP Paris 6). Le choc hémorragique était défini par une transfusion initiale de 4 concentrés érythrocytaires en 6h. Etaient exclus les patients avec un GCS =3 et/ou arrêt cardiaque pré-hospitalier. Le critère de jugement principal était la survie à J28. Les variables explicatives pour le critère de jugement et/ou l’attribution du traitement (vasopresseur=Noradrénaline=NAD) étaient déterminées par une démarche de Delphi. Les variables retenues étaient : sexe, âge, mécanisme, pression artérielle systolique (PAS) en pré-hospitalier (ph), score de Glasgow (GCSph), fréquence cardiaque (FCph), hémoglobine capillaire (Hbc ph) et à l’arrivée, delta-hémoglobine (Hbc ph-arrivée), volume d’expansion volémique ph, PAS à l'arrivée, lactate ph et à l'arrivée, Index de pulsatilité (IP) sur Doppler transcrânien à l’arrivée, scores lésionnels (ISS) et de gravité (IGS II). La mortalité des patients avec et sans vasopresseur à la phase initiale était comparée après ajustement des variables explicatives par méthode multivariée et appariement par score de propension.

 

Résultats

De 7141 patients, 793 étaient exclus selon les critères. Parmi les 6353 patients éligibles, 518 étaient en choc et inclus. Avant appariement le groupe sans NAD 317 (NAD-) et 201 (NAD+) patients dans chaque groupe, le hazard ratio (HR) était en défaveur de l’utilisation d’un vasopresseur (HR [IC à 95%] = 2.16 [1.45 - 3.23] ; p<0.001). Après appariement sur le score de propension selon les critères d’attribution du traitement (table 1) restait 98 patients dans chaque groupe, le HR à J28 était [IC à 95%] = 0.95 [0.45 - 2.01] (p=0.89), figure 1.

 

Conclusion

Cette étude à partir d’une grande cohorte multicentrique démontre que l’utilisation de vasopresseurs à la phase initiale du choc hémorragique traumatique n’était pas un facteur.


SFAR2016/MED-2072


http://sfar.org/bourses-recherche/prix-accordes/

De la nécessité de registres français en traumatologie

M. Raux · A. Harrois · T. Gauss · S. Hamada

Sept pour cent des décès français étaient d’origine traumatique en 2009 [1]. Le traumatisme sévère constitue la première cause d’années de vie perdues chez les jeunes et une source conséquente de handicap. En France, la grande majorité des patients sévèrement traumatisés sont pris en charge par une équipe médicale sur les lieux de l’accident. Cette médicalisation précoce, organisée par le Samu du départe- ment concerné, permet à la fois l’évaluation de la gravité du patient, la mise en œuvre rapide de manœuvres de réanimation et son orientation vers un centre hospitalier adapté [2].

Comme toute spécialité médicale, la médecine d’urgence adapte ses pratiques au gré des résultats d’études scientifiques dans les domaines qui la concernent. Force est de constater que, s’agissant de la traumatologie « lourde », ces études ont majoritairement été conduites dans des pays dont le système de secours pré-hospitaliers diffère du nôtre. Les différences portent à la fois sur le maillage du territoire, influençant les délais et durées de prise en charge, sur la régulation médicale de l’intervention, sur les moyens humains mis en œuvre (présence d’un médecin, d’un paramedic ou de secouristes) et sur la nature des traumatismes. Eu égard à ces différences, la transposition des résultats de ces études à notre pratique devrait donc se faire avec précaution. Ce n’est pas toujours le cas !

Prenons l’exemple de l’intubation trachéale pré-hospitalière des patients traumatisés : quelques publications remettent en question le bénéfice de cette pratique, montrant une augmentation du rapport de cote (odds ratio) de mortalité après intubation pré-hospitalière par des paramedics [3,4]. Or Lossius et al. [5] viennent de montrer que le taux de succès lors de l’intubation pré-hospitalière était significativement réduit lorsque l’opérateur n’était pas médecin. Ne nous trompons pas, la surmortalité du groupe des patients intubés n’est pas uniquement liée à leur gravité : la qualité des soins qui leur sont délivrés joue un rôle majeur. Les mauvais résultats de ces études, conduites au sein d’équipes pré-hospitalières singulièrement différentes des nôtres, ne sont pas transposables à notre système de santé.

Au-delà des pratiques, la typologie de la traumatologie souffre d’une grande hétérogénéité, d’un pays ou d’un territoire à l’autre. Ainsi les patients inclus dans les études de traumatologie en Amérique du Nord sont plus volontiers victimes de plaies par arme à feu (18 à 42 %) [6-8] que dans les études conduites en France (9 %) [9]. Il n’apparaît pas raisonnable de fonder ses pratiques sur des résultats d’études conduites sur des populations de patients victimes de traumatismes de nature aussi différente.

Nous devons connaître notre population de patients traumatisés sévères afin d’évaluer l’applicabilité des résultats de ces études à notre système de santé. Pour ce faire, il n’y a pas d’autre issue que la création de registres, ou bases de don- nées. Les informations contenues dans les bases de données administratives (type Programme de médicalisation des systèmes d’information) sont insuffisantes, car trop vagues. Au- delà de la simple description des patients victimes de traumatismes sévères, l’analyse de ces registres permet d’identifier les facteurs liés au pronostic propres à notre système de soins pré-hospitaliers. L’identification de ces facteurs permet la mise en place de mesures de prévention et de correction adaptées à notre mode de fonctionnement, et non dérivées d’études aux patients si différents des nôtres. Les données contenues dans ces registres nous permettent par ailleurs d’évaluer les pratiques, et leur évolution au cours du temps. L’évaluation des pratiques et la mise en place de procédures de prise en charge des traumatisés sévères vont de pair, contribuant tous les deux indirectement à la réduction de la mortalité des patients qui en sont victimes [10].

Les données extraites de ces registres constituent le terreau de la recherche clinique et expérimentale de demain dans le domaine de la traumatologie. Elles permettent de formuler des hypothèses et d’adapter la méthodologie des études à venir aux caractéristiques de notre population de traumatisés sévères. Les registres existant ont d’ores et déjà permis de créer des outils d’évaluation de la gravité propres à notre activité, tel le score MGAP [11]. Ils ont été utilisés pour évaluer la performance de scores de traumatologie existant (Revised Trauma Score, Trauma Related Injury Severity Score) appliqués à notre système de santé [2] ou évaluer la pertinence de variables utilisées en routine (score de Glasgow [12], saturation en oxygène [13]).

Les informations qu’ils portent permettent aussi d’évaluer la performance de nos parcours de soins, et d’adapter ces derniers aux besoins. Il s’agit là d’un point crucial pour la sécurité des patients. Les registres offrent aux autorités de tutelle des informations leur permettant de guider leurs décisions de politique de santé à l’échelon d’un territoire, et aider à définir les ressources à allouer. Pour cela, nombre de pays ont mis en place des bases de données régionales ou nationales (Norvège, Suède, Italie, Allemagne, Royaume-Uni).

Pour toutes ces raisons, il faut saluer le travail de Yeguiayan et al. [14] issu du registre FIRST et publié dans ce numéro des Annales françaises de médecine d’urgence. Ce registre a permis, au travers de cette publication, de décrire la typologie des patients traumatisés sévères sur le territoire national français. Il documente parfaitement la sévérité des patients pris en charge : un patient sur deux présente un score de Glasgow inférieur à 13, la moitié des patients est intubée et séjourne plus de sept jours en réanimation, dans les suites d’un traumatisme sévère puisque l’Injury Severity Score médian est de 25. Cette étude révèle légalement des écarts aux procédures qui nous font nous interroger sur nos propres pratiques, et justifient la mise en œuvre de mesures correctrices suivies d’évaluation des pratiques professionnelles. Ainsi 7 % des traumatisés graves ne bénéficient pas d’une prise en charge médicale dans un centre hospitalier adapté à leur état. Le taux d’osmothérapie devant une anomalie pupillaire est insuffisant. Un patient intubé sur six n’est pas sédaté par la suite. Le monitorage de l’ETCO2 peut être amélioré. Ce registre FIRST a permis par ailleurs de mettre en évidence le bénéfice d’une médicalisation préhospitalière au cours de la prise en charge de patients traumatisés sévères [15]. Enfin, les données qu’il contient ont permis de montrer que le score de Glasgow ne pouvait se résumer à sa valeur motrice [12].

Mettre en place un registre n’est toutefois pas simple. De nombreux obstacles doivent être franchis. Le premier d’entre eux est d’ordre financier. Outre l’entretien du support informatique des informations qu’il contient, les données saisies doivent être vérifiées et les données manquantes récupérées. Ces étapes requièrent l’assistance d’attachés de recherche clinique et d’un data manager. L’analyse ne peut être conduite que par un professionnel de la méthodologie et des biostatistiques. Réunir toutes ces compétences requiert une source de financement pérenne tout au long de la vie du registre.

Disposer des données n’est pas suffisant. Elles doivent être saisies selon un canevas qui rend le registre comparable aux autres registres du même domaine à des fins de comparaison. La standardisation du recueil selon le style d’Utstein constitue pour cela une aide majeure [16].

Les contraintes règlementaires (déclaration au Comité consultatif sur le traitement de l’information en matière de recherche dans le domaine de la santé, CCTIRS, à la Commission nationale informatique et libertés, CNIL), et bientôt la soumission du projet à un Comité de protection des personnes, doivent et devront être respectées.

Les obstacles sont nombreux, mais le jeu en vaut la chandelle. Nous avons nombre d’années de retard sur nos collègues européens dans le domaine du recueil systématisé de données médicales en traumatologie. Il est temps de créer notre propre source de données épidémiologiques dans le domaine de la traumatologie lourde. Relevons-nous les manches !

Ann. Fr. Med. Urgence

DOI 10.1007/s13341-012-0203-z

link.springer.com/journal/13341

Evaluation of the performance of French physician-staffed emergency medical service in the triage of major trauma patients

BACKGROUND: Proper prehospital triage of trauma patients is a cornerstone for the process of care of trauma patients. In France, emergency physicians perform this process according to a national triage algorithm called Vittel Triage Criteria (VTC), introduced in 2002 to help the triage decision-making process. The aim of this two-center study was to evaluate the performance of the triage process based on the VTC to identify major trauma patients in the Paris area.

METHODS: This was a retrospective analysis of two cohorts. The first cohort consisted of all patients admitted between January 2011 and September 2012 in two trauma referral centers in the region of Paris (Ile de France) and allowed estimation of overtriage. Undertriage was assessed in a second cohort made up of all prehospital trauma interventions from one emergency medicine sector during the same period. Adequate triage was defined by a direct admission of patients with an Injury Severity Score (ISS) greater than 15 into one of the regional trauma centers, and undertriage was defined as an initial nonadmission to a trauma center. Overtriage was defined by an admission of patients with an ISS of 15 or lower to a trauma center. The performance of the VTC was evaluated according to a strict to-the-letter application of the VTC and termed as theoretical triage. Logistic regression was performed to identify VTC criteria able to predict major trauma.

RESULTS: Among 998 admitted patients of the first cohort, 173 patients (17%) were excluded because they were not directly admitted in the first 24 hours. In the first cohort (n = 825), adequate triage was 58% and overtriage was 42%. In the second cohort (n = 190), adequate triage was 40%, overtriage was 60%, and undertriage was less than 1%. Theoretical triage generated a nonsignificantly lower overtriage and a higher undertriage compared with observed triage. The most powerful predictors of major trauma were paralysis (odds ratio [OR,] 0.09; 95% confidence interval [CI], 0.03Y0.22), flail chest (OR, 0.1; 95% CI, 0.01Y0.03), and Glasgow Coma Scale (GCS) score of less than 13 (OR, 0.28; 95% CI, 0.17Y0.45), whereas global assessments of speed and mechanism alone were poor predictors (positive likelihood ratio, 0.92Y1.4).

CONCLUSION: In the Paris area, the French physician-based prehospital triage system for patients with suspicion of major trauma showed a high rate of overtriage and a low rate of undertriage. Criteria of global assessment of speed and mechanism alone were poor predictors of major trauma

J Trauma Acute Care Surg. 2014;76: 1476Y1483. Copyright * 2014 by Lippincott Williams & Wilkins

KEYWORDS: Triage process; prehospital care; undertriage; French system; algorithm.

https://www.ncbi.nlm.nih.gov/pubmed/24854319

Limits of agreement between measures obtained from standard laboratory and the point-of-care device Hemochron 60 Signature Elite during acute haemorrhage

Background: Rapid diagnosis of coagulopathy in the bleeding patient using point-of-care (POC) devices would be ideal. The Hemochron Signature Elitew (HCw) is a POC device that 75 determines international normalized ratio (INR) and activated partial thromboplastin time (aPTT). The aim of the study was to evaluate the agreement for INR and aPTT between the HCw and standard laboratory values in acute haemorrhage.

Methods: This was a single-centre observational prospective study including patients with acute 80 haemorrhage. Laboratory INR and aPTT were compared with simultaneous measurements performed with the HCw. The diagnostic performance of HCw was determined; bias and limits

of agreement were calculated according to the method of Bland and Altman.

Results: Seventy-two pairs of measurements from 39 patients were analysed. The bias between the INR-HCw and aPTT-HCw measurements and the central laboratory were 85 0.02 and 21.13, respectively. The Spearman’s correlation coefficients for the INR-HCw/ INR-lab and the aPTT-HCw/aPTT-lab were 0.68 and 20.29, respectively. Twenty-seven per cent of INR-HCw values and 89% of the aPTT-HCw values exceeded the predefined limits of agreement. The INR-HCw measurement identified patients with a central laboratory INR .1.5 with a sensitivity, specificity, and positive and negative predictive 90 values of 83%, 70%, 76%, and 77%, respectively.

Conclusions: The results showed a lack of agreement between the INR-HCw and the aPTT- HCw measurements and the standard laboratory in the context of acute haemorrhage. The INR-HCw showed moderate performance as a decision-making tool to detect 95 coagulopathy in the context of acute haemorrhage.

Keywords: blood coagulation disorders; haemorrhage; injuries; point-of-care systems; surgical blood loss 

https://www.ncbi.nlm.nih.gov/pubmed/24335551

The initial care of severe trauma patients on hospital admission

Harrois A, Hamada S, Laplace C, Duranteau J, Vigué B.

The initial management of trauma patient is a critical period aiming at 1/ stabilizing the vital functions 2/ following a rigorous injury assessment 3/ defining a therapeutic strategy. This management has to be organized to minimize loss of time that would be deleterious for the patients outcome. Thus, before patient arrival, the trauma team alert should lead to the initiation of care procedures adapted to the announced severity of the patient. Moreover, each individual should know its role in advance and the team should be managed by only one individual (the trauma leader) to avoid conflicts of decision. A rapid trauma assessment aims not only at guiding resuscitation (chest drainage, pelvic contention, to define the mean arterial pressure goal) but also to decide a critical intervention in case of hemodynamic instability (laparotomy, thoracotomy, arterial embolisation). This initial assessment includes a chest and a pelvic X-ray, abdominal ultrasound (extended to the lung) and transcranial doppler. The whole body scanner with administration of intravenous contrast material is the cornerstone of the trauma assessment but should be done for patients stabilized after the initial resuscitation.

Ann Fr Anesth Reanim. 2013 Jul-Aug;32(7-8):483-91.

doi: 10.1016/j.annfar.2013.07.006.

https://www.ncbi.nlm.nih.gov/pubmed/23910065