Publications

Arthur James, Anatole Harrois, Paer-Selim Abback, Jean Denis Moyer, Caroline Jeantrelle, Jean-Luc Hanouz, Mathieu Boutonnet, Thomas Geeraerts, Anne Godier, Julien Pottecher, Delphine Garrigue-Huet, Jean Cotte, Jean Pasqueron, Arnaud Foucrier, Tobias Gauss, Mathieu Raux; French Observatory for Major Trauma (TraumaBase).

Importance: Electric scooter (e-scooter) use is increasing in France and in many urban environments worldwide. Yet little is known about injuries associated with use of e-scooters.

Objective: To describe characteristics and outcomes of major trauma involving e-scooters.

Design, setting, and participants: A multicenter cohort study was conducted in France using the national major trauma registry between January 1, 2019, and December 20, 2022. All patients admitted to a participating major trauma center following a road traffic crash (RTC) involving an e-scooter, a bicycle, or a motorbike were included.

Exposure: Included patients were compared according to the 3 mechanisms.

Main outcomes and measures: The primary outcome was trauma severity as defined by the Injury Severity Score (ISS). Secondary outcomes included the trends of the number of patients per year, a comparison of the RTC epidemiologic factors, injury severity, resources used, and in-hospital outcomes.

Results: A total of 5233 patients involved in RTCs were admitted (median age, 33 [IQR, 24-48] years; 4629 [88.5%] men; median ISS, 13 [IQR, 8-22]). The population included 229 e-scooter RTCs (4.4%), 4094 motorbike RTCs (78.2%), and 910 bicycle RTCs (17.4%). The number of patients treated following e-scooter RTCs increased by 2.8-fold in 4 years (from 31 in 2019 to 88 in 2022), while bicycle RTCs increased by 1.2-fold and motorbike RTCs decreased by 0.9-fold. At admission, 36.7% of e-scooter users had a blood alcohol content higher than the legal threshold (n = 84) and 22.5% wore a protective helmet (n = 32). Among e-scooter RTCs, 102 patients (45.5%) had an ISS of 16 or higher. This proportion was similar for patients with motorbike RTCs (1557 [39.7%]; P = .10) and bicycle RTCs (411 [47.3%]; P = .69). With a proportion of 25.9% (n = 50), patients with e-scooter RTCs had twice as many severe traumatic brain injuries (Glasgow Coma Scale ≤8) as motorbike RTCs (445 [11.8%]) and a proportion comparable to bicycle RTCs (174 [22.1%]). The mortality of e-scooter RTCs was 9.2% (n = 20), compared with 5.2% (n = 196) (P = .02) for motorbikes and 10.0% (n = 84) (P = .82) for bicycles.

Conclusions and relevance: The findings of this study suggest that trauma involving e-scooters in France has significantly increased over the past 4 years. These patients presented with injury profiles as severe as those of individuals who experienced bicycle or motorbike RTCs, with a higher proportion of severe traumatic brain injury.

JAMA Netw Open. 2023 Jun 1;6(6):e2320960.

doi: 10.1001/jamanetworkopen.2023.20960.

Imke Mayer, Julie Josse; Traumabase Group.

We focus on the problem of generalizing a causal effect estimated on a randomized controlled trial (RCT) to a target population described by a set of covariates from observational data. Available methods such as inverse propensity sampling weighting are not designed to handle missing values, which are however common in both data sources. In addition to coupling the assumptions for causal effect identifiability and for the missing values mechanism and to defining appropriate estimation strategies, one difficulty is to consider the specific structure of the data with two sources and treatment and outcome only available in the RCT. We propose three multiple imputation strategies to handle missing values when generalizing treatment effects, each handling the multisource structure of the problem differently (separate imputation, joint imputation with fixed effect, joint imputation ignoring source information). As an alternative to multiple imputation, we also propose a direct estimation approach that treats incomplete covariates as semidiscrete variables. The multiple imputation strategies and the latter alternative rely on different sets of assumptions concerning the impact of missing values on identifiability. We discuss these assumptions and assess the methods through an extensive simulation study. This work is motivated by the analysis of a large registry of over 20,000 major trauma patients and an RCT studying the effect of tranexamic acid administration on mortality in major trauma patients admitted to intensive care units. The analysis illustrates how the missing values handling can impact the conclusion about the effect generalized from the RCT to the target population.

Biom J. 2023 Jun;65(5):e2100294.

doi: 10.1002/bimj.202100294.

Paer-Selim Abback, Alison Benchetrit, Nathalie Delhaye, Jean-Luc Daire, Arthur James, Arthur Neuschwander, Mathieu Boutonnet, Fabrice Cook, Hélène Vinour, Jean-Luc Hanouz, Jean Cotte , Bruno Pastene , Viridiana Jouffroy , Tobias Gauss , Traumabase Group.

Background: Fetal radiation exposure in pregnant women with trauma is a concern. The purpose of this study was to evaluate fetal radiation exposure with regard to the type of injury assessment performed.

Methods: It is a multicentre observational study. The cohort study included all pregnant women suspected of severe traumatic injury in the participating centres of a national trauma research network. The primary outcome was the cumulative radiation dose (mGy) received by the fetus with respect to the type of injury assessment initiated by the physician in charge of the pregnant patient. Secondary outcomes were maternal and fetal morbi-mortality, the incidence of haemorrhagic shock and the physicians' imaging assessment with consideration of their medical specialty.

Results: Fifty-four pregnant women were admitted for potential major trauma between September 2011 and December 2019 in the 21 participating centres. The median gestational age was 22 weeks [12-30]. 78% of women (n = 42) underwent WBCT. The remaining patients underwent radiographs, ultrasound or selective CT scans based on clinical examination. The median fetal radiation doses were 38 mGy [23-63] and 0 mGy [0-1]. Maternal mortality (6%) was lower than fetal mortality (17%). Two women (out of 3 maternal deaths) and 7 fetuses (out of 9 fetal deaths) died within the first 24 h following trauma.

Conclusions: Immediate WBCT for initial injury assessment in pregnant women with trauma was associated with a fetal radiation dose below the 100 mGy threshold. Among the selected population with either a stable status with a moderate and nonthreatening injury pattern or isolated penetrating trauma, a selective strategy seemed safe in experienced centres.

Scand J Trauma Resusc Emerg Med. 2023 May 2;31(1):22.

doi: 10.1186/s13049-023-01084-y.

Florian Roquet, Anne Godier, Delphine Garrigue-Huet, Jean-Luc Hanouz, Fanny Vardon-Bounes, Vincent Legros , Romain Pirracchio, Sylvain Ausset, Jacques Duranteau , Bernard Vigué , Sophie Rym Hamada ; Traumabase® group.

Purpose: The 5^th edition of The European recommendations for the management of major bleeding and coagulopathy following trauma leaves room for various coagulation factor administration strategies. The present study examines these strategies reporting prevalence and timing of administration, quantity dispensed, and transfusion ratios in French trauma centers and their compliance with recommendations alongside associated mortality data.

Methods: All adult patients, admitted directly to participating centers between 2011 and 2019, were extracted from a trauma registry. Two subpopulations were studied: severe hemorrhage (SH) and massive transfusion (MT) groups.

Results: A total of 19,396 patients were included, among whom 8.4% (1630) experienced SH and 3% (579) received MT. Within the first 24 hours, 10% received fresh frozen plasma (FFP), rising to 93% and 99% in the subgroups of patients experiencing SH and MT respectively. Only, 8% received fibrinogen concentrate (FC), increasing to 75% and 92% in subgroups SH and MT respectively. Co-administration of FFP and FC became the dominant strategy with 68% of patients at 6 h and 72% at 24 h in SH subgroup. In unadjusted data, mortality was systematically lower in groups that complied with recommendations, a lower mortality than expected was mostly observed in contrast to non-compliant subgroups. The per-patient compliance to studied recommendations was 21% and 22% in SH and MT subgroups.

Conclusion: The main hemostatic strategy for major bleeding combined the administration of both FFP and FC, favoring an early additional supply of fibrinogen. Compliance with the recommendations was low in SH and MT subgroups.

Anaesth Crit Care Pain Med. 2022. Nov 29;42(2):101180.

doi: 10.1016/j.accpm.2022.101180.

Jean-Denis Moyer, Patrick Lee, Charles Bernard, Lois Henry, Elodie Lang , Fabrice Cook , Fanny Planquart , Mathieu Boutonnet , Anatole Harrois, Tobias Gauss ; Traumabase Group®.

Abstract

Background: Rapid referral of traumatic brain injury (TBI) patients requiring emergency neurosurgery to a specialized trauma center can significantly reduce morbidity and mortality. Currently, no model has been reported to predict the need for acute neurosurgery in severe to moderate TBI patients. This study aims to evaluate the performance of Machine Learning-based models to establish to predict the need for neurosurgery procedure within 24 h after moderate to severe TBI.

Methods: Retrospective multicenter cohort study using data from a national trauma registry (Traumabase®) from November 2011 to December 2020. Inclusion criteria correspond to patients over 18 years old with moderate or severe TBI (Glasgow coma score ≤ 12) during prehospital assessment. Patients who died within the first 24 h after hospital admission and secondary transfers were excluded. The population was divided into a train set (80% of patients) and a test set (20% of patients). Several approaches were used to define the best prognostic model (linear nearest neighbor or ensemble model). The Shapley Value was used to identify the most relevant pre-hospital variables for prediction.

Results: 2159 patients were included in the study. 914 patients (42%) required neurosurgical intervention within 24 h. The population was predominantly male (77%), young (median age 35 years [IQR 24-52]) with severe head injury (median GCS 6 [3-9]). Based on the evaluation of the predictive model on the test set, the logistic regression model had an AUC of 0.76. The best predictive model was obtained with the CatBoost technique (AUC 0.81). According to the Shapley values method, the most predictive variables in the CatBoost were a low initial Glasgow coma score, the regression of pupillary abnormality after osmotherapy, a high blood pressure and a low heart rate.

Conclusion: Machine learning-based models could predict the need for emergency neurosurgery within 24 h after moderate and severe head injury. Potential clinical benefits of such models as a decision-making tool deserve further assessment. The performance in real-life setting and the impact on clinical decision-making of the model requires workflow integration and prospective assessment.

World J Emerg Surg. 2022 Aug 3;17(1):42.

doi: 10.1186/s13017-022-00449-5

Arthur James , Paer-Selim Abback, Pierre Pasquier, Sylvain Ausset, Jacques Duranteau, Clément Hoffmann, Tobias Gauss, Sophie Rym Hamada; Traumabase Group.

Purpose: Traumatic hemorrhagic shock (THS) is a complex, dynamic process and, no consensual definition of THS is available. This study aims (1) to explore existing definitions of traumatic hemorrhagic shock (THS), (2) to identify essential components of these definitions and (3) to illustrate in a pragmatic way the consequences of applying five of these definitions to a trauma registry.

Methods: We conducted (1) a scoping review to identify the definitions used for traumatic hemorrhagic shock (THS); (2) an international experts survey to rank by relevance a selection of components extracted from these definitions and (3) a registry-based analysis where several candidate definitions were tested in a large trauma registry to evaluate how the use of different definitions affected baseline characteristics, resources use and patient outcome.

Results: Sixty-eight studies were included revealing 52 distinct definitions. The most frequently used was "a systolic blood pressure (SBP) less than or equal to 70 mmHg or between 71 and 90 mmHg if the heart rate is greater than or equal to 108 beats per min". The expert panel identified base excess, blood lactate concentration, SBP and shock index as the most relevant physiological components to define THS. Five definitions of THS were tested and highlighted significant differences across groups on important outcomes such as the proportion of massive transfusion, the need for surgery, in-hospital length of stay or in-hospital mortality.

Conclusions: This study demonstrates a large heterogeneity in the definitions of THS suggesting a need for standardization. Five candidate definitions were identified in a three-step process to illustrate how each shapes study cohort composition and impacts outcome. The results inform research stakeholders in the choice of a consensual definition.

Eur J Trauma Emerg Surg. 2022 Dec;48(6):4639-4649.

doi: 10.1007/s00068-022-01998-9. Epub 2022 Jun 22.

Tobias Gauss , Justin E Richards, Costanza Tortù, François-Xavier Ageron, Sophie Hamada, Julie Josse, François Husson, Anatole Harrois, Thomas M Scalea, Valentin Vivant, Eric Meaudre, Jonathan J Morrison, Samue Galvagno, Pierre Bouzat, French Trauma Research Initiative

Importance: Hemorrhagic shock is a common cause of preventable death after injury. Vasopressor administration for patients with blunt trauma and hemorrhagic shock is often discouraged.

Objective: To evaluate the association of early norepinephrine administration with 24-hour mortality among patients with blunt trauma and hemorrhagic shock.

Design, setting, and participants: This retrospective, multicenter, observational cohort study used data from 3 registries in the US and France on all consecutive patients with blunt trauma from January 1, 2013, to December 31, 2018. Patients were alive on admission with hemorrhagic shock, defined by prehospital or admission systolic blood pressure less than 100 mm Hg and evidence of hemorrhage (ie, prehospital or resuscitation room transfusion of packed red blood cells, receipt of emergency treatment for hemorrhage control, transfusion of >10 units of packed red blood cells in the first 24 hours, or death from hemorrhage). Blunt trauma was defined as any exposure to nonpenetrating kinetic energy, collision, or deceleration. Statistical analysis was performed from January 15, 2021, to February 22, 2022.

Exposure: Continuous administration of norepinephrine in the prehospital environment or resuscitation room prior to hemorrhage control, according to European guidelines.

Main outcomes and measures: The primary outcome was 24-hour mortality, and the secondary outcome was in-hospital mortality. The average treatment effect (ATE) of early norepinephrine administration on 24-hour mortality was estimated according to the Rubin causal model. Inverse propensity score weighting and the doubly robust approach with 5 distinct analytical strategies were used to determine the ATE.

Results: A total of 52 568 patients were screened for inclusion, and 2164 patients (1508 men [70%]; mean [SD] age, 46 [19] years; median Injury Severity Score, 29 [IQR, 17-36]) presented with acute hemorrhage and were included. A total of 1497 patients (69.1%) required emergency hemorrhage control, 128 (5.9%) received a prehospital transfusion of packed red blood cells, and 543 (25.0%) received a massive transfusion. Norepinephrine was administered to 1498 patients (69.2%). The 24-hour mortality rate was 17.8% (385 of 2164), and the in-hospital mortality rate was 35.6% (770 of 2164). None of the 5 analytical strategies suggested any statistically significant association between norepinephrine administration and 24-hour mortality, with ATEs ranging from -4.6 (95% CI, -11.9 to 2.7) to 2.1 (95% CI, -2.1 to 6.3), or between norepinephrine administration and in-hospital mortality, with ATEs ranging from -1.3 (95% CI, -9.5 to 6.9) to 5.3 (95% CI, -2.1 to 12.8).

Conclusions and relevance: The findings of this study suggest that early norepinephrine infusion was not associated with 24-hour or in-hospital mortality among patients with blunt trauma and hemorrhagic shock. Randomized clinical trials that study the effect of early norepinephrine administration among patients with trauma and hypotension are warranted to further assess whether norepinephrine is safe for patients with hemorrhagic shock.

S R Hamada , D Garrigue , H Nougue, A Meyer, M Boutonnet, E Meaudre, A Culver, E Gaertner, G Audibert, B Vigué, J Duranteau, A Godier, and the TraumaBase Group.

Background:

Trauma-induced coagulopathy includes thrombocytopenia and platelet dysfunction that impact patient outcome. Nevertheless, the role of platelet transfusion remains poorly defined. The aim of the study was 1/ to evaluate the impact of early platelet transfusion on 24-h all-cause mortality and 2/ to describe platelet count at admission (PCA) and its relationship with trauma severity and outcome.

Methods: Observational study carried out on a multicentre prospective trauma registry. All adult trauma patients directly admitted in participating trauma centres between May 2011 and June 2019 were included. Severe haemorrhage was defined as ≥ 4 red blood cell units within 6 h and/or death from exsanguination. The impact of PCA and early platelet transfusion (i.e. within the first 6 h) on 24-h all-cause mortality was assessed using uni- and multivariate logistic regression.

Results: Among the 19,596 included patients, PCA (229 G/L [189,271]) was associated with coagulopathy, traumatic burden, shock and bleeding severity. In a logistic regression model, 24-h all-cause mortality increased by 37% for every 50 G/L decrease in platelet count (OR 0.63 95% CI 0.57-0.70; p < 0.001). Regarding patients with severe hemorrhage, platelets were transfused early for 36% of patients. Early platelet transfusion was associated with a decrease in 24-h all-cause mortality (versus no or late platelets): OR 0.52 (95% CI 0.34-0.79; p < 0.05).

Conclusions: PCA, although mainly in normal range, was associated with trauma severity and coagulopathy and was predictive of bleeding intensity and outcome. Early platelet transfusion within 6 h was associated with a decrease in mortality in patients with severe hemorrhage. Future studies are needed to determine which doses of platelet transfusion will improve outcomes after major trauma.

Crit Care; 2022 Feb 21;26(1):49.

doi: 10.1186/s13054-022-03928-y.

Malik Haddam  , Laura Kubacsi, Sophie Hamada, Anatole Harrois, Arthur James, Olivier Langeron, Mathieu Boutonnet, Mathilde Holleville, Delphine Garrigue, Marion Leclercq, Jean-Luc Hanouz, Julien Pottecher, Gérard Audibert, Mickael Cardinale, Hélène Vinour, Laurent Zieleskiewicz, Noemie Resseguier, Marc Leone, for TraumaBase Group.

Background:

This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision.

Design:

This observational study assessed data from 14 French centres listed in the TraumaBaseTM registry. All trauma patients hospitalised for more than 48 h were prospectively included.

Results:

Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n=907) of which 47% (n=422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death.

Conclusion:

Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.

Eur J Anaesthesiol; 2022 Feb 14.

doi: 10.1097/EJA.0000000000001671.

Elodie Lang , Arthur Neuschwander, Gersende Favé, Paer-Selim Abback, Pierre Esnault, Thomas Geeraerts, Anatole Harrois, Jean-Luc Hanouz, Eric Kipnis, Marc Leone, Vincent Legros, Nouchan Mellati, Julien Pottecher, Sophie Hamada, Romain Pirracchio, for Traumabase Group.

Background:

Deviation from guidelines is frequent in emergency situations, and this may lead to increased mortality. Probably because of time constraints, 55% is the greatest reported guidelines compliance rate in severe trauma patients. This study aimed to identify among all available recommendations a reasonable bundle of items that should be followed to optimize the outcome of hemorrhagic shocks (HSs) and severe traumatic brain injuries (TBIs).

Methods:

We first estimated the compliance with French and European guidelines using the data from the French TraumaBase registry. Then, we used a machine learning procedure to reduce the number of recommendations into a minimal set of items to be followed to minimize 7-day mortality. We evaluated the bundles using an external validation cohort.

Results:

This study included 5,924 trauma patients (1,414 HS and 4,955 TBI) between 2011 and August 2019 and studied compliance to 36 recommendation items. Overall compliance rate to recommendation items was 71.6% and 66.9% for HS and TBI, respectively. In HS, compliance was significantly associated with 7-day decreased mortality in univariate analysis but not in multivariate analysis (risk ratio [RR], 0.91; 95% confidence interval [CI], 0.90-1.17; p = 0.06). In TBI, compliance was significantly associated with decreased mortality in univariate and multivariate analysis (RR, 0.85; 95% CI, 0.75-0.92; p = 0.01). For HS, the bundle included 13 recommendation items. In the validation cohort, when this bundle was applied, patients were found to have a lower 7-day mortality rate (RR, 0.46; 95% CI, 0.27-0.63; p = 0.01). In TBI, the bundle included seven items. In the validation cohort, when this bundle was applied, patients had a lower 7-day mortality rate (RR, 0.55; 95% CI, 0.34-0.71; p = 0.02).

Discussion:

Using a machine-learning procedure, we were able to identify a subset of recommendations that minimizes 7-day mortality following traumatic HS and TBI. These two bundles remain to be evaluated in a prospective manner.

J Trauma Acute Care Surg; 2022 Jan 1;92(1):135-143.

doi: 10.1097/TA.0000000000003401

Louis Boutin, Marie-Josée Caballero, Delphine Guarrigue, Emmanuelle Hammad, Isabelle Rennuit, Nathalie Delhaye, Arthur Neuschwander, Alain Meyer, Valérie Bitot, Quentin Mathais, Mathieu Boutonnet ,Pierre Julia ,Mercier Olaf ,Jacques Duranteau, Sophie R. Hamada, For theTraumaBase Group.

Objective:

Blunt traumatic aortic injury (BTAI) in severe trauma patients is rare but potentially lethal. The aim of this work was to perform a current epidemiological analysis of the clinical and surgical management of these patients in a European country.

Methods:

This was a multicentre, retrospective study using prospectively collected data from the French National Trauma Registry and the National Uniform Hospital Discharge Database from 10 trauma centres in France. The primary endpoint was the prevalence of BTAI. The secondary endpoints focused chronologically on injury characteristics, management, and patient outcomes.

Results:

209 patients were included with a mean age of 43 19 years and 168 (80%) were men. The calculated prevalence of BTAI at hospital admission was 1% (162/15 094) (BTAI admissions/all trauma). The time to diagnosis increased with the severity of aortic injury and the clinical severity of the patients (grade 1: 94 [74, 143] minutes to grade 4: 154 [112, 202] minutes, p ¼ .020). This delay seemed to be associated with the intensity of the required resuscitation. Sixty seven patients (32%) received no surgical treatment. Among those treated, 130 (92%) received endovascular treatment, 14 (10%) open surgery (two were combined), and 123 (85%) were treated within the first 24 hours. Overall mortality was 20% and the attributed cause of death was haemorrhagic shock (69%). Mortality was increased according to aortic injury severity, from 6% for grade 1 to 65% for grade 4 (p < .001). Twenty-six (18.3%) patients treated by endovascular aortic repair had complications.

Conclusion:

BTAI prevalence at hospital admission was low but occurred in severe high velocity trauma patients and in those with a high clinical suspicion of severe haemorrhage. The association of shock with high grade aortic injury and increasing time to diagnosis suggests a need to optimise early resuscitation to minimise the time to treatment. Endovascular treatment has been established as the reference treatment, accounting for more than 90% of interventional treatment options for BTAI.

Eur J Vasc Endovasc Surg; 2 Feb 7;S1078-5884(21)00782-6.

doi: 10.1016/j.ejvs.2021.09.043.

Jean-Denis Moyer , Paer-Selim Abback, Sophie Hamada, Thibault Martinez, Marie Werner, Arthur James, Traumabase®Group.

Background:

During the SARS-CoV-2 pandemic, the French Government imposed various containment strategies, such as severe lockdown (SL) or moderate lockdown (ML). The aim of this study was to evaluate the effect of both strategies on severe trauma admissions and ICU capacity in Ile-de-France region (Paris Area).

Main text: We conducted a multicenter cohort-based observational study from 1^stJanuary 2017 to 31th December 2020, including all consecutive trauma patients admitted to the trauma centers of Ile-de-France region participating in the national registry (Traumabase®). Two periods were defined, the "non-pandemic period" (NPP) from 2017 to 2019, and the "pandemic period" (PP) concerning those admitted in 2020. The number of ICU beds released during 2020 pandemic period (overall period, SL and ML) was estimated by multiplying difference in trauma admissions by the median length of stay during the same week of pandemic period (ICU day-beds in 2020). A 15% yearly reduction of trauma patients was observed during the PP, associated with the release of 6422 ICU day-beds in 2020. During SL and ML, the observed decrease in trauma admission was respectively 49 and 39% compared with similar dates of the NPP. The number of beds released was 1531 days-beds in SL and 679 day-beds in ML. Those reductions respectively accounted for 4.5 and 6.0% of the overall ICU admission for COVID-19 in Ile-de-France.

Conclusion: The lockdown strategies during pandemic resulted in a reduction of severe trauma admissions. In addition to the social distancing effect, lockdown strategies freed up an important number of ICU beds in trauma centers, available for severe COVID-19 patients.

Scand J Trauma Resusc Emerg Med. 2021 Sep 14;29(1):135.

doi: 10.1186/s13049-021-00918-x.

https://pubmed.ncbi.nlm.nih.gov/34521446/

Jean-Denis Moyer, Sophie Rym Hamada, Julie Josse, Olivier Auliard, Tobias Gauss, Traumabase Group

Anaesth Crit Care Pain Med. 2021 Apr;40(2):100827.

doi: 10.1016/j.accpm.2021.100827.

Louis-Marie Paget, Mathieu Boutonnet, Jean-Denis Moyer, Nathalie Delhaye, Erwan D'Aranda, Nathalie Beltzer, Sophie Rym Hamada.

 Introduction: In France, there is a lack of recent data on Traumatic brain injury (TBI), remaining a major global health challenge in terms of morbidity and mortality. The present study reports the epidemiology and the factors associated with mortality of patients with TBI admitted to 9 French trauma centres.

Method: Patients ≥ 15 years old admitted, between the 1st of January and the 31st of December 2017, following TBI (Abbreviated Injury Scale head ≥ 2) were included. Descriptive analyses were carried out and a logistic regression was used in order to identify in-hospital mortality predictors.

Results: 1,177 patients (889 males (76%), median age 42 [26-59]) were admitted following TBI. Road traffic accidents were the primary mechanism of TBI. Mechanisms leading to TBI were highly correlated with age. The in-hospital mortality was 23%. In-hospital mortality increased with age, from 15% in 15-24-year-olds to 71% among patients aged 85 years and older. Age, relevant past medical history, Glasgow coma scale motor score, subdural haematoma, systolic arterial blood pressure < 110 mmHg, pupillary abnormality and haemoglobin level were significantly associated with in-hospital mortality.

Conclusions: TBI is still a major public health concern affecting mostly young patients, victims of road traffic accidents and elderly patients, victims of falls. These findings could help clinicians adjusting medical approaches, targeting prevention measures and planning new research projects according to these French TBI population characteristics.

Keywords: Epidemiology; Injuries; Traumatic brain injury.

Anaesth Crit Care Pain Med; 2021 Feb;40(1):100804. doi: 10.1016/j.accpm.2021.100804.

DOI: 10.1016/j.accpm.2021.100804

Chloé Descamps , Sophie Hamada , Jean-Luc Hanouz, Fanny Vardon-Bounes, Arthur James, Delphine Garrigue, Paer Abback, Mickaël Cardinale, Guillaume Dubreuil, Jeanne Chatelon, Fabrice Cook, Arthur Neuschwander, Nathalie de Garambé, Sylvain Ausset, Mathieu Boutonnet, Traumabase Group.

Purpose:

Severe trauma is a major problem worldwide. In France, blunt trauma (BT) is predominant and few studies are available on penetrating trauma (PT). The purpose of this study was to perform a descriptive analysis of severe gunshot (GSW) and stab wounds (SW) in patients who were treated in French trauma centers.

Methods: Retrospective study on prospectively collected data in a national trauma registry. All adult (> 15 years) trauma patients primarily admitted in 1 of the 17 trauma centers members of the Traumabase between January 2015 to December 2018 were included. Data from patients who had a PT were compared with those who had suffered a BT over the same period. Due to the known differences between GSW and SW, sub-group analyses on data from GSW, SW and BT were also performed.

Results: 8128 patients were included. Twelve percent of the study group had a PT. The main mechanism of PT was SW (68.1%). Five hundred and eighty patients with PT (59.4%) required surgery within the first 24 h. Severe hemorrhage was more frequent in penetrating traumas (11.2% vs. 7.8% p < 0.001). Hospital mortality following PT was 8.9% vs 11% for blunt trauma (p = 0.047). Among PT the mortality after GSW was ten times higher than after SW (23.8% vs 2%).

Conclusion: This work is the largest study to date that has specifically focused on GSW and SW in France, and will help improving knowledge in managing such patients in our country.

Eur J Trauma Emerg Surg. 2021 Jul 7

DOI: 10.1007/s00068-021-01742-9

Ron Birnbaum , Rudy Bitton, Romain Pirracchio, Anne-Laure Féral-Pierssens, Anne-Laure Constant, Clément Dubost, Benjamin Chousterman, Thomas Lescot, Brice Lortat-Jacob, Anatole Harrois, Paer-Selim Abback, Anissa Belbachir, Emmanuel Basto, Yves Castier, Philippe Laitselart, Pierre Carli, Frédéric Lapostolle, Jean Pierre Tourtier, Matthieu Langlois, Mathieu Raux, Roman Mounier, TRAUMABASE Group

Background:

We aimed to assess the incidence and the risk factors for secondary wound infections associated to high-energy ammunition injuries (HEAI) in the cohort of civilian casualties from the 2015 terrorist attacks in Paris.

Methods: This retrospective multi-centric study included casualties presenting at least one HEAI who underwent surgery during the first 48 hours following hospital admission. HEAI associated infection was defined as a wound infection occurring within the initial 30 days following trauma. Risk factors were assessed using univariate and multivariate analysis.

Results: Among the 200 included victims, the rate of infected wounds was 11.5%. The median time between admission and the surgical revision for secondary wound infection was 11 days [9-20]. No patient died from an infectious cause. Infections were poly-microbial in 44 % of the cases. The major risk factors for secondary wound infection were ISS (p < 0.001), SAPS II (p < 0.001), MGAP (p < 0.001), haemorrhagic shock (p = 0.003), use of vasopressors (p < 0.001), blood transfusion (p < 0.001), abdominal penetrating trauma (p = 0.003), open fracture (p = 0.01), vascular injury (p = 0.001), duration of surgery (p = 0.009), presence of surgical material (p = 0.01). In the multivariate analysis, the SAPS II score (OR 1.07 [1.014-1.182], p = 0.019) and the duration of surgery (OR 1.005 [1.000-1.012], p = 0.041) were the only risk factors identified.

Conclusion: We report an 11.5% rate of secondary wound infection following high-energy ammunition injuries. Risk factors were an immediately severe condition and a prolonged surgery.

Keywords: High–energy ammunition injury; combat-related injury; risk factor; terrorist attack; wound infection.

Anaesth Crit Care Pain Med. 2021 Jun 23;100908

DOI: 10.1016/j.accpm.2021.100908

Jean-Denis Moyer, Arthur James, Clément Gakuba, Mathieu Boutonnet, Emeline Angles, Emmanuel Rozenberg, Jean Bardon, Thomas Clavier, Vincent Legros, Marie Werner, Quentin Mathais, Véronique Ramonda, Pierre Le Minh, Yann Berthelot, Clélia Colas, Julien Pottecher, Tobias Gauss, and the Traumabase Group

Background: Emerging evidence suggests that the reallocation of health care resources during the COVID-19 pandemic negatively impacts health care system. This study describes the epidemiology and the outcome of major trauma patients admitted to centers in France during the first wave of the COVID-19 outbreak.

Methods: This retrospective observational study included all consecutive trauma patients aged 15 years and older admitted into 15 centers contributing to the TraumaBase® registry during the first wave of the SARS-CoV-2 pandemic in France. This COVID-19 trauma cohort was compared to historical cohorts (2017-2019).

Results: Over a 4 years-study period, 5762 patients were admitted between the first week of February and mid-June. This cohort was split between patients admitted during the first 2020 pandemic wave in France (pandemic period, 1314 patients) and those admitted during the corresponding period in the three previous years (2017-2019, 4448 patients). Trauma patient demographics changed substantially during the pandemic especially during the lockdown period, with an observed reduction in both the absolute numbers and proportion exposed to road traffic accidents and subsequently admitted to traumacenters (348 annually 2017-2019 [55.4% of trauma admissions] vs 143 [36.8%] in 2020 p < 0.005). The in-hospital observed mortality and predicted mortality during the pandemic period were not different compared to the non-pandemic years.

Conclusions: During this first wave of COVID-19 in France, and more specifically during lockdown there was a significant reduction of patients admitted to designated trauma centers. Despite the reallocation and reorganization of medical resources this reduction prevented the saturation of the trauma rescue chain and has allowed maintaining a high quality of care for trauma 

Wei Jiang, Julie Josse, Marc Lavielle, TraumaBase Group

Abstract

Logistic regression is a common classification method in supervised learning. Surprisingly, there are very few solutions for performing logistic regression with missing values in the covariates. We suggest a complete approach based on a stochastic approximation version of the EM algorithm to do statistical inference with missing values including the estimation of the parameters and their variance, derivation of confidence intervals and a model selection procedure. We also tackle the problem of prediction for new observations (on a test set) with missing covariate data. The methodology is computationally efficient, and its good coverage and variable selection properties are demonstrated in a simulation study where we contrast its performances to other methods. For instance, the popular approach of multiple imputation by chained equations can lead to estimates that exhibit meaningfully greater biases than the proposed approach. We then illustrate the method on a dataset of severely traumatized patients from Paris hospitals to predict the occurrence of hemorrhagic shock, a leading cause of early preventable death in severe trauma cases. The aim is to consolidate the current red flag procedure, a binary alert identifying patients with a high risk of severe hemorrhage. The methodology is implemented in the R package misaem.

Lecture Notes in Statistics, 2019.

Sophie Rym Hamada, Romain Pirracchio, Jocelyn Beauchesne, Mohammed Nadjib Benlaldj, Eric Meaudre, Marc Leone, Julien Pottecher, Paer Selim Abback, Tobias Gauss, Mathieu Boutonnet, Fabrice Cook, Delphine Garrigue, Frédéric Lesache, Josse Julie, Alexandra Rouquette, Jacques Duranteau

Background: 

Fibrinogen concentrate is widely used in traumatic hemorrhagic shock despite weak evidence in the literature. The aim of the study was to evaluate the effect of fibrinogen concentrate administration within the first 6 hours on 24-hour all-cause mortality in traumatic hemorrhagic shock using a causal inference approach.

Methods: Observational study from a French multicenter prospective trauma registry was performed. Hemorrhagic shock was defined as transfusion of four or more red blood cell units within the first 6 hours after admission. The confounding variables for the outcome (24-hour all-cause mortality) and treatment allocation (fibrinogen concentrate administration within the first 6 hours) were chosen by a Delphi method. The propensity score was specified with a data-adaptive algorithm and a doubly-robust approach with inverse proportionality of treatment weighting allowed to compute the average treatment effect. Sensitivity analyses were performed.

Results: Of 14,336 patients in the registry during the study period, 1,027 in hemorrhagic shock were analyzed (758 receiving fibrinogen concentrate within 6 hours and 269 not receiving fibrinogen concentrate). The average treatment effect, expressed as a risk difference, was -0.031 (95% confidence interval, -0.084 to 0.021). All sensitivity analysis confirmed the results.

Conclusions: Fibrinogen concentrate administration within the first 6 hours of a traumatic hemorrhagic shock did not decrease 24-hour all-cause mortality.

J Trauma Acute Care Surg. 2020 May;88(5):661-670.

PMID: 32068718 DOI: 10.1097/TA.0000000000002624

Imke Mayer, Stefan Wager, Tobias Gauss, Jean-Denis, Moyer, and Julie Josse.

Abstract:

Missing attributes are ubiquitous in causal inference, as they are in most applied statistical work. In this paper, we consider various sets of assumptions under which causal inference is possible despite missing attributes and discuss corresponding approaches to average treatment effect estimation, including generalized propensity score methods and multiple imputation. Across an extensive simulation study, we show that no single method systematically out-performs others. We find, however, that doubly robust modifications of standard methods for average treatment effect estimation with missing data repeatedly perform better than their non-doubly robust baselines; for example, doubly robust generalized propensity score methods beat inverse-weighting with the generalized propensity score. This finding is reinforced in an analysis of an observations study on the effect on mortality of tranexamic acid administration among patients with traumatic brain injury in the context of critical care management. Here, doubly robust estimators recover confidence intervals that are consistent with evidence from randomized trials, whereas non-doubly robust estimators do not.

 ANNALS OF APPLIED STATISTICS, septembre 2020.

Thibault Martinez, Anne François, Thomas Pouget, Pierre Carli, Frédéric Lapostolle, Tobias Gauss, Sophie Rym Hamada, Matthieu Langlois, Youri Yordanov, Anne-Laure Féral-Pierssens, Alexandre Woloch, Carl Ogereau, Etienne Gayat, Arié Attias, Dominique Pateron, Yves Castier, Bertrand Ludes, Emmanuelle Dolla, Jean-Pierre Tourtier, Bruno Riou, Mathieu Raux, Sylvain Ausset, TRAUMABASE group.

Objective:

Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015.

Methods:

We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack.

Results:

Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets.

Conclusion:

Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile.

J Trauma Acute Care Surg 2020 Sep;89(3):496-504.

DOI: 10.1097/TA.0000000000002729

Josefine S Baekgaard, Paer-Selim Abback, Marouane Boubaya, Jean-Denis Moyer, Delphine Garrigue, Mathieu Raux, Benoit Champigneulle, Guillaume Dubreuil, Julien Pottecher, Philippe Laitselart, Fleur Laloum, Coralie Bloch-Queyrat, Frédéric Adnet, Catherine Paugam-Burtz, Traumabase® Study Group.

Background:

Hyperoxemia has been associated with increased mortality in critically ill patients, but little is known about its effect in trauma patients. The objective of this study was to assess the association between early hyperoxemia and in-hospital mortality after severe trauma. We hypothesized that a PaO₂ ≥ 150 mmHg on admission was associated with increased in-hospital mortality.

Methods:

Using data issued from a multicenter prospective trauma registry in France, we included trauma patients managed by the emergency medical services between May 2016 and March 2019 and admitted to a level I trauma center. Early hyperoxemia was defined as an arterial oxygen tension (PaO₂) above 150 mmHg measured on hospital admission. In-hospital mortality was compared between normoxemic (150 > PaO₂ ≥ 60 mmHg) and hyperoxemic patients using a propensity-score model with predetermined variables (gender, age, prehospital heart rate and systolic blood pressure, temperature, hemoglobin and arterial lactate, use of mechanical ventilation, presence of traumatic brain injury (TBI), initial Glasgow Coma Scale score, Injury Severity Score (ISS), American Society of Anesthesiologists physical health class > I, and presence of hemorrhagic shock).

Results:

A total of 5912 patients were analyzed. The median age was 39 [26-55] years and 78% were male. More than half (53%) of the patients had an ISS above 15, and 32% had traumatic brain injury. On univariate analysis, the in-hospital mortality was higher in hyperoxemic patients compared to normoxemic patients (12% versus 9%, p < 0.0001). However, after propensity score matching, we found a significantly lower in-hospital mortality in hyperoxemic patients compared to normoxemic patients (OR 0.59 [0.50-0.70], p < 0.0001).

Conclusion:

In this large observational study, early hyperoxemia in trauma patients was associated with reduced adjusted in-hospital mortality. This result contrasts the unadjusted in-hospital mortality as well as numerous other findings reported in acutely and critically ill patients. The study calls for a randomized clinical trial to further investigate this association.

Crit Care 2020 Oct 12;24(1):604.

doi: 10.1186/s13054-020-03274-x.

Arthur James  , Youri Yordanov, Sylvain Ausset, Matthieu Langlois, Jean-Pierre Tourtier, Pierre Carli, Bruno Riou, Mathieu Raux, TRAUMABASE Group.

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.

Eur J Emerg Med 2020 Nov 27.

doi: 10.1097/MEJ.0000000000000771

Sophie Rym Hamada, Nathalie Delhaye, Samuel Degoul, Tobias Gauss, Mathieu Raux, Marie-Laure Devaud, Johan Amani, Fabrice Cook, Camille Hego, Jacques Duranteau , Alexandra Rouquette, Traumabase Group

Background:

Transporting a severely injured patient directly to a trauma center (TC) is consensually considered optimal. Nevertheless, disagreement persists regarding the association between secondary transfer status and outcome. The aim of the study was to compare adjusted mortality between road traffic trauma patients directly or secondarily transported to a level 1 trauma center (TC) in an exclusive French trauma system with a physician staffed prehospital emergency medical system (EMS).

Methods:

A retrospective cohort study was performed using 2015-2017 data from a regional trauma registry (Traumabase®), an administrative database on road-traffic accidents and prehospital-EMS records. Multivariate logistic regression models were computed to determine the role of the modality of admission on mortality and to identify factors associated with secondary transfer. The primary outcome was day-30 mortality. Results: During the study period, 121.955 victims of road-traffic accident were recorded among which 4412 trauma patients were admitted in the level 1 regional TCs, 4031 directly and 381 secondarily transferred from lower levels facilities. No significant association between all-cause 30-day mortality and the type of transport was observed (Odds ratio 0.80, 95% confidence interval (CI) [0.3-1.9]) when adjusted for potential confounders. Patients secondarily transferred were older, with low-energy mechanism and presented higher head and abdominal injury scores. Among all 947 death, 43 (4.5%) occurred in lower-level facilities. The population-based undertriage leading to death was 0.15%, 95%CI [0.12-0.19].

Conclusion:

In an exclusive trauma system with physician staffed prehospital care, road-traffic victims secondarily transferred to a TC do not have an increased mortality when compared to directly transported patients.

PLoS One 2019 Nov 21;14(11):e0223809.

DOI:

10.1371/journal.pone.0223809

Gauss T, Ageron FX, Devaud ML, Debaty G, Travers S, Garrigue D, Raux M, Harrois A, Bouzat P; French Trauma Research Initiative.

Importance:

The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain.

Objective:

To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality.

Design, Setting, and Participants:

This cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018.

Main Outcomes and Measures:

The association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality.

Results:

A total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 (14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score ≥3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]).

Conclusions and Relevance:

In this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

JAMA Surg. 2019 Sep 25

DOI: 10.1001/jamasurg.2019.3475

Roquet F, Neuschwander A, Hamada S, Favé G, Follin A, Marrache D, Cholley B, Pirracchio R; Traumabase Group

Importance:

Optimal transfusion management is crucial when treating patients with trauma. However, the association of an early, high transfusion ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) with survival remains uncertain.

Objective:

To study the association of an early, high FFP-to-PRBC ratio with all-cause 30-day mortality in patients with severe bleeding after trauma.

Design, Setting, and Participants:

This cohort study analyzes the data included in a multicenter national French trauma registry, Traumabase, from January 2012 to July 2017. Traumabase is a prospective, active, multicenter adult trauma registry that includes all consecutive patients with trauma treated at 15 trauma centers in France. Overall, 897 patients with severe bleeding after trauma were identified using the following criteria: (1) received 4 or more units of PRBC during the first 6 hours or (2) died from hemorrhagic shock before receiving 4 units of PRBC.

Exposures:

Eligible patients were divided into a high-ratio group, defined as an FFP-to-PRBC ratio more than 1:1.5, and a low-ratio group, defined as an FFP-to-PRBC ratio of 1:1.5 or less. The ratio was calculated using the cumulative units of FFP and PRBC received during the first 6 hours of management.

Main Outcomes and Measures:

A Cox regression model was used to analyze 30-day survival with the transfusion ratio as a time-dependent variable to account for survivorship bias.

Results:

Of the 12 217 patients included in the registry, 897 (7.3%) were analyzed (median [interquartile range] age, 38 (29-54) years; 639 [71.2%] men). The median (interquartile range) injury severity score was 34 (22-48), and the overall 30-day mortality rate was 33.6% (301 patients). A total of 506 patients (56.4%) underwent transfusion with a high ratio and 391 (43.6%) with a low ratio. A high transfusion ratio was associated with a significant reduction in 30-day mortality (hazard ratio, 0.74; 95% CI, 0.58-0.94; P = .01). When only analyzing patients who had complete data, a high transfusion ratio continued to be associated with a reduction in 30-day mortality (hazard ratio, 0.57; 95% CI, 0.33-0.97; P = .04).

Conclusions and Relevance:

In this analysis of the Traumabase registry, an early FFP-to-PRBC ratio of more than 1:1.5 was associated with increased 30-day survival among patients with severe bleeding after trauma. This result supports the use of early, high FFP-to-PRBC transfusion ratios in patients with severe trauma.

JAMA Netw Open. 2019 Sep 4;2(9):e1912076

DOI: 10.1001/jamanetworkopen.2019.12076

Raux M, Carli P, Lapostolle F, Langlois M, Yordanov Y, Féral-Pierssens AL, Woloch A, Ogereau C, Gayat E, Attias A, Pateron D, Castier Y, François A, Ludes B, Dolla E, Tourtier JP, Riou B; TRAUMABASE Group

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.

Intensive Care Med. 2019 Sep;45(9):1231-1240.

DOI: 10.1007/s00134-019-05724-9

Harrois A, Soyer B, Gauss T, Hamada S, Raux M, Duranteau J; Traumabase® Group.

BACKGROUND:

Organ failure, including acute kidney injury (AKI), is the third leading cause of death after bleeding and brain injury in trauma patients. We sought to assess the prevalence, the risk factors and the impact of AKI on outcome after trauma.

METHODS:

We performed a retrospective analysis of prospectively collected data from a multicenter trauma registry. AKI was defined according to the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) classification from serum creatinine only. Prehospital and early hospital risk factors for AKI were identified using logistic regression analysis. The predictive models were internally validated using bootstrapping resampling technique.

RESULTS:

We included 3111 patients in the analysis. The incidence of AKI was 13% including 7% stage R, 3.7% stage I and 2.3% stage F. AKI incidence rose to 42.5% in patients presenting with hemorrhagic shock; 96% of AKI occurred within the 5 first days after trauma. In multivariate analysis, prehospital variables including minimum prehospital mean arterial pressure, maximum prehospital heart rate, secondary transfer to the trauma center and data early collected after hospital admission including injury severity score, renal trauma, blood lactate and hemorrhagic shock were independent risk factors in the models predicting AKI. The model had good discrimination with area under the receiver operating characteristic curve of 0.85 (0.82-0.88) to predict AKI stage I or F and 0.80 (0.77-0.83) to predict AKI of all stages. Rhabdomyolysis severity, assessed by the creatine kinase peak, was an additional independent risk factor for AKI when it was forced into the model (OR 1.041 (1.015-1.069) per step of 1000 U/mL, p < 0.001). AKI was independently associated with a twofold increase in ICU mortality.

CONCLUSIONS:

AKI has an early onset and is independently associated with mortality in trauma patients. Its prevalence varies by a factor 3 according to the severity of injuries and hemorrhage. Prehospital and early hospital risk factors can provide good performance for early prediction of AKI after trauma. Hence, studies aiming to prevent AKI should target patients at high risk of AKI and investigate therapies early in the course of trauma care.

Crit Care. 2018 Dec 18;22(1):344.

DOI: 10.

1186/s13054-018-2265-9

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-Hb_prehosp) and upon patient's admission to the hospital (POC-Hb_hosp), the difference between POC-Hb_hosp and POC-Hb_prehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Lab_hosp).

RESULTS:

A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hb_prehosp 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-Hb_prehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hb_hosp and Hb-Lab_hosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hb_hosp 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-Hb_prehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hb_hosp 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.

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.

M Decavèle, N Gault, T Gauss, S Pease, J D Moyer, C Paugam-Burtz, A Foucrier.

Background: The significance of cardiac troponin I (cTnI) elevation after trauma is debated. We therefore explored the association between cTnI elevation at admission after trauma and ICU mortality.

Methods: We performed a retrospective analysis from a prospectively constituted database, of patients admitted to ICU after trauma at a single centre, over a 36 month period. According to cTnI plasma concentration at admission, patients were categorised into three groups: normal (<0.05 ng ml-1), intermediate (0.05-0.99 ng ml-1), or high concentration (≥1.0 ng ml-1). Associations of pre-hospital conditions or cTnI elevation and mortality were analysed by multivariate logistic regression.

Results: Among the 994 patients, 177 (18%) had cTnI elevation at ICU admission. Of this total, 114 (11%) patients died in the ICU. The cTnI release was an independent predictor of ICU mortality with a concentration-response relationship [odds ratio (OR) 4.90 (2.19-11.16) and 14.83 (4.68-49.90) for intermediate and high concentrations, respectively] and Day 2 mortality [OR 2.23 (1.18-5.80) and 7.49 (2.77-20.12) for intermediate and high concentrations, respectively]. The severity of thoracic trauma [OR 2.25 (1.07-4.55) and 3.23 (2.00-5.27) for Abbreviated Injury Scale scores 1-2 and ≥3, respectively], out-of-hospital maximal heart rate ≥120 beats min-1 [OR 2.22 (1.32-3.69)], and out-of-hospital shock [OR 2.02 (1.20-3.38)] were independently associated with cTnI elevation.

Conclusions: Release of cTnI was an independent predictor of ICU mortality, suggesting that this biomarker can be used in daily practice for early stratification of the risk of ICU death. Thoracic trauma was strongly associated with cTnI elevation.

Keywords: prognosis; trauma; troponin.

Br J Anaesth. 2018 Jun;120(6):1158-1164. doi: 10.1016/j.bja.2018.03.010.

PMID: 29793582 DOI: 10.1016/j.bja.2018.03.010

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.

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.

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

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

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.

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, many of these studies adopt a deficit-based analysis approach and focus on dysfunctions rather than positive lessons.

In contrast, Brandrud et al. 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” 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. 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

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

Sept pour cent des décès français étaient d’origine traumatique en 2009. 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.

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. Or Lossius et al. 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 %) que dans les études conduites en France (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 données. 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.

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. 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 ou évaluer la pertinence de variables utilisées en routine (score de Glasgow, saturation en oxygène).

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. 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. Enfin, les données qu’il contient ont permis de montrer que le score de Glasgow ne pouvait se résumer à sa valeur motrice.

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.

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

LE MONDE

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

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

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.

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.

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.