Arnaud Follin

Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience.

AIM Neuroprotective effects of hypothermia may explain surprisingly high survival rates reported after drowning in cold water despite prolonged submersion. We described a cohort of refractory hypothermic cardiac arrests (CA) due to drowning treated by extracorporeal life support (ECLS) and aimed to identify criteria associated with 24-h survival. METHODS Eleven-year period (2002-2012) retrospective study in the surgical intensive care unit (ICU) of a tertiary hospital (European Hospital Georges Pompidou, Paris, France). All consecutive hypothermic patients admitted for refractory CA after drowning in the Seine River were included. Patients with core temperature below 30°C and submersion duration of less than 1h were potentially eligible for ECLS resuscitation. RESULTS Forty-three patients were admitted directly to the ICU during the study period. ECLS was initiated in 20 patients (47%). Among these 20 patients, only four (9%) survived more than 24h. A first hospital core temperature ≤26°C and a potassium serum level between 4.2 and 6mM at hospital admission have a sensitivity of 100% [95%CI: 28-100%] and a specificity of 100% [95%CI: 71-100%] to discriminate patients who survived more than 24h. Overall survival at ICU discharge and at 6-months was 5% [95%CI: 1-16%] (two patients). CONCLUSIONS Despite patient hypothermia and aggressive resuscitation with ECLS, the observed survival rate is low in the present cohort. Like existing algorithms for ECLS management in avalanche victims, we recommend to use first core temperature and potassium serum level to indicate ECLS for refractory CA due to drowning.

Paris terrorist attack: Early lessons from the intensivists

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.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.

Tree-based algorithm for prehospital triage of polytrauma patients

BACKGROUND There is a need for better allocation of medical resources in polytrauma, by optimizing both the over and undertriage rates. The goal of this study is to provide a new working definition for polytrauma based on the prediction of the need for specialized trauma care. METHODS This is a prospective, observational study, performed in a specialized trauma center in Paris. All consecutive patients admitted for a trauma at a major trauma center in Paris were included in the study. The primary outcome was the need for specialized trauma care as defined by the North American consensus. The explanatory variables included basic variables collected on scene. The modeling approach relied on recursive partitioning based decision trees. Its prediction performance was evaluated both internally and externally on a validation cohort, and compared to the MGAP (Mechanism, Glasgow coma scale, Age and Arterial pressure) score. MEASUREMENTS AND MAIN RESULTS 1160 patients were included in the analysis over a 3-year period (2012-2014), out of which 41% needed specialized trauma care as defined by the recent US guidelines. The decision tree outperformed the MGAP and reached an area under the receiver operating characteristic curve of 0.82 [0.79-0.84]. This optimal decision rule was associated with a sensitivity of 0.94 [0.92-0.96], a specificity of 0.48 [0.44-0.52]. A conservative decision rule (refer to a trauma center all patient with a predicted probability ≥0.34) would result in an undertriage rate of 5.7% and an overtriage of 52.3% (respectively 7% and 64% in the validation cohort). CONCLUSIONS Our tree-based decision algorithm is a user-friendly and reliable alternative to the preexisting scores, which offers good performance to predict the need for specialized trauma care.

Veno-Arterial-ECMO in the Intensive Care Unit:From Technical Aspects to Clinical Practice

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a salvage therapy in cardiogenic shock is becoming of current practice. While VA-ECMO is potentially a life-saving technique, results are sometimes mitigated, emphasising the need for selecting the right indication in the right patient. This relies upon a clear definition of the individual therapeutic project, including the potential for recovery as well as the possible complications associated with VA-ECMO. To maximise the benefits of VA-ECMO, the basics of extracorporeal circulation should be perfectly understood since VA-ECMO can sometimes be detrimental. Hence, to be successful, VA-ECMO should be used by teams with sufficient experience and initiated after a thorough multidisciplinary discussion considering patients medical history, pathology as well the anticipated evolution of the disease.

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

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.