Fabrice Cook

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.

From the Skin to the Brain: Pathophysiology of Colonization and Infection of External Ventricular Drain, a Prospective Observational Study.

Ventriculostomy-related infection (VRI) is a serious complication of external ventricular drain (EVD) but its natural history is poorly studied. We prospectively tracked the bacteria pathways from skin towards ventricles to identify the infectious process resulting in ventriculostomy-related colonization (VRC), and VRI. We systematically sampled cerebrospinal fluid (CSF) on a daily basis and collected swabs from both the skin and stopcock every 3.0 days for microbiological analysis including in 101 neurosurgical patient. Risk factors for positive event defined as either VRC or VRI were recorded and related to our microbiological findings. A total of 1261 CSF samples, 473 skin swabs, and 450 stopcock swabs were collected. Skin site was more frequently colonized than stopcock (70 (60%) vs 34 (29%), p = 0.023), and earlier (14 ±1.4 vs 24 ±1.5 days, p<0.0001). Sixty-one (52%) and 32 (27%) skin and stopcock sites were colonized with commensal bacteria, 1 (1%) and 1 (1%) with pathogens, 8 (7%) and 1 (1%) with combined pathogens and commensal bacteria, respectively. Sixteen positive events were diagnosed; a cutaneous origin was identified in 69% of cases. The presence of a pathogen at skin site (6/16 vs 4/85, OR: 11.8, [2.5–56.8], p = 0.002) and CSF leakage (7/16 vs 6/85, OR 10 [2.4–41.2], p = 0.001)) were the two independent significant risk factors statistically linked to positive events occurrence. Our results suggest that VRC and VRI mainly results from an extra-luminal progression of pathogens initially colonizing the skin site where CSF leaks.

Biofilm-associated infection: the hidden face of cerebrospinal fluid shunt malfunction

Diagnosis of cerebrospinal fluid (CSF) shunt infection is difficult. Growing evidence links this pattern to biofilm-associated infections (BAI). Biofilm may explain the indolent development of the infection, and the poor efficiency of traditional microbiologic methods. We report the case of a patient admitted for hydrocephalus associated to CSF shunt malfunction. None of the clinical, serum, or CSF laboratory findings were in favor of an infectious process. Only scanning electron microscopy (SEM) revealed the presence of biofilm. Hence, despite a broad CSF shunt infection definition, some infections could remain undiagnosed by the traditional approach. This study is the first to provide some direct evidence for bacterial biofilm-associated CSF shunt infection.

Iliac crest bone harvest : Should we really use continuous infusion of ropivacaine?

To the Editor:— We read with interest the study by Scavone et al. that demonstrates the absence of efficacy of a prophylactic epidural blood patch after inadvertent dural puncture. We suggest that two factors could have influenced the negative result of this trial. First, inadvertent dural puncture could have been overdiagnosed, namely when loss of resistance to saline was used to locate epidural space. This could explain the lower incidence of post–dural puncture headache and less frequent realization of therapeutic epidural blood patch reported in this study compared with others. Second, 20 ml may not be the adequate blood volume to test a prophylactic epidural blood patch. This volume has tended to increase over time to 20 ml or more, 23 5 ml in a study by Safat-Tisseront et al. The optimal blood volume may be the volume at which pain in the back, buttocks, or legs occurs, which was only achieved for seven patients in the study of Scavone et al. This higher volume may lead to either a larger patch over the dural tear or a significantly higher increase in lumbar and intracranial pressure, leading to reduced cerebral vasodilation. Olivier Pruszkowski, M.D.,* Orlando Goncalves, M.D., Claude Lentschener, M.D., Alexandre Mignon, M.D., Ph.D. *Hôpital Cochin Maternité Port-Royal, Assistance Publique–Hôpitaux de Paris, Paris, France. olivier.prus@club-internet.fr

Multidrug resistant Acinetobacter baumannii ventriculostomy-related infection, treated by a Colistin, Tigecycline and intraventricular fibrinolysis

BACKGROUND Acinetobacter baumannii meningitis and ventriculitis are difficult issues, because of the low diffusion of antibiotics in the cerebrospinal fluid and bacterial multidrug resistance. The presence of an infected intraventricular hematoma, constituting an equivalent of undrained abscess, may promote biofilm formation and failure of medical treatment. CASE DESCRIPTION In this case of ventriculostomy-related infection after ventricular hemorrhage, Acinetobacter baumannii was sensitive only to colistin and tigecycline. Despite a combination therapy involving intraventricular injections of colistin, we observed clinical and bacteriologic failure. Therefore, at day 4 of antibiotic therapy, we performed intraventricular fibrinolysis, which dissolved the clot, enabling sterilization of the cerebrospinal fluid after 48 hours. CONCLUSION This clinical case suggests the usefulness of intraventricular fibrinolysis to lyse the clot and optimize the action of antibiotics.

Strategic proposal for a national trauma system in France

In this road map for trauma in France, we focus on the main challenges for system implementation, surgical and radiology training and upon innovative training techniques. Regarding system organisation: procedures for triage, designation and certification of trauma centres are mandatory to implement trauma networks on a national scale. Data collection with registries must be created, with a core dataset defined and applied through all registries. Regarding surgical and radiology training, diagnostic-imaging processes should be standardised and the role of the interventional radiologist within the trauma team and the trauma network should be clearly defined. Education in surgery for trauma is crucial and recent changes in medical training in France will promote trauma surgery as a specific sub-specialty. Innovative training techniques should be implemented and be based on common objectives, scenarios and evaluation, so as to improve individual and team performances. The group formulated 14 proposals that should help to structure and improve major trauma management in France over the next 10 years.

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia

Object We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. Methods We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. Results Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21–64]) with severe trauma (initial Simplified Acute Score II = 42 [32–52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient’s characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. Conclusions Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults.

An unusual cause of cruralgia

A 66-year-old patient was referred to the pain management center for worsening cruralgia associated with vomiting, evolving for several weeks. Medical history consisted of endovascular aneurysm repair of a juxtarenal aortic aneurysm 3 years before, with uneventful follow-up. He recently received a spinal infiltration of corticosteroids to treat his pelvic pain. Five days later, he presented to our emergency department with pain exacerbation, fever, and hypotension associated with vomiting. The patient provided written consent for this report. Abdominal pelvic computed tomography revealed a periprosthetic abscess and abscesses of both psoas muscles with many gas bubbles (A and B). The patient underwent urgent open abdominal surgery, which confirmed that aortic endograft infection extended to both psoas muscles. The infected endograft was replaced by cryopreserved allograft. Streptococcus anginosus was identified on surgical bacteriologic samples and blood cultures. The patient was discharged from the intensive care unit 2 weeks later. Although endograft infection is a rare complication (0.2%-5%), morbidity and mortality remain high (13%-58%). In addition, because of both the low incidence and a majority of indolent clinical presentations, diagnosis may be delayed, resulting in torpid septic syndromes associated with systemic complications. Early computed tomography scanning should be undertaken in the case of atypical abdominal pelvic symptoms in a patient treated by endovascular aneurysm repair.

Late diagnosis of post-traumatic ruptured pericardium with cardiac herniation

A 52-yr-old woman was found wandering in the lobby of a hotel with an apparently isolated head trauma. Because of rapid deterioration of her neurologic status (Glasgow Coma Scale, 4; unilateral dilated pupil), the patient was intubated, sedated, and transferred to our trauma centre. Computed tomography (CT) examination of her head revealed an isolated acute subdural hematoma. Urgent surgical evacuation was performed uneventfully. Clinical examination revealed no other obvious traumatic lesions though chest radiography showed a small, left-sided pleural effusion. On postoperative day 2, the patient exhibited complete neurologic recovery and was weaned from mechanical ventilation. No arrhythmia, hemodynamic, or respiratory compromise was noted, although diffusely inverted T waves subsequently became apparent on the bedside cardiac monitor and were confirmed by 12-lead electrocardiography. The inverted T waves prompted performance of a high sensitivity troponin T assay which was significantly elevated (1807 ng L; normal \ 14 ng L). Post-extubation chest radiography showed new left apical pneumothorax and leftward shift of the cardiac silhouette (panel A). Chest CT examination showed left hemopneumothorax, left lung consolidation, and deviation of the heart into the left hemithorax with clockwise rotation of the cardiac apex (panel B). As rupture of the pericardium with cardiac herniation was suspected, she underwent sternotomy, which confirming a vertical pericardial tear extending from the left pulmonary hilum to the left hemi-diaphragm. The heart was relocated and the pericardium repaired. The patient was discharged from the intensive care unit on postoperative day 6. Subsequent investigation by the police revealed that the patient had indeed fallen from the third floor of the hotel but had stood up and walked into the hotel lobby before being discovered. The patient had no recollection of the event. Traumatic rupture of the pericardium is a difficult diagnosis because pericardial defects, even with cardiac herniation, are not always associated with clinical symptoms. Radiologic investigations (including CT scans) in the absence of cardiac herniation are most often not specific enough to confirm the diagnosis. In our patient, the diagnosis was likely further delayed because of the positive-pressure mechanical ventilation, which F. Cook, MD R. Mounier, MD M. Martin, MD (&) G. Dhonneur, MD, PhD Surgical Intensive Care Unit – Trauma Center, Department of Anaesthesiology and Critical Care Medicine, Henri Mondor University Hospital of Paris (APHP), Créteil, France e-mail: mathieu.martin@hmn.aphp.fr

Keep calm… and prepare

On 22 July 2011, a terrible attack by a lone shooter on the Norwegian island of Utoya cost 77 young lives, injured 78 and changed the lives of hundreds forever within 73 min. In the current international context of increased threat, sharing experience about disaster response is crucial. With some exceptions,1–3 many of these studies adopt a deficit-based analysis approach and focus on dysfunctions rather than positive lessons. In contrast, Brandrud et al 4 adopted an original approach. The group used the conclusions of two official and independent commissions as starting point, namely that the medical response to the incident was particularly well managed. This enabled a ‘ positive deviance’ 5 6 analysis to draw important lessons from this incident. The authors attempted to gather crucial insights with the help of detailed group interviews and expert review: How did a rural district hospital, Ringerike , that is not a level-1 trauma centre manage a major disaster effectively, despite the fact that its resources were exhausted 40 min 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 by the study are …