Jean-Michel Yeguiayan

Decrease in the Stroke Case Fatality Rates in a French Population-Based Twenty-Year Study

Background: The aim of the study was to estimate trends in stroke case fatality in a French population-based study over the last 20 years, and to compare trends in men and women. Methods: We prospectively ascertained first-ever strokes in a well-defined population-based study, from 1985 to 2004, in Dijon (France) (150,000 inhabitants). The study was both specific and exhaustive. The follow-up made it possible to analyze case fatality, according to stroke subtypes and sex. Results: From the ascertainment of 3,691 strokes divided in 1,920 cerebral infarcts from large artery atheroma, 725 cerebral infarcts from small perforating artery atheroma, 497 cardioembolic infarcts, 134 cerebral infarcts from undetermined mechanism, 341 primary cerebral hemorrhages and 74 subarachnoïd hemorrhages, we observed a significant decrease in 28-day case fatality rates of almost 25% (p = 0.03). Case fatality rates decreased in men aged >75 years (p = 0.01) and in women aged >75 years (p = 0.02) and >65 years (p = 0.03). The magnitude of the decrease was smaller in women but not significantly so. According to stroke subtypes, case fatality rates significantly decreased for small perforating artery infarct (p = 0.04) and for primary cerebral hemorrhage (p = 0.03). In multivariate regression analyses, hemorrhagic stroke, the first period of the study (1985–1989), blood hypertension, previous myocardial infarction and age <85 years had a negative effect. Conclusion: This is the first population-based study using continuous ascertainment over a period of 20 years that has demonstrated a significant reduction in case fatality rates. We did not observe any significant differences between men and women.

Impact of emergency medical helicopter transport directly to a university hospital trauma center on mortality of severe blunt trauma patients until discharge

IntroductionThe benefits of transporting severely injured patients by helicopter remain controversial. This study aimed to analyze the impact on mortality of helicopter compared to ground transport directly from the scene to a University hospital trauma center.MethodsThe French Intensive Care Research for Severe Trauma cohort study enrolled 2,703 patients with severe blunt trauma requiring admission to University hospital intensive care units within 72 hours. Pre-hospital and hospital clinical data, including the mode of transport, (helicopter (HMICU) versus ground (GMICU), both with medical teams), were recorded. The analysis was restricted to patients admitted directly from the scene to a University hospital trauma center. The main endpoint was mortality until ICU discharge.ResultsOf the 1,958 patients analyzed, 74% were transported by GMICU, 26% by HMICU. Median injury severity score (ISS) was 26 (interquartile range (IQR) 19 to 34) for HMICU patients and 25 (IQR 18 to 34) for GMICU patients. Compared to GMICU, HMICU patients had a higher median time frame before hospital admission and were more intensively treated in the pre-hospital phase. Crude mortality until hospital discharge was the same regardless of pre-hospital mode of transport. After adjustment for initial status, the risk of death was significantly lower (odds ratio (OR): 0.68, 95% confidence interval (CI) 0.47 to 0.98, P = 0.035) for HMICU compared with GMICU. This result did not change after further adjustment for ISS and overall surgical procedures.ConclusionsThis study suggests a beneficial impact of helicopter transport on mortality in severe blunt trauma. Whether this association could be due to better management in the pre-hospital phase needs to be more thoroughly assessed.

The motor component does not convey all the mortality prediction capacity of the Glasgow Coma Scale in trauma patients

PURPOSE We tested the hypothesis that the motor component of the Glasgow Coma Scale (GCS) conveys most of the predictive information of triage scores (Triage Revised Trauma Score [T-RTS] and the Mechanism, GCS, Age, arterial Pressure score [MGAP]) in trauma patients. METHOD We conducted a multicenter prospective observational study and evaluated 1690 trauma patients in 14 centers. We compared the GCS, T-RTS, MGAP, and Trauma Related Injury Severity Score (reference standard) using the full GCS or its motor component only using logistic regression model, area under the receiver operating characteristic curve, and reclassification technique. RESULTS Although some changes were noted for the GCS itself and the Trauma Related Injury Severity Score, no significant change was observed using the motor component only for T-RTS and MGAP when considering (1) the odds ratio of variables included in the logistic model as well as their discrimination and calibration characteristics, (2) the area under the receiver operating characteristic curve (0.827 ± 0.014 vs 0.831 ± 0.014, P = .31 and 0.863 ± 0.011 vs 0.859 ± 0.012, P = .23, respectively), and (3) the reclassification technique. Although the mortality rate remained less than the predetermined threshold of 5% in the low-risk stratum, it slightly increased for MGAP (from 1.9% to 3.9%, P = .048). CONCLUSION The use of the motor component only of the GCS did not change the global performance of triage scores in trauma patients. However, because a subtle increase in mortality rate was observed in the low-risk stratum for MGAP, replacing the GCS by its motor component may not be recommended in every situation.

Psychiatric drug-induced fatal abdominal compartment syndrome.

Several drugs used in psychiatry may induce constipation, paralytic ileus, or acute megacolon (Ogilvies syndrome). We report here 2 cases of patients presenting with fatal abdominal compartment syndrome related to the absorption of antidepressants and benzodiazepines. Two patients (a 27-year-old man and a 57-year-old woman) with a previous psychiatric history and treatment with psychiatric drugs were admitted to the emergency department for coma. Both presented hypothermia; a hard, distended abdomen; and ischemia of the lower limbs. In both cases, the abdominal scan showed massive colonic dilatation without mechanical obstruction; there was even aortic compression and ischemia of the abdominal viscera. Emergency laparotomy with bowel decompression was performed in both cases, but multiple organ failure led to death in both patients. Psychiatric drugs may induce acute severe megacolon with life-threatening abdominal compartment syndrome.

Impact of diverting general practitioner's after-hour calls to emergency medical dispatch centers in patients with acute myocardial infarction.

Objective The aim of this study was to analyze the impact of diverting off-hour calls to Emergency Medical Dispatch Centers (EMDC) on time delays and revascularization procedures for patients with ST-segment elevation myocardial infarction (STEMI) in a French region. Methods A total of 3376 consecutive patients admitted for acute STEMI were included from the RICO survey (a French regional survey for acute myocardial infarction). Patients were retrospectively classified into two groups: before (2001–2004) and after EMDC (2005–2008) implementation and followed up for mortality as primary outcomes. In addition, we examined the impact of the diversion on the delay to definitive care. Results During the study, 1781 (53%) patients were evaluated before and 1595 (47%) after the EMDC implementation. Access to healthcare facilities was similar for the two groups. The rate of off-hour calls remained stable over time. The median delay from first medical intervention to hospital admission decreased from 75 to 60 min. The off-hour median interval from door to primary percutaneous coronary intervention dropped from 152 to 98 min. The multivariate analyses showed that EMDC implementing reduced preadmission delays even when adjusting for potential confounders. Moreover, EMDC implementing was associated with a fall in 30-day mortality by 60% in patients admitted during off hours and undergoing primary percutaneous coronary intervention (10 vs. 4%). Conclusion In a real world setting, improving the quality of prehospital organization was effective not only on reducing delays but also on improving access to revascularization. Our results showed the beneficial impact of EMDC implementing on management of STEMI.

Tranexamic acid for trauma

After its publication in July, 2010, the CRASH-2 study generated widespread interest in the early administration of the antifi brinolytic agent tranexamic acid to patients with traumatic bleeding. Tranexamic acid is an inexpensive, easily used, and relatively safe drug, and it seemed to have saved lives. However, how it did so was unclear—the blood-transfusion requirements of the tranexamic acid and placebo groups were similar and, survival bias notwithstanding, the mortality benefi t might have been attributable to an eff ect of tranexamic acid on something other than acute traumatic coagulopathy. This issue is partly addressed with the publication in The Lancet of a follow-up analysis that used the outcome of death due to bleeding rather than all-cause mortality. The CRASH-2 collaborators report a 32% reduction in death due to bleeding when tranexamic acid is given within 1 h of injury. Although markers of coagulopathy were not measured, the mortality benefi t is probably mediated through antifi brinolytic eff ects on clot stabilisation. While it will not prevent the massive haemorrhage from disrupted vessels or organs that needs surgical intervention, tranexamic acid appears to improve survival through its eff ect on mild to moderate bleeding. Early administration is necessary, however, and benefi t was only seen in CRASH-2 when tranexamic acid was administered within 3 h of injury. Unlike coagulopathy that is secondary to haemodilution, hypothermia, or acidosis, acute traumatic coagulopathy is a hyperacute process in which systemic fi brinolysis releases D-dimers that are detectable within 30 min of injury. While the mechanisms are poorly understood, shock and tissue injury seem to be important initiators. Not all severely injured patients develop acute coagulopathy, but those who do are much more likely to die and to die early. The earlier that tranexamic acid is administered, the more likely it might be to prevent full activation of fi brinolysis. Once fully activated, fi brinolysis has been shown to continue unabated until endogenous antifi brinolytic elements are restored. Importantly, the CRASH-2 collaborators report increased mortality due to bleeding in patients receiving tranexamic acid when it is given more than 3 h after injury. The cause of these deaths is unclear. Reports exist of prothrombotic eff ects of each of the anti-fi brinolytic drugs. Alternatively, it might refl ect some factor of the patients who received it late. Whatever the mechanism, the CRASH-2 collaborators have cautioned against the use of tranexamic acid when more than 3 h have expired after injury. Who, then, should be treated with tranexamic acid? Most of the 274 study sites in CRASH-2 were in low-income and middle-income countries, where other treatments directed at coagulopathy, such as fresh frozen plasma, platelets, and cryoprecipitate, are less available. Although many patients with acute coagulopathy will die before reaching hospital, tranexamic acid is a practical, aff ordable, and eff ective treatment for bleeding trauma patients in such centres, provided they receive it within 3 h of injury. Far less clear is the place for tranexamic acid in high income countries where massive transfusion protocols incorporate fresh-frozen plasma that contains all the endogenous antifi brinolytic elements in plasma. Plasma can cause harm as well as benefi t, and there is little prospective evidence regarding its effi cacy. However, because it is in widespread use, and because late administration of tranexamic acid can be harmful, it is unlikely that many clinicians in major trauma centres will choose tranexamic acid as fi rst-line treatment. The best place for tranexamic acid in developed trauma systems might actually be in the prehospital environment. Helicopter and road transport direct to major trauma centres has reduced overall injury mortality, but has extended the time before patients