Philippe Declety

Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures.

OBJECTIVE The purpose of this study was to describe a blinded intra-aortic balloon occlusion (IABO) procedure in pelvic fractures (PF) for patients with critically uncontrollable hemorrhagic shock (CUHS). METHODS Of 2,064 patients treated for PF, 13 underwent IABO during initial resuscitation to control massive pelvic bleeding leading to CUHS. Our IABO procedure consists of internal aortic occlusion without fluoroscopy, using a latex balloon inflated in the infrarenal aorta. Retrospectively collected data included demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiologic parameters, and survival. RESULTS All balloons were successfully placed, and a significant increase in systolic blood pressure (70 mm Hg, p = 0.001) was observed immediately after IABO. Twelve of 13 patients became transferrable. Angiography performed after IABO was positive for arterial injury in 92% of patients, and 9 patients benefitted from arterial embolization. Survival rate was 46% (6 of 13) and was inversely related to the length of inflation (p = 0.026) and the mean Injury Severity Score (p = 0.011). CONCLUSION This IABO procedure can be life saving in the management of patients with CUHS from PF, permitting transport to angiography. However, the decision for such treatment must be as quickly as possible after trauma to reduce the time of occlusion.

Transcranial Doppler to screen on admission patients with mild to moderate traumatic brain injury.

BACKGROUND:Detecting patients at risk for secondary neurological deterioration (SND) after mild to moderate traumatic brain injury is challenging. OBJECTIVE:To assess the diagnostic accuracy of transcranial Doppler (TCD) on admission in screening these patients. METHODS:This prospective, observational cohort study enrolled 98 traumatic brain injury patients with an initial Glasgow Coma Scale score of 9 to 15 whose initial computed tomography (CT) scan showed either absent or mild lesions according to the Trauma Coma Data Bank (TCDB) classification, ie, TCDB I and TCDB II, respectively. TCD measurements of the 2 middle cerebral arteries were obtained on admission under stable conditions in all patients. Neurological outcome was reassessed on day 7. RESULTS:Of the 98 patients, 21 showed SND, ie, a decrease of ≥ 2 points from the initial Glasgow Coma Scale or requiring any treatment for neurological deterioration. Diastolic cerebral blood flow velocities and pulsatility index measurements were different between patients with SND and patients with no SND. Using receiver-operating characteristic analysis, we found the best threshold limits to be 25 cm/s (sensitivity, 92%; specificity, 76%; area under curve, 0.93) for diastolic cerebral blood flow velocity and 1.25 (sensitivity, 90%; specificity, 91%; area under curve, 0.95) for pulsatility index. According to a recursive-partitioning analysis, TCDB classification and TCD measurements were the most discriminative among variables to detect patients at risk for SND. CONCLUSION:In patients with no severe brain lesions on CT after mild to moderate traumatic brain injury, TCD on admission, in complement with brain CT scan, could accurately screen patients at risk for SND.

A major trauma course based on posters, audio-guides and simulation improves the management skills of medical students: Evaluation via medical simulator

BACKGROUND Medical competence requires the acquisition of theoretical knowledge and technical skills. Severe trauma management teaching is poorly developed during internship. Nevertheless, the basics of major trauma management should be acquired by every future physician. For this reason, the major trauma course (MTC), an educational course in major traumatology, has been developed for medical students. Our objective was to evaluate, via a high fidelity medical simulator, the impact of the MTC on medical student skills concerning major trauma management. METHODS The MTC contains 3 teaching modalities: posters with associated audio-guides, a procedural workshop on airway management and a teaching session using a medical simulator. Skills evaluation was performed 1 month before (step 1) and 1 month after (step 3) the MTC (step 2). Nineteen students were individually evaluated on 2 different major trauma scenarios. The primary endpoint was the difference between steps 1 and 3, in a combined score evaluating: admission, equipment, monitoring and safety (skill set 1) and systematic clinical examinations (skill set 2). RESULTS After the course, the combined primary outcome score improved by 47% (P<0.01). Scenario choice or the order of use had no significant influence on the skill set evaluations. CONCLUSION This study shows improvement in student skills for major trauma management, which we attribute mainly to the major trauma course developed in our institution.