Tobias Gauss

Evaluation of the performance of French physician-staffed emergency medical service in the triage of major trauma patients.

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], 0.03–0.22), flail chest (OR, 0.1; 95% CI, 0.01–0.03), and Glasgow Coma Scale (GCS) score of less than 13 (OR, 0.28; 95% CI, 0.17–0.45), whereas global assessments of speed and mechanism alone were poor predictors (positive likelihood ratio, 0.92–1.4). 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.

Feasibility of cardiac output estimation by ultrasonic cardiac output monitoring in the prehospital setting.

The possible benefits of ultrasonic cardiac output monitoring (USCOM) in emergency medicine practice could be significant if evaluated in a goal-directed protocol. The aim of this study was to perform a feasibility study in a physician-staffed prehospital emergency medicine system. This study enrolled a convenient sample of 50 patients with circulatory distress. Main criteria were visualization of acceptable curves and obtaining interpretable values. Acceptable curves and interpretable values (main criterion) were obtained for 35 patients (70%). In case of failure, the patient was very often dyspneic (80 vs. 23%, when the technique was successful, P<0.001). Mean duration of USCOM examination was 105±60 s. The acceptable success rate for a new technique we observed and the high easy-to-use score suggests that the use of USCOM is feasible in prehospital emergency medicine.

Comparison of central and mixed venous saturation during liver transplantation in cirrhotic patients: a pilot study.

Background and objective Liver transplantation is associated with important haemodynamic variations requiring cardiac output and oximetric data monitoring. The mixed venous saturation (SvO2) integrates parameters combining information about oxygen consumption, cardiac output and haemoglobin concentration. Central venous saturation (ScvO2) can be directly measured from blood drawn in the superior venous system via a central venous catheter. ScvO2 has been proposed as an alternative to SvO2 for intraoperative haemodynamic monitoring. The aim of the present study was to examine the level of agreement between SvO2 and ScvO2 during the preanhepatic and the neohepatic stage of liver transplantation in cirrhotic patients. Materials and methods After agreement from the regulatory authorities for medical research and having obtained informed consent, 30 patients with cirrhosis undergoing liver transplantation were prospectively included. Blood gas samples were simultaneously drawn from the arterial line, the right atrium port and the pulmonary artery port of the catheter: during the preanhepatic stage (two times) and two times 30–40 min after graft revascularization. Arterial saturation (SaO2), haemoglobin concentration, cardiac index, SvO2, ScvO2 and oxygen consumption, delivery and extraction (VO2, DO2 and EO2, respectively) were measured. A Bland–Altman test was used to determine bias and limits of agreement between SvO2 and ScvO2. Both parameters were considered to be equivalent if limits of agreement were within ±5%. Results Bland–Altman analysis revealed a bias (limit of agreement) of −1.2% (−9.1 to 6.6%), −0.3% (−4.8 to 4%) and −2.1% (−12 to 7.8%) for the overall measurements and preanhepatic and postgraft reperfusion measurements, respectively. SvO2 decreased significantly between hepatectomy and reperfusion, whereas cardiac index, VO2, DO2 and EO2 showed significantly higher values after reperfusion. ScvO2 and SaO2 levels did not display different values between the two periods. Discussion Measurements of SvO2 and ScvO2 showed a good level of agreement during the preanhepatic stage, whereas the level of agreement was low after liver graft reperfusion. The increase of VO2 associated with the decrease of SvO2 and the stability of ScvO2 between the two periods suggest an incomplete mixing of splanchnic venous blood into the right atrium. In addition, our samples were taken from the right atrium, which is not possible using a conventional central venous catheter, as the tip must lie in the superior vena cava and not in the right atrium. ScvO2 cannot be considered equivalent to SvO2 for the haemodynamic monitoring of patients with cirrhosis undergoing liver transplantation.

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.

Long-term prognosis after out-of-hospital resuscitation of cardiac arrest in trauma patients: prehospital trauma-associated cardiac arrest

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.

Comparison of the Prognostic Significance of Initial Blood Lactate and Base Deficit in Trauma Patients.

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 (R2 = 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.

Fibrinogen on Admission in Trauma score: Early prediction of low plasma fibrinogen concentrations in trauma patients

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−1 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−1 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−1, free intraabdominal fluid on sonography, decrease in haemoglobin concentration from prehospital to admission of more than 2 g dl−1, capillary haemoglobin concentration on admission less than 12 g dl−1 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−1 or less on admission in trauma patients. This easy-to-use score could allow early, goal-directed therapy to trauma patients.

In-Flight Evaluation and Management of Cardiac Illness

Cardiac diseases represent the most frequent in-flight emergencies (almost 50% of cases) and the overwhelming majority of diversions. In-flight cardiac arrest is fortunately quite rare (0.3% of in-flight emergencies) but is responsible for 86% of in-flight events resulting in death. The introduction of automated external defibrillators (AED) on-board definitely changed the management of this condition. Diversion should be promptly considered if CPR is attempted. Acute coronary syndromes are a medical challenge without the help of the ECG nor biomarkers. In cases of likely acute coronary syndrome in an ill-appearing patient or in patients presenting with unstable features (deranged vital signs/clinical signs of cardiac failure), the captain should be advised to divert immediately. Syncope and pre-syncope are the most frequent condition occurring aboard commercial flights. The challenge is to made the distinction between vagal faintness and true intravascular volume depletion. In the case of rapid resolution of symptoms in a previously health person, it is reasonable to advise against diversion. Conversely, persistent symptoms, significant pre-existing conditions, or the presence of cardiac risk factors plead for diversion. Correctly diagnosing acute decompensated heart failure is a clinical challenge for physicians regardless of setting. The principal measure to set up urgently is the administration of supplemental oxygen. Diversion for ground based rescue should be advised in most suspected cases of decompensated heart failure as therapeutic options on-board are very limited.

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.

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.