Isolated basilar artery dissection following blunt trauma challenging the Glasgow coma score: A case report.

Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14 year old male fell 10 m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported. Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded.

Cardiac troponin I as an early prognosis biomarker after trauma: a retrospective cohort study.

BACKGROUND: The significance of cardiac troponin I (cTnI) elevation after trauma is debated. We therefore explored the association between cTnI elevation at admission after trauma and ICU mortality. METHODS: We performed a retrospective analysis from a prospectively constituted database, of patients admitted to ICU after trauma at a single centre, over a 36 month period. According to cTnI plasma concentration at admission, patients were categorised into three groups: normal (<0.05 ng ml-1), intermediate (0.05-0.99 ng ml-1), or high concentration (≥1.0 ng ml-1). Associations of pre-hospital conditions or cTnI elevation and mortality were analysed by multivariate logistic regression. RESULTS: Among the 994 patients, 177 (18%) had cTnI elevation at ICU admission. Of this total, 114 (11%) patients died in the ICU. The cTnI release was an independent predictor of ICU mortality with a concentration-response relationship [odds ratio (OR) 4.90 (2.19-11.16) and 14.83 (4.68-49.90) for intermediate and high concentrations, respectively] and Day 2 mortality [OR 2.23 (1.18-5.80) and 7.49 (2.77-20.12) for intermediate and high concentrations, respectively]. The severity of thoracic trauma [OR 2.25 (1.07-4.55) and 3.23 (2.00-5.27) for Abbreviated Injury Scale scores 1-2 and ≥3, respectively], out-of-hospital maximal heart rate ≥120 beats min-1 [OR 2.22 (1.32-3.69)], and out-of-hospital shock [OR 2.02 (1.20-3.38)] were independently associated with cTnI elevation. CONCLUSIONS: Release of cTnI was an independent predictor of ICU mortality, suggesting that this biomarker can be used in daily practice for early stratification of the risk of ICU death. Thoracic trauma was strongly associated with cTnI elevation.

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.

[Medical information system (PMSI) does not adequately identify severe trauma]. / La codification PMSI identifie mal les traumatismes graves.

BACKGROUND: Resource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims. METHODS: We studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient. RESULTS: During the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %). CONCLUSION: DCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding.

Limits of agreement between measures obtained from standard laboratory and the point-of-care device Hemochron Signature Elite(R) during acute haemorrhage.

BACKGROUND: Rapid diagnosis of coagulopathy in the bleeding patient using point-of-care (POC) devices would be ideal. The Hemochron Signature Elite(®) (HC(®)) is a POC device that determines international normalized ratio (INR) and activated partial thromboplastin time (aPTT). The aim of the study was to evaluate the agreement for INR and aPTT between the HC(®) and standard laboratory values in acute haemorrhage. METHODS: This was a single-centre observational prospective study including patients with acute haemorrhage. Laboratory INR and aPTT were compared with simultaneous measurements performed with the HC(®). The diagnostic performance of HC(®) was determined; bias and limits of agreement were calculated according to the method of Bland and Altman. RESULTS: Seventy-two pairs of measurements from 39 patients were analysed. The bias between the INR-HC(®) and aPTT-HC(®) measurements and the central laboratory were 0.02 and -1.13, respectively. The Spearman's correlation coefficients for the INR-HC(®)/INR-lab and the aPTT-HC(®)/aPTT-lab were 0.68 and -0.29, respectively. Twenty-seven per cent of INR-HC(®) values and 89% of the aPTT-HC(®) values exceeded the predefined limits of agreement. The INR-HC(®) measurement identified patients with a central laboratory INR >1.5 with a sensitivity, specificity, and positive and negative predictive values of 83%, 70%, 76%, and 77%, respectively. CONCLUSIONS: The results showed a lack of agreement between the INR-HC(®) and the aPTT-HC(®) measurements and the standard laboratory in the context of acute haemorrhage. The INR-HC(®) showed moderate performance as a decision-making tool to detect coagulopathy in the context of acute haemorrhage.

Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery.

BACKGROUND: Perioperative coordination facilitates team communication and planning. The aim of this study was to determine how often deviation from predicted surgical conditions and a pre-established anaesthetic care plan in major abdominal surgery occurred, and whether this was associated with an increase in adverse clinical events. METHODS: In this prospective observational study, weekly preoperative interdisciplinary team meetings were conducted according to a joint care plan checklist in a tertiary care centre in France. Any discordance with preoperative predictions and deviation from the care plan were noted. A link to the incidence of predetermined adverse intraoperative events was investigated. RESULTS: Intraoperative adverse clinical events (ACEs) occurred in 15 % of all cases and were associated with postoperative complications [relative risk (RR) = 1.5; 95 % confidence interval (1.1; 2.2)]. Quality of prediction of surgical procedural items was modest, with one in five to six items not correctly predicted. Discordant surgical prediction was associated with an increased incidence of ACE. Deviation from the anaesthetic care plan occurred in around 13 %, which was more frequent when surgical prediction was inaccurate (RR > 3) and independently associated with ACE (odds ratio 6). CONCLUSION: Surgery was more difficult than expected in up to one out of five cases. In a similar proportion, disagreement between preoperative care plans and observed clinical management was independently associated with an increased risk of adverse clinical events.

French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury.

OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

Can we refine the management of blunt liver trauma?

AIM: To describe the management of blunt liver injury and to study the potential relation between delayed complications, type of trauma mechanisms and liver lesions. PATIENTS AND METHODS: This is a retrospective single center study including 116 consecutive patients admitted with blunt liver injury between 2007 and 2015. RESULTS: Initial CT-scan identified an active bleeding in 33 (28%) patients. AAST (American Association for the Surgery of Trauma) grade was 1 to 3 in 82 (71%) patients and equal to 5 in 15 (13%) patients. Eighty (69%) patients had NOM, with a success rate of 96%. Other abdominal organ lesions were associated to invasive initial management. A follow-up CT-scan was useful to detect hepatic and extra-hepatic complications (46 complications in 80 patients), even without clinical or biological abnormalities. Subsequent hepatic complications such as bleeding, pseudo aneurysms, biloma and biliary peritonitis developed in 15 patients and were associated with the severity of blunt liver injury according to AAST classification (3.7±1.0 vs. 3.0±1.1, P=0.010). Total biliary complications occurred in 13 patients and were significantly more frequently observed in patients with injury of central segments 1, 4 and 9 (69% vs. 36%, P=0.033). CONCLUSIONS: Non-operative management is possible in most blunt liver injury with a success rate of 96%. A systematic CT-scan should be advocated during follow-up, especially when AAST grade is equal or superior to 3. Biliary complications should be suspected when lesions involve segments 1, 4 and 9.

How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study.

BACKGROUND: The diagnostic value of hemoglobin (Hb) for detecting a significant hemorrhage (SH) in the early phase of trauma remains controversial. The present study aimed to assess the abilities of Hb measurements taken at different times throughout trauma management to identify patients with SH. METHODS: All consecutive adult trauma patients directly admitted to six French level-1 trauma centers with at least one prehospital Hb measurement were analyzed. The abilities of the following variables to identify SH (≥ 4 units of red blood cells in the first 6 h and/or death related to uncontrolled bleeding within 24 h) were determined and compared to that of shock index (SI): Hb as measured with a point-of-care (POC) device by the prehospital team on scene (POC-Hbprehosp) and upon patient's admission to the hospital (POC-Hbhosp), the difference between POC-Hbhosp and POC-Hbprehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Labhosp). RESULTS: A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hbprehosp significantly predicted SH with an area under ROC curve (AUC) of 0.72 and best cutoff values of 12 g/dl for women and 13 g/dl for men. POC-Hbprehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hbhosp and Hb-Labhosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hbhosp were 10 g/dl for women and 12 g/dl for men. DeltaPOC-Hb also predicted SH with an AUC of 0.77, a best cutoff value of - 2 g/dl irrespective of the gender. For a same prehospital fluid volume infused, DeltaPOC-Hb was significantly larger in patients with significant hemorrhage than in controls. CONCLUSIONS: Challenging the classical idea that early Hb measurement is not meaningful in predicting SH, POC-Hbprehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hbhosp had a greater ability to predict SH when compared to shock index. For a given prehospital fluid volume infused, the magnitude of the Hb drop was significantly higher in patients with significant hemorrhage than in controls.

Femoral arterial and central venous catheters in the trauma resuscitation room.

BACKGROUND: Arterial and central venous femoral catheters (fAC-CVC) use during the initial management of severe trauma patients is not a standard technique in most trauma centers. Arguments in favor of their use are: continuous monitoring of blood pressure, safe drug administration, easy blood sampling and potentially large bore venous access. The lack of evidence makes the practice heterogeneous. The aim of the present study was to describe the use and complications of fAC-CVC in the trauma bay in two centers where they are routinely used. METHODS: This was a retrospective analysis of routine fAC-CVC use from two French trauma centers. All patients admitted directly to the trauma resuscitation room were included. Demographic, clinical and biological data were collected from the scene to discharge to describe the use of catheters during initial trauma management including infectious, mechanical and thrombotic complications. RESULTS: 243 pairs of femoral catheters were inserted among 692 patients admitted in both trauma centers. Femoral AC-CVC use was more frequent in critically ill patients with higher ISS 26 [17; 41] vs 13 [8; 24], p < 0.001(median [quartile 1-3]), severe traumatic brain injury (AIS head 1[0-4] vs 0[0-3], p < 0.001), lower systolic blood pressure, 92 (37) vs 113 (28) mmHg, p < 0.001 mean (standard deviation), lower haemoglobin on arrival, 10.9 (3) vs 13.3 (2.1) g/dL (p < 0.001), and higher blood lactate concentration, 4.0 (3.9) vs 2.1 (1.8) mmol/L (p < 0.001). In patients with fAC-CVC use time in the trauma room was longer, 46 [40;60] vs 30 [20;40] minutes (p < 0.05). In total 52 colonizations and 3 bloodstream infections were noted in 1000 catheter days. An incidence of 12% of mechanical complications and of 42% deep venous thromboses were observed. Of the latter none was associated with confirmed pulmonary embolism. CONCLUSION: Femoral AC-CVC appeared to be deployed more often in critically ill patients, presenting with shock and/or traumatic brain injury in particular. The observed rate of complications in this sample seems to be low compared to reported rates.