Prehospital parameters can help to predict coagulopathy and massive transfusion in trauma patients.

BACKGROUND: This study aimed to evaluate the accuracy of prehospital parameters, including vital signs and resuscitation (fluids, vasopressor), to predict trauma-induced coagulopathy (TIC, fibrinogen <1·5 g/l or PTratio > 1·5 or platelet count <100 × 109 /l), and a massive transfusion (MT, ≥10 RBC units within the first 24 h). METHODS: From a trauma registry (2011-2015), in which patients are prospectively included, we retrospectively retrieved the heart rate (HR), systolic blood pressure (SBP), volume of prehospital fluids and administration of noradrenaline. We calculated the shock index (SI: HR/SBP), the MGAP prehospital triage score and the Injury Severity Score (ISS). We also identified patients who had positive criteria from the Resuscitation Outcome Consortium (ROC, SBP < 70 mmHg or SBP 70-90 and HR > 107 pulse/min). For these parameters, we drew a ROC curve and defined a cut-off value to predict TIC or MT. The strength of association between prehospital parameters and TIC as well as MT was assessed using logistic regression, and cut-off values were determined using ROC curves. RESULTS: Among the 485 patients included in the study, TIC was observed in 112 patients (23%) and MT in 22 patients (5%). For the prediction of TIC, ISS had good accuracy (AUC: 0·844, 95% confidence interval, CI: 0·799-0·879), as did the volume of fluids (>1000 ml) given during prehospital care (AUC: 0·801, 95% CI: 0·752-0·842). For the prediction of MT, ISS had excellent accuracy (AUC: 0·932, 95% CI: 0·866-0·966), whereas good accuracy was found for SI (> 0·9; AUC: 0·859, 95% CI: 0·705-0·936), vasopressor administration (AUC: 0·828, 95% CI: 0·736-0·890) and fluids (>1000 ml; AUC: 0·811, 95% CI: 0·737-0·867). Vasopressor administration, ISS and SI were independent predictors of TIC and MT, whereas fluid volume and ROC criteria were independent predictor of TIC but not MT. No independent relationship was found between MGAP and TIC or MT. CONCLUSIONS: Prehospital parameters including the SI and resuscitation may help to better identify the severity of bleeding in trauma patients and the need for blood product administration at admission.

[Original vacuum dressing for the treatment of open femur fracture with gangrene immobilized by external fixation]. / Pansement aspiratif pour gangrène sur fracture ouverte du fémur immobilisée par fixateur externe.

We report a case of gangrene, which developed following an open fracture of the femur immobilized with an external fixator in a 45-year-old patient. A conventional vacuum dressing (VAC Therapy) could not be applied with the external fixator in place. An original vacuum dressing was thus fashioned after surgical debridement. Scabs were covered with calcium alginate. The lower limb was enveloped in sterile dressings and vacuum was achieved by suction with gastric tubes under adhesive films. The dressing was redone every 48 h in a surgical setting. Antibiotic prophylaxis enabled cure of the infection. Budding appeared within two weeks enabling skin grafting. Centro-medullary nailing was undertaken on day 30 to accelerate bone healing. At three months from the trauma, the initial loss of sensitivity in the leg and foot noted at the first weight bearing required programmed disarticulation of the knee after femur and wound healing. At six months, the patient had resumed his occupational activities and was pain free. This type of dressing could be useful for tissue loss over a fracture immobilized with an external fixator. This type of assembly can easily be installed in the operating room.

Wound ballistics and blast injuries.

Wounds due to gunshot and explosions, while usually observed during battlefield combat, are no longer an exceptional occurrence in civilian practice in France. The principles of wound ballistics are based on the interaction between the projectile and the human body as well as the transfer of energy from the projectile to tissues. The treatment of ballistic wounds relies on several principles: extremity wound debridement and absence of initial closure, complementary medical treatment, routine immobilization, revision surgery and secondary closure. Victims of explosions usually present with a complex clinical picture since injuries are directly or indirectly related to the shock wave (blast) originating from the explosion. These injuries depend on the type of explosive device, the environment and the situation of the victim at the time of the explosion, and are classed as primary, secondary, tertiary or quaternary. Secondary injuries due to flying debris and bomb fragments are generally the predominant presenting symptoms while isolated primary injuries (blast) are rare. The resulting complexity of the clinical picture explains why triage of these victims is particularly difficult. Certain myths, such as inevitable necrosis of the soft tissues that are displaced by the formation of the temporary cavitation by the projectile, or sterilization of the wounds by heat generated by the projectile should be forgotten. Ballistic-protective body armor and helmets are not infallible, even when they are not perforated, and can even be at the origin of injuries, either due to missile impact, or to the blast.

Abbreviated laparotomy or damage control laparotomy: Why, when and how to do it?

The goal of abbreviated laparotomy is to treat severely injured patients whose condition requires an immediate surgical operation but for whom a prolonged procedure would worsen physiological impairment and metabolic failure. Indeed, in severely injured patients, blood loss and tissue injuries enhance the onset of the "bloody vicious circle", triggered by the triad of acidosis-hypothermia-coagulopathy. Abbreviated laparotomy is a surgical strategy that forgoes the completeness of operation in favor of a physiological approach, the overriding preference going to rapidity and limiting the procedure to control the injuries. Management is based on sequential association of the shortest possible preoperative resuscitation with surgery limited to essential steps to control injury (stop the bleeding and contamination), without definitive repair. The latter will be ensured during a scheduled re-operation after a period of resuscitation aiming to correct physiological abnormalities induced by the trauma and its treatment. This strategy necessitates a pre-defined plan and involvement of the entire medical and nursing staff to reduce time loss to a strict minimum.

[Laparoscopic Janeway gastrostomy: an advantageous solution for self-sufficient enteral feeding]. / Gastrostomie tubulisée coelioscopique : une solution avantageuse pour une nutrition entérale autonome.

INTRODUCTION: Laparoscopic gastrostomy according to Janeway (LGJ) is an alternative to percutaneous gastrostomy techniques. METHODS: A series of 10 LGJ is reported. The laparoscopic technique involves an isoperistaltic tube of 6-7 cm of length and 10-12 mm of diameter is created by 2 applications of linear stapling and cutting device. The tube is led out, opened and fixed to the fascial and cutaneous planes and a Foley catheter is inserted. RESULTS: Mean operation time was 35 minutes. There was no complication. The LGJ was indicated in 9 patients with tumour of the pharynx and 1 patient with encephalopathy. CONCLUSION: The main drawback of the LGJ is the need of general anaesthesia. The main advantage is the creation by minimal invasive surgery of a permanent gastrostomy equipped with a removable catheter easily changeable by non specialized health professionals, and even by the patient himself.

Imaging of non-traumatic abdominal emergencies in adults.

Non-traumatic abdominal pathology is one of the most common reasons for consultation in emergency care services. Abdominal pain is the presenting symptom for many diseases, which often requires urgent care. Clinical history and physical examination are rarely sufficient to establish a definite diagnosis and imaging is usually necessary. The choice of imaging modality is oriented by the clinical context and guided by the institutional capabilities, safety and cost-effectiveness of the available tests. Plain radiographs have little or no place in the evaluation of the acute abdomen. Magnetic resonance imaging (MRI) still has limited availability in many hospitals, thus narrowing the imaging choice to ultrasound (US) and computerized tomography (CT). No scientific evidence exists to allow the imposition of one single strategy. At the present time, the clinician may choose either routine US evaluation complemented by CT in case the US is inconclusive or first-line CT (except for the evaluation of right lower quadrant [RLQ] pain, right upper quadrant [RUQ] pain and in pregnant women where ultrasound is the first-line study).

[Resuscitative transverse thoracotomy]. / Thoracotomie transverse de réanimation.

The technique of resuscitative transverse thoracotomy is for use in case of circulatory arrest in the trauma patient. This technique, performed after orotracheal intubation, is initiated by a 5th intercostal space thoracostomy in each mid-axillary line. If the circulatory arrest is not caused by a tension pneumothorax, bilateral thoracotomies in the 5th intercostal spaces with transverse transsection of the sternum is performed. Middle vertical incision of the pericardium allows the evacuation of a cardiac tamponade. This wide surgical access has proved simple to perform, even by non experienced operators. It allows digital control of a heart wound, cross-clamping of the thoracic descending aorta or of pulmonary hilum, rapid perfusion of warm fluids through the right auricle and the performance of bimanual internal cardiac massage.

[Cryosurgery of liver neoplasms]. / La cryochirurgie des tumeurs du foie.

Cryosurgery is the in situ destruction of tissue using subzero temperatures. Its use for the treatment of some unresectable liver tumors has been clearly established as a therapeutic option. Experimental studies have demonstrated the feasibility of freezing of large liver volumes without any major metabolic and hemorrhagic complications. Modern cryosurgery has received substantial impetus from the development of automated cryosurgical apparatuses using liquid nitrogen. Intraoperative ultrasound has enhanced the process by enabling visualization of tissue freezing and ensuring precise and optimal treatment of the tumor. Clinical reports of cryosurgery for liver primary tumors and metastases have confirmed the safety of the procedure. Major complications include myoglobinuria, coagulopathy and pleural effusions. The benefit of cryosurgery is that it broadens the number of patients that can be brought to surgery and can potentially become disease-free.

[Appendectomy: evaluation of medical record maintenance in a series of 200 cases]. / Appendicectomies: évaluation de la tenue du dossier médical sur une série de 200 cas.

To improve the management of appendicular syndromes, two hundred files of patients undergoing appendectomy in an emergency surgery department between January 1993 and August 1994 were submitted to a retrospective and descriptive study with evaluation of the medical file content. To evaluate clinical and investigations data collecting, a histopathological review protocol was elaborated to obtain an objective and reliable criterion of the degree of inflammation of the appendix. This review was possible only for 197 files that were included. Data collecting rates are inferior than expected rates, particularly for the association of temperature, abdominal defence and white blood cells count that was found in only 159 files (80.7%). Data were less collected for women, patients operated by celioscopy and when histopathologic review concluded to absence of acute inflammation. Rate of acute appendicitis was 73.6% (145/197). Appendectomies without acute inflammation were higher for women (34.6% = 37/107) than for men (16.7% = 15/90) and for patients who underwent celioscopic appendectomy (42.9% = 33/77) than for patients who underwent Mac Burney appendectomy (16% = 19/119). These results highlight the need to improve competition of medical files with better collection of clinical data, which could lead to improve care quality and management of operated appendicular syndromes, first step to a reduction of the number of appendectomies. A global assessment of file completion could be proposed on the basis of clinical audit.

[Diaphragm rupture in closed trauma]. / Rupture du diaphragme dans les traumatismes fermés.

Ruptures of the diaphram occur in approximately 2% of cases of severe thoraco-abdominal trauma. They are present on the left in 80% of cases. The rupture is cupolar, sagittal or transversal, with peripheral desinsertion (the last always observed on the right), or paravertebral and retropericardiac posterior tears. Movement of the abdominal viscera toward the thorax can be progressive, with signs appearing only after 3 or 4 days or more. Any attempt to evacuate an intrathoracic effusion should be made carefully. In half the cases in polytraumatic patients, the lesion is confirmed by clinical suspicion or by appropriate surgical exploration. The first emergency step is repair. In cases of recent occurrence and for reasons of abdominal safety, coeliotomy is preferred. Mortality ranges from 20 to 30% and depends on the polytraumatic state but also on heart and respiratory failure and on infectious complications.

[Subclavian artery rupture after road crash: many similitaries]. / Rupture de l'artère sous-clavière après un accident de la route : de nombreuses similitudes !

INTRODUCTION: Traumatic Subclavian Arterial Ruptures (TSCAR) are rare and with a poor prognosis. The aim of this study was to describe the epidemiological data and the medical charts of the initial care of each patient suffering a TSCAR following a traffic accident. METHODS: Using the register of the road crash in the Rhone department (France) that records every casualty using the AIS codes, we retrospectively reviewed the prehospital and intrahospital medical, biological and radiological charts of every patient. Follow-up was obtained at day 60 post-trauma. RESULTS: Among the 1181 severe traumatic injuries, five casualties have been recorded in the register with a TSCAR (0.4%). Four of the five patients died in an early dramatic fatal hemorrhagic shock. Similarities between casualties were observed for patients still alive at hospital arrival that associate 1) a two-wheel motorized rider (2-WMR) crashing without antagonist 2) a severe polytraumatism including thoracic and 3) orthopaedic lesions; 4) clinical and biological signs of a severe haemorrhagic shock; 5) radiological signs of scapulothoracic dissociation. CONCLUSION: TSCAR are rare with a high mortality. We recommend improving the early care by the recognition of the triad associating early severe shock, polytraumatism (thorax and superior limb) and radiological signs evocating scapulothoracic dissociation in a 2-WMR. These signs must lead to the operating theatre as fast as possible in association with early massive transfusions.

Review and evaluation of anatomy sites on the Internet (updated 1999).

In a preceding study, we had reviewed and evaluated the anatomy sites available on the Internet. The evolution of the available sites, the disappearance of certain sites and the appearance of new sites led us to update this list. In addition, the German-speaking sites were included in the study, which previously included only the Anglophone and French-speaking sites. Forty-eight sites were indexed and their addresses are available on the site of the Laboratory of Anatomy of the Faculty of Medicine Lyon-Nord (http://rockefeller.univ-lyon1.fr/Anatomie-Lyon- Nord). Compared to the scores allotted in 1998, we noted in 1999 a significant increase (p = 0.03) in the total score (12.13 +/- 2.98 vs. 11.23 +/- 2.28/20), which shows that the quality of the anatomic sites available on the Internet has improved.

Rat multiple organ blocks: microsurgical technique of removal for ex vivo aerobic organ preservation using a fluorocarbon emulsion.

A multiple organ block (MOB) is composed of en bloc removed organs (heart, lungs, liver, pancreas, kidneys, and bowel), connected by the vascular system, of which blood circulation is maintained by the heart and oxygenation by the lungs under artificial ventilation. The aim of this study is the description of a surgical technique of MOB removal in the rat. Ninety-five MOBs were removed from Wistar rats. The rats were anesthetized, a tracheotomy was performed, and the cannula was connected to a pressure-regulated respirator. A colectomy was performed. Ureters, vena cava inferior, aorta, and bile duct were cannulated using an operative microscope. The vessels that joined the MOB to the carcass were tied or coagulated to make removal of the MOBs possible. Once removed, the MOBs were placed in a vaseline oil bath at 37 degrees C and the aorta and vena cava were connected to an accessory vascular circuit to stabilize arterious pressure. Success rate (ex vivo survival of more than 10 min) after the 30th attempt was 90% and after the 60th attempt was 95% (global success rate 82%). Ex vivo survival of MOBs at 37 degrees C ranged from 1 to 450 min. Rat MOBs allows us to study the normothermic preservation of all the organs susceptible of being transplanted in one single series of experiments. We showed that removal of rat MOBs is feasible. This microsurgical technique is codified. Rat MOBs are suitable if perfusion liquids are difficult to obtain or if a great number of experiments are required. As MOBs are composed of synergically functioning organs in the absence of striated muscle, bone, and nervous system, they also could be useful for physiologic and pharmacologic studies.