Base Excess usefulness for prediction of immediate mortality in severe trauma patients admitted to the Emergency department.

BACKGROUND: Trauma is a leading cause of death in young people and hemorrhagic shock is a leading mechanism of this mortality. Hypoperfusion can be difficult to diagnose clinically, especially in younger patients. Arterial Base Excess (BE) has been used as an early indicator of hypoperfusion. AIM: To evaluate the prognostic value of admission BE in severe trauma patients admitted to the emergency department (ED). METHODS: In this prospective study, severe trauma patients meeting high velocity criteria admitted to the ED during the study period were included. BE was calculated from arterial blood gas samples. Multivariate analysis was performed for Day-1 and Day-7 post trauma mortality. ROC characteristics and survival curves were used. RESULTS: We included 479 patients. Median age was 37 (18-90). Eighty-one per cent were male. Clinical characteristics n(%): GCS<13: 170(35); SBP<90 mmHg: 64(13) and SpO2 <90%: 82(17). Mean ISS was 22 ± 13. Mortality was at days 1 and 7: 2.2% and 27.3%, respectively. Median BE was -3.2 mmol/l (-25; 28). Forty-five per cent had a BE ≤ -3.5 mmol/l. In multivariate analysis, initial BE ≤ -6.5 mmol/l was predictive of first day mortality with an Odds Ratio; [CI95%] = 3.17; [1.4-7.1]; p=0.005. Similar results were found at Day 7: Odds Ratio; [CI95%] = 1.5; [1.14-1.96]; p=0.003. BE showed high prognostic value for both mortality rates. Survival curve was significant for BE> -6.5mmol/l. CONCLUSION: in this study, a high BE above 6.5mmol/L showed a significant prognostic value in immediate and early mortality and is proposed as a marker of injury severity in trauma patients admitted to the ED. Prediction was better for the immediate mortality and thus could be proposed as a triage tool in the ED.

Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study.

STUDY OBJECTIVE: The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. METHODS: This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. RESULTS: We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. CONCLUSION: For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

[Mechanical ventilation in intensive care units: indications, modalities and complications. Results of a prospective multicenter survey in Tunisia]. / La Ventilation artificielle en réanimation: indications, conduite pratique et complications. Résultats d'une enquête prospective multicentrique tunisienne.

The survey was performed during the month of March 1998 and concerned 9 ICUs located in teaching hospitals. To be included each ICU had to MV for more than 12 hours were included in the study and had a 28 day follow-up in the ICU or until hospital discharge. Collected parameters were indications of MV, modalities of MV and of weaning, complication and outcome at hospital discharge. Assist-control ventilation was the most used ventilation modality (69.8%). Weaning of MV was performed in 63% of the study patients and was based on a once-a-day attempt of spontaneous breathing through a T-piece (59.5%) and a combination of intermittent mandatory ventilation with pressure support (IMV-PS: 27%) or pressure support alone (11.2%). Mean length of hospital stay was 19.7 +/- 15.9 days of which 11.6 days were spent in the ICU. Fifty nine patients (54%) were alive at discharge form the ICU of whom 4 ultimately died during their hospital stay. MV practice as well as ICU facilities are not homogenous in Tunisia. Recommendations and guidelines should be built in order to standardize MV practice in Tunisia.

[The obstetrical advantages of epidural analgesia in a trial of labor]. / Les avantages obstetricaux de l'analgesie peridurale au cours de l'épreuve de travail.

Two series of labour trial were compared in a forward-looking study. The first series of 24 parturient women (series I) to whom the labour trial took place under peridural analgesy. The second series of 80 parturient women (series II) to whom the labour trial took place without peridural analgesy. The rate of caesarean section is significantly less important in the series I (33.3% versus 58%) P = 0.37. The average duration of the labour trial is significantly prolonged under peridural analgesy but without bared effects for the newborn children. The authors consider that the peridural analgesy is the method that brings ideal conditions for a real test allowing to eliminate dynamic dystocia and maternal restlessness in order to have an accurate cephalo-pelvic confrontation.