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Goal: To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre., Design: A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset 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 the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded., Methods: The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient 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' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an 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 severe limb trauma patients., (Copyright © 2021 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2020 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Objective: We compared the effectiveness of nerve blocks (regional anaesthesia, [RA]) versus local anaesthesia (LA) to treat face and hand wounds. Emergency physicians who had not previously used nerve blocks administered the anaesthesia based on anatomic landmarks., Methods: This prospective observational open study was conducted at a military teaching hospital emergency department (ED) between May 1, 2013 and January 31, 2014. All patients requiring treatment of facial or hand wounds were included. The primary outcome was anaesthesia effectiveness 15minutes post-administration. We also recorded the number of injections sites, injected volume, pain of administration, operator comfort, and complications. Lidocaine anaesthesia without epinephrine was used., Results: Of the 1090 treated patients, 617 patients were included in the analysis: 316 with hand wounds and 301 with facial wounds. Overall, 130 wrist blocks and 63 facial blocks were performed. RA effectiveness was comparable to that of LA: for facial wounds, RA=88.9% versus LA=89% (P=0.86); for hand wounds, RA=82.2% versus LA=90.1% (P=0.15). RA groups had significantly fewer injections than the LA groups, and less anesthetic was injected in the facial RA group. The pain of anaesthesia administration and operator comfort was similar. There was no complication during the 9-month data collection period., Conclusion: Facial and wrist nerve blocks are easy to administer and as efficient as local infiltrations, plus they require fewer injection sites, and, for facial RA, less anesthetic. Their teaching and use should be more widespread in EDs., (Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background: While guidelines advocate goal-directed resuscitation based on timed bundles, the management of septic shock (SS) outside an ICU setting has been poorly studied in intermediate care units (IMCU)., Patients and Method: We reviewed all cases of septic shock patients admitted to our IMCU between January 2013 and June 2014. The characteristics of sepsis, compliance of bundles, and outcomes were collected. The IMCU population was compared with the SS patients admitted to the ICU during the same period. The primary objective was to evaluate the feasibility of care in an IMCU., Results: We treated 59 patients in the IMCU. Forty-three patients (73%) were fully managed in the IMCU and 16 patients (27%) were secondarily transferred to the ICU. In the first 3hours, the compliance to bundles was: blood cultures (95%), plasma lactate concentration (90%), vascular filling volume (1500ml (1000-2000)) and antibiotics (100%). A central venous line and an arterial catheter were inserted in 85% and 98.3% of the cases. At 24h, patients who were transferred to the ICU had higher lactate concentrations than the other patients (1.4±0.7mmol versus 2.9±3.4mmol; P=0.03). A 24 hours-SOFA score>4 was correlated with a transfer in ICU (OR 7,75 (95% CI 2.08-28,81; P=0.002))., Conclusions: Our work demonstrated the ability to manage SS patients solely in an IMCU. It showed that the SS resuscitation bundle can be successfully implemented outside the ICU. A lack of improvement at the 24th hour is associated with a transfer to the ICU., (Copyright © 2017 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objectives: This study aimed to assess the short-term respiratory tolerance and haemodynamic efficiency of low-volume resuscitation with hypertonic saline and hydroxyethylstarch (HS/HES) in a pig model of lung contusion and controlled haemorrhagic shock. We hypothesised that a low-volume of HS/HES after haemorrhagic shock did not impact contused lungs in terms of extravascular lung water 3hours after trauma., Methods: A lung contusion resulting from blunt chest trauma was induced in 28 anaesthetised female pigs with five bolt-shots to the right thoracic cage, followed by haemorrhagic shock and fluid resuscitation. Pigs were randomly allocated into two groups: fluid resuscitation by 4ml/kg of HS/HES, or fluid resuscitation by 10ml/kg of normal saline (NS). Monitoring was based on transpulmonary thermodilution and a pulmonary artery catheter. After 3h, animals were euthanized to measure extravascular lung water (EVLW) by gravimetry., Results: Blunt chest trauma was followed by a transient collapse and hypoxaemia in both groups. Post-mortem gravimetric assessment demonstrated a significant difference between EVLW in the NS-group (8.1±0.7ml/kg) and in the HS/HES-group (6.2±0.6ml/kg, P=0.038). Based on a pathological EVLW threshold of > 7ml/kg, results indicated that only the NS-group experienced moderate pulmonary oedema, contrary to the HS/HES-group. After haemorrhagic shock, HS/HES infusion enabled the restoration of effective mean arterial pressure and cardiac index. Intrapulmonary shunting increased transiently after fluid resuscitation but there was no significant impairment of oxygenation., Conclusion: In this pig model of lung contusion, the short-term assessment of fluid resuscitation after haemorrhagic shock with 4ml/kg of HS/HES showed that pulmonary oedema was avoided compared to fluid resuscitation with 10ml/kg of NS., (Copyright © 2017 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Aim: Over-triage rates related to the use of Vittel criteria are unknown. We compared severe stable trauma patients with and without significant visceral injuries., Study Design: A single-centre retrospective analysis of a single-centre prospective cohort., Patients and Methods: Trauma patients with at least one positive Vittel criterion from June 2010 to January 2012 in a level-1 trauma centre. Initial management included a systematic whole-body scanner. All significant lesions in stable trauma patients were recorded., Results: A total of 252 trauma patients were admitted. One hundred and twenty were stable. In this group without vital distress, 72 (60%) had at least one occult lesion, 21 (17.5%) had an isolated orthopaedic injury and 27 (22.5%) had no injury. Thoracic injuries accounted for 44% of visceral injuries, abdominal for 17%, spinal for 16% and cerebral for 15%. Overall, the over-triage rate was 19%. Surgery for significant visceral injury was performed in 13 patients (18%) and arteriography in 4 patients (5.5%). Admission in an intensive care unit was required for 13 patients with occult injuries and for one patient without such a lesion (18% versus 2%, P=0.008). Hospital stays were longer in the group with visceral injuries (4±7 versus 9±8days; P=0.006)., Conclusion: Vittel criteria use in trauma patients induces an acceptable over-triage rate. A large proportion of stable trauma patients have occult lesions. These visceral injuries frequently require special care. These data highlight the imperative need to transport major trauma patients immediately to a dedicated trauma centre and supports whole-body scanner use., (Copyright © 2015 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)