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The study of preventable trauma deaths is one mechanism used to examine the quality of care and outcomes of a trauma system. The present study aims to define the rate of preventable (PD) and potentially preventable death (PPD) in our mature trauma center, determine its leading causes, and evaluate the evolution of this rate over the years.We performed a retrospective observational study in the Sainte Anne Military Teaching Hospital, Toulon (Var), France. From January 2013 to December 2020, all patients with severe trauma admitted to our trauma center and who died were analyzed. An independent group of 4 experts in the management of severe trauma performed the classification of deaths using a DELPHI method.During the study period, 180 deaths occurred among 2642 consecutive severe trauma patients (overall mortality 6.8%). 169 deaths were analyzed, Eleven (6.5%) were considered PD, and thirty-eight (22.1%) were PPD. 69 errors were identified. The most frequent errors were in pre-hospital (excessive pre-hospital times 33.3% and inadequate management 29%). Time before surgery was considered excessive in 15.9% of cases. Over the study period, the rates of PD and PPD deaths remained stable.PD and PPD rates are still high and do not decrease over the years in our mature trauma center. It confirms the need for progress in the management of severe trauma patients. Reducing the time to provide care seems to be the main area for improvement. Further studies will be necessary to better target the points to be improved.

In modern and asymmetric conflicts, traumatic airway obstruction caused by penetrating injury to the face and neck anatomy is the second leading cause of preventable mortality. Definitive airway management in the emergency setting is most commonly accomplished by endotracheal intubation. When this fails or is not possible, a surgical airway, usually cricothyrotomy, is indicated. The clinical choice for establishing a definitive airway in the austere setting is impacted by operational factors such as a mass casualty incident or availability and type of casualty evacuation. This is a case report of a patient with severe cervicofacial injuries with imminent airway compromise in the setting of a mass casualty incident, without possibility of sedation and mechanical ventilation during his evacuation. The authors seek to highlight the considerations and lessons learned for emergency cricothyrotomy.

Background and objectives Our study sought to evaluate and compare different prediction scores for massive transfusion in-hospital packed red blood cell (PRBC) transfusions. Materials and methods Between January 2013 and December 2018, 1843 trauma patients were enrolled in the registry of a level-1 trauma centre. All prehospital and in-hospital variables needed to calculate the Shock Index and RED FLAG, Assessment of Blood Consumption (ABC) and Trauma Associated Severe Hemorrhage (TASH) scores were prospectively collected in the registry. The primary endpoint was the initiation of transfusion within the first hour of the patient's arrival at the hospital. Results A total of 1767 patients were included for analysis with a mean age of 43 years (±19) and a mean Injury Severity Score of 15 (±14). The in-hospital TASH score had the highest predictive performance overall (area under the curve [AUC] = 0.925, 95% confidence interval [CI] [0.904-0.946]), while the RED FLAG score (AUC = 0.881, 95% CI [0.854-0.908]) had the greatest prehospital predictive performance compared to the ABC score (AUC = 0.798, 95% CI [0.759-0.837]) and Shock Index (AUC = 0.795, 95% CI [0.752-0.837]). Using their standard thresholds, the RED FLAG score was the most efficient in predicting early transfusion (sensitivity: 87%, specificity: 76%, positive predictive value: 25%, negative predictive value: 99%, Youden index: 0.63). Conclusion The RED FLAG score appears to outperform both the ABC score and the Shock Index in predicting early in-hospital transfusion in trauma patients managed by pre-hospital teams. If adopted, this score could be used to give advance warning to trauma centres or even to initiate early transfusion during pre-hospital care.

The use of norepinephrine (NE) during uncontrolled haemorrhagic shock (HS) has mostly been investigated in experimental studies. Clinical data including norepinephrine dose and its impact on fluid resuscitation and organ function are scarce. We hypothesized that there is great variability in NE use and that high doses of NE could lead to increased organ dysfunction as measured by the sequential organ failure assessment (SOFA).We included patients with HS (systolic blood pressure90 mmHg in severely injured patients) who required haemostasis surgery and a transfusion of more than 4 packed red blood cells (PRBC) in the first 6 h of admission and the used of norepinephrine infusion to maintain the blood pressure goal, between admission and the end of haemostasis surgery in a prospective trauma database. A ROC curve determined that, using Youden's criterion, a dose of NE ≥ 0.6 µg/kg/min was the optimal threshold associated with intrahospital mortality. Patients were compared according to this threshold in a propensity score (PS) model. In a generalized linear mixed model, we searched for independent factors associated with a SOFA ≥ 9 at 24 h RESULTS: A total of 89 patients were analysed. Fluid infusion rate ranged from 1.43 to 57.9 mL/kg/h and norepinephrine infusion rate from 0.1 to 2.8 µg/kg/min. The HDNE group received significantly less fluid than the LDNE group. This dose is associated with a higher SOFA score at 24h: 9 (7-10) vs. 7 (6-9) (p = 0.003). Factors independently associated with a SOFA score ≥ 9 at 24 h were maximal norepinephrine rate ≥ 0.6 µg/kg/min (OR 6.69, 95% CI 1.82 - 25.54; p = 0.004), non-blood resuscitation volume9 mL/kg/h (OR 3.98, 95% CI 1.14 - 13.95; p = 0.031) and lactate at admission ≥ 5 mmol/L (OR 5.27, 95% CI 1.48 - 18.77; p = 0.010) CONCLUSION: High dose of norepinephrine infusion is associated with deleterious effects as attested by a higher SOFA score at 24 h and likely hypovolemia as measured by reduced non-blood resuscitation volume. We did not find any significant difference in mortality over the long term.

BACKGROUND Recent terrorist attacks in France highlight a weakness in massive casualties management and advocate for simulation-based education to improve the whole process. OBJECTIVE The purpose of this paper is to describe both the conception and the production of Traumasims, a serious game (SG) dedicated to on-scene triage in case of massive casualties. METHODS A group of 14 experts in prehospital care as well as emergency and trauma surgery co-produced an SG with Medusims: Traumasims. Clinical benchmarks were identified by the expert panel. Features of high-fidelity simulation-based education were applied to improve the learning of these clinical benchmarks. The SG thus integrates feedback at the end of each scenario, the repetition of scenarii, increasing degrees of difficulty, and individualized teaching. Traumasims was designed according to principles of virtual reality for education purposes: training and assessment. RESULTS Using 3-D real-time video game technology, trainees are in the position of a doctor organizing a casualty collection point (CCP). Immersion is guaranteed by first-person gaming and interaction with caregivers and wounded avatars. To simulate victims, 48 avatars were produced based on real cases, individually tested and care-dependent evolutive. By varying numbers of caregivers and victims, trainees experienced scenarii of massive casualties with increasing difficulty. A personal debriefing was integrated at the end of each simulation. This debriefing allows for an individualized learning curve for each trainee. CONCLUSIONS The development of Traumasims involved a collaborative platform with interdisciplinary actors from the French Military Health Service (FMHS) and its emergency health-care system. This SG was designed to meet the simulation training needs highlighted by recent terrorist attacks. CLINICALTRIAL none

BackgroundFrom a series of penetrating head and neck trauma managed in a level-1 Trauma Center, the main aim of this study was to determine predictive factors for early definitive airway management, during pre-hospital time or in the emergency room. The secondary objective was to perform a descriptive epidemiological analysis of the series.MethodsA single-center retrospective study was conducted between January 1 2012 and June 30 2020. in a French Level 1 Trauma Center. The patients included were adults treated for penetrating head and neck trauma, regardless of the mechanism and the causal agent.Results 56 patients were included. Ballistic origin, Shock Index >0.9 and active bleeding in the emergency room were predictive criteria for definitive airway management during pre-hospital time or in the emergency room. 78.6% of patients were male. Median age was 54 years. The trauma followed a suicide attempt in 50% of cases, an accident in 26.7% and an assault in 23.2%, with use of a knife in 42.9% and firearm in 26.8%. Mortality was 10.7%. 16.1% of patients had undergone pre-hospital intubation and 19.1% intubation in the emergency room. CT scan was performed in 87.5% of cases, surgery in 96.4% and tracheotomy in 37.5%. A laryngotracheal lesion was seen in 14.2%. In 50% of patients, primary admission was to intensive care. Conclusions Ballistic origin, Shock Index >0.9 and active bleeding in the emergency room were predictive criteria for early definitive airway management. This study established the profile of patients suffering from penetrating head and neck trauma managed in a Trauma Center over a period of 9 years.

Introduction: Several prehospital major trauma patient triage scores have been developed, the triage revised trauma score (T-RTS), Vittel criteria, Mechanism/Glasgow Coma Scale/Age/Systolic...

Background Post-traumatic hemorrhage is still the leading cause of potentially preventable death in patients with severe trauma. Traumatic-induced coagulopathy has been described as a risk factor for significant hemorrhage and mortality in this population. Fibrin monomers (FMs) are a direct marker of thrombin action, and thus reflect coagulation activation. This study sought to determine the association of FMs levels at admission with significant hemorrhage and 28-day mortality after a severe trauma. Methods We conducted a retrospective, observational study including all severe trauma patients admitted in a level-1 trauma center between January 2012 and December 2017. Patients with severe traumatic brain injury or previous anticoagulant / antiaggregant therapies were excluded. FMs measurements and standard coagulation test were taken at admission. Significant hemorrhage was defined as a hemorrhage requiring the transfusion of ≥ 4 Red Blood Cells units during the first 6 h. Multivariable analysis was applied to identify predictors of significant hemorrhage and a simple logistic regression analysis was applied to identify an association between FMs and 28-day mortality. Results Overall, 299 patients were included. A total of 47 (16%) experienced a significant hemorrhage. The ROC curve demonstrated that FMs had a poor accuracy to predict the occurrence of significant hemorrhage with an AUC of 0.65 (0.57–0.74). The best threshold at 92.45 µg/ml had excellent sensitivity (87%) and negative predictive value (95%), but was not independently associated with significant hemorrhage (OR = 1.5; 95%CI (0.5–4.2)). The 28-day mortality rate was 5%. In simple logistic regression analysis, FMs values ≥109.5 µg/ml were significantly associated with 28-day mortality (unadjusted OR = 13.2; 95%CI (1.7–102)). Conclusions FMs levels at admission are not associated with the occurrence of a significant hemorrhage in patients with severe trauma. However, the excellent sensitivity and NPV of FMs could help to identify patients with a low risk of severe bleeding during hospital care. In addition, FMs levels ≥109.5 µg/ml might be predictive of 28-day mortality.

BACKGROUND Early transfusion of high ratio of fresh frozen plasma (FFP) and red blood cells (RBC) is associated with mortality reduction. However, time to reach high ratio is limited by the need to thaw the FFP. French lyophilized plasma (FLYP) used by French army and available in military teaching hospital does not need to be thawed and is immediately available. We hypothesize that the use of FLYP may reduce time to reach a plasma/RBC ratio of 1:1. METHODS A retrospective study performed in a Level 1 trauma center between January 2012 and December 2015. Severe trauma patients who received 2 U of RBC in the emergency room were included and assigned to two groups according to first plasma transfused: FLYP group and FFP group. RESULTS Forty-three severe trauma patients in the FLYP group and 29 in the FFP group were included. The time until first plasma transfusion was shorter in the FLYP group than in the FFP group, respectively 15 min (10-25) versus 95 min (70-145) (p < 0.0001). Time until a 1:1 ratio was shorter in the FLYP group than in the FFP group. There were significantly fewer cases of massive transfusion in the FLYP group than in the FFP group with respectively 7% vs. 45% (p < 0.0001). CONCLUSION The use of FLYP provided significantly faster plasma transfusions than the use of FFP as well as a plasma and RBC ratio superior to 1:2 that was reached more rapidly in severe trauma patients. These results may explain the less frequent need for massive transfusion in the patients who received FLYP. These positive results should be confirmed by a prospective and randomized evaluation. LEVEL OF EVIDENCE Therapeutic, level IV.

Resume L’hemorragie demeure la principale cause de « deces evitables » au cours des conflits armes. La reanimation transfusionnelle (RT) constitue un des aspects du « damage control ressuscitation » qui vise a arreter l’hemorragie et preserver la coagulation. En effet les moyens logistiques sont limites et les besoins transfusionnels superieurs a ceux de la traumatologie civile qui est majoritairement fermee. L’acide tranexamique doit etre utilise des la zone des combats car son benefice est d’autant plus important que son injection est precoce. La transfusion « prehospitaliere » au cours de l’evacuation vers la structure chirurgicale de l’avant est realisee pour les patients les plus graves. A cet effet, le plasma lyophilise, prepare par le Centre de Transfusion Sanguine des Armees, universel pour le groupage sanguin et securise, est particulierement interessant. La majorite des armees achemine des concentres de globules rouges (CGR) et du plasma mais disposent tres rarement de plaquettes sur les theâtres d’operation. Le choix du ratio de transfusion de plasma/CGR se situe entre 1/2 et 1/1 mais dans un souci d’efficacite la regle du 1/1 est plus simple a appliquer pour les blesses les plus graves. Le recours exceptionnel a la transfusion de sang total, preleve et qualifie sur place, est justifie par le besoin en plaquettes. Le risque residuel infectieux estime est tres inferieur au risque de deces par choc hemorragique traumatique. La biologie delocalisee est utilisee pour ajuster la RT mais les donnees cliniques priment tant que l’hemostase chirurgicale n’a pas ete realisee.

Background In France, the pre-hospital field triage of trauma patients is currently based on the Vittel criteria algorithm. This algorithm was originally created in 2002 before the stratification of trauma centers and, at the national level, has not been revised since. This could be responsible for the overtriage of trauma patients in Level I Trauma Centers. The principal aim of this study was to evaluate the correlation between each Vittel field triage criterion and trauma patients’ Injury Severity Score. Methods Our Level I Trauma Center receives an average of 300 trauma patients per year. Demographic and physiological data, along with the entire trauma patient management process and Vittel field triage criteria, are recorded in a local trauma registry. The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are calculated after a complete assessment of the trauma victim during their in-hospital management. Results were concerned with the presence of an ISS of greater than 15, which defined a major trauma patient; mortality within 30 days; and admission to the intensive care unit. This study is a registry analysis from January 2013 to September 2017. Results Of the 1373 patients in the registry, 1151 were included in the analysis with a mean age of 43 years (± 19) and a median ISS of 13 (IQR = 5–22), where 887 (77%) were male. Nine of the 24 Vittel criteria were associated with an ISS > 15. In a multivariate analysis, no criterion related to kinetic elements was significantly correlated with an ISS > 15, mortality within 30 days, or admission to intensive care. Three algorithm categories were predictive of a major trauma patient (ISS > 15): physiological variables, pre-hospital resuscitation, and physical injuries, while kinetic elements were not. Conclusions Criteria related to physiological variables, pre-hospital resuscitation, and physical injuries are the most relevant to predicting the severity of a trauma patient’s condition. A revision of the VCA could potentially have beneficial effects on the over and undertriage phenomena, which constitute ongoing medical and financial concerns.

In the French army, combat casualty care (CCC) training involves the use of simulation. The application of this pedagogic method in a cross-cultural environment has not previously been described. In this report, we explore the challenges highlighted by multiple training sessions for foreign medical providers in West Africa.We collected the data from six 2-week courses held in Libreville, Gabon. Our main objective was to describe the course; our secondary objective was to assess our trainees' progress in their knowledge of CCC.The first week involved lectures, technical workshops, and single-patient simulations. The second part emphasized multiple-victim simulations and interactions with combatants and was held in the Gabonese rainforest. Sixty- two trainees undertook the six sessions. Their knowledge improved during the course, from a median score of 4 (of a maximum of 40) before to 9.5 after (p.05).Our study is the first to describe medical-level CCC training in a cross-cultural environment. Challenges are numerous, notably differences in the expected roles of instructors and trainees. Mitigating those difficulties is possible through cultural awareness and self-awareness. Our results are limited by the absence of evaluation of improvement in the actual management of patients.CCC training using medical simulation is feasible in a cross-cultural environment.

Identification of microorganisms by MALDI-TOF MS has been widely accepted in clinical microbiology. However, for Mycobacterium spp. and Nocardia spp. such identification has not yet reached the optimal level of routine testing. Here we describe the development of an identification tool for 49 and 15 species of Mycobacterium spp. and Nocardia spp., respectively. During database construction, a number of ambiguous reference identifications were revealed and corrected via molecular analyses. Eventually, more than 2000 individual mass spectra acquired from 494 strains were included in a reference database and subjected to bio-statistical analyses. This led to correct species identification and correct combination of species into several complexes or groups, such as the Mycobacterium tuberculosis complex. With the Advanced Spectrum Classifier algorithm, class-specific bin weights were determined and tested by cross-validation experiments with good results. When challenged with independent isolates, overall identification performance was 90% for identification of Mycobacterium spp. and 88% for Nocardia spp. However, for a number of Mycobacterium sp. isolates, no identification could be achieved and in most cases, this could be attributed to the production of polymers that masked the species-specific protein peak patterns. For the species where >20 isolates were tested, correct identification reached 95% or higher. With the current spectral database, the identification of Mycobacterium spp. and Nocardia spp. by MALDI-TOF MS can be performed in routine clinical diagnostics although in some complicated cases verification by sequencing remains mandatory.

To compare characteristics and outcome in children undergoing extracorporeal life support initiated in an extracorporeal life support center or at the patient's bedside in a local hospital, by means of a mobile cardiorespiratory assistance unit.A retrospective study in a single PICU during 6 years. Extracorporeal life support was started either in our center (control group) or in the local hospital (mobile cardiorespiratory assistance unit group). The data collected were demographics, markers of patient's preextracorporeal life support condition, and outcome.One hundred twenty-six children underwent extracorporeal life support, 105 in the control group and 21 in the mobile cardiorespiratory assistance unit group. There was no difference between groups in terms of age, weight, or Pediatric Risk of Mortality II score. There was a significant difference in organ failure etiology between groups, with more respiratory cases in the mobile cardiorespiratory assistance unit group (76.2%) and more cardiac surgery cases in the control group (60%; p0.001). The duration of extracorporeal life support was longer in the mobile cardiorespiratory assistance unit group than in the control group (10 [1-36] vs 5 [0-33] d; p = 0.003). PICU length of stay and mortality (60% vs 47.6%; p = 0.294) were not significantly different between the two groups. To allow comparison of a more homogenous population, a subgroup analysis was performed including only respiratory failure patients from the two groups (R-control group [n = 22] and R-mobile cardiorespiratory assistance unit group [n = 16]). PICU length of stay was 17 (3-64) days in the R-control group and 23 (1-45) days in the R-mobile cardiorespiratory assistance unit group (p = 0.564), and PICU mortality rate was 54.5% in the R-control group and 43.8% in the R-mobile cardiorespiratory assistance unit group (p = 0.511). There was no difference between the R-groups for age, weight, Pediatric Risk of Mortality II score, and markers of kidney or liver dysfunction, and lactate blood levels.Extracorporeal life support can be safely initiated at children's bedside in the local hospital and then transported to the specialized referral center. Our results support the validity of an interregional organization of mobile cardiorespiratory assistance unit teams.

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 ± 8 days; 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.

The Healthcare Workers Treatment Center of Conakry, Guinea, was inaugurated in january 2015. It is dedicated to the diagnosis and the treatment of healthcare workers with probable or confirmed Ebola viral disease. It is staffed by the french army medical service. The french military team may reconcile their medical practice and the ethno-cultural imperatives to optimise the patient adherence during his hospitalization.

The extent of thermal strain while wearing personal protective equipment (PPE) during care activities for Ebola virus disease patients has not yet been characterized. From January to March 2015, 25 French healthcare workers (HCWs) in Conakry, Guinea, volunteered to be monitored while wearing PPE using an ingestible thermal sensor. The mean (standard deviation) working ambient temperature and relative humidity were 29.6 °C (2.0 °C) and 65.4% (10.3%), respectively; the mean time wearing PPE was 65.7 (13.5) minutes; and the mean core body temperature increased by 0.46 °C (0.20 °C). Four HCWs reached or exceeded a mean core body temperature of ≥ 38.5 °C. HCWs wearing PPE for approximately 1 hour exhibited moderate but safe thermal strain.

Brucella are highly infectious bacterial pathogens responsible for a severely debilitating zoonosis called brucellosis. Half of the human population worldwide is considered to live at risk of exposure, mostly in the poorest rural areas of the world. Prompt diagnosis of brucellosis is essential to prevent complications and to control epidemiology outbreaks, but identification of Brucella isolates may be hampered by the lack of rapid and cost-effective methods. Nowadays, many clinical microbiology laboratories use Matrix-Assisted Laser Desorption Ionization–Time Of Flight mass spectrometry (MALDI-TOF MS) for routine identification. However, lack of reference spectra in the currently commercialized databases does not allow the identification of Brucella isolates. In this work, we constructed a Brucella MALDI-TOF MS reference database using VITEK MS. We generated 590 spectra from 84 different strains (including rare or atypical isolates) to cover this bacterial genus. We then applied a novel biomathematical approach to discriminate different species. This allowed accurate identification of Brucella isolates at the genus level with no misidentifications, in particular as the closely related and less pathogenic Ochrobactrum genus. The main zoonotic species (B. melitensis, B. abortus and B. suis) could also be identified at the species level with an accuracy of 100%, 92.9% and 100%, respectively. This MALDI-TOF reference database will be the first Brucella database validated for diagnostic and accessible to all VITEK MS users in routine. This will improve the diagnosis and control of brucellosis by allowing a rapid identification of these pathogens., Author summary Brucella are bacteria that mainly infect animals. They can also be transmitted to humans and cause a serious disease called brucellosis. Half the world's population is considered exposed, especially in the poorest rural areas. Experts agree that prompt identification of Brucella isolates is essential to provide appropriate treatment to patients and to control epidemiological outbreaks. Mis-identification of these highly infectious pathogens may lead to delays in diagnosis, but also to increased risks of accidental exposure for laboratory workers. MALDI-TOF mass spectrometry is now the first line of bacterial identification in many routine diagnostic laboratories. However, not all clinical mass spectrometers can identify Brucella. In this work, we updated a database with Brucella spectra to improve the performance of MALDI-TOF mass spectrometers. These instruments will now be able to identify accurately Brucella isolates. This will greatly improve the diagnosis of brucellosis.

BACKGROUND The pathogenesis of Ebola virus disease (EVD) remains unclear. The sporadic nature of Ebola outbreaks and their occurrence in resource-limited settings have precluded the acquisition of extensive clinical and laboratory data. Rhabdomyolysis during EVD has been suggested to occur in previous studies showing increased aspartate aminotransferase-alanine aminotransferase ratios, but, to date, has not been confirmed with creatine kinase (CK) assays. METHODS We performed an observational study of 38 patients admitted to an Ebola treatment center from January to April 2015. CK values from patients with confirmed EVD were compared with those in patients without confirmed EVD. A panel of other analyses were also performed. In patients with EVD, characteristics were compared between survivors and nonsurvivors. RESULTS High levels of CK were more frequent in patients with EVD than in those without (P = .002), and rhabdomyolysis was more frequent (59% vs 19%, respectively; P = .03). CK levels >5000 U/L were observed in 36% of patients with EVD. Also in patients with EVD, fatal outcome was significantly associated with higher creatinine and bilirubin levels, international normalized ratio, and viral load. CONCLUSIONS Rhabdomyolysis is a frequent disorder in EVD and seems to be more common than in other viral infections. It may contribute to the renal failure observed in nonsurviving patients. More studies are needed to determine the impact of rhabdomyolysis on EVD outcome.

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

We report 77 cases of occupational exposures for 57 healthcare workers at the Ebola Treatment Center in Conakry, Guinea, during the Ebola virus disease outbreak in 2014-2015. Despite the high incidence of 3.5 occupational exposures/healthcare worker/year, only 18% of workers were at high risk for transmission, and no infections occurred.

Early-onset ventilator-associated pneumonia (EOVAP) occurs frequently in severe traumatic brain-injured patients, but potential consequences on cerebral oxygenation and outcome have been poorly studied. The objective of this study was to describe the incidence, risk factors for, and consequences on cerebral oxygenation and outcome of EOVAP after severe traumatic brain injury (TBI). We conducted a retrospective, observational study including all intubated TBI admitted in the trauma center. An EOVAP was defined as a clinical pulmonary infection score >6, and then confirmed by an invasive method. Patient characteristics, computed tomography (CT) scan results, and outcome were extracted from a prospective register of all intubated TBI admitted in the intensive care unit (ICU). Data concerning the cerebral oxygenation monitoring by PbtO2 and characteristics of EOVAP were retrieved from patient files. Multivariate logistic regression models were developed to determine the risk factors of EOVAP and to describe the factors independently associated with poor outcome at 1-year follow-up. During 7 years, 175 patients with severe TBI were included. The overall incidence of EOVAP was 60.6% (47.4/1000 days of ventilation). Significant risk factors of EOVAP were: therapeutic hypothermia (OR 3.4; 95% CI [1.2–10.0]), thoracic AIS score ≥3 (OR 2.4; 95% CI [1.1–5.7]), and gastric aspiration (OR 5.2, 95% CI [1.7–15.9]). Prophylactic antibiotics administration was a protective factor against EOVAP (OR 0.3, 95% CI [0.1–0.8]). EOVAP had negative consequences on cerebral oxygenation. The PbtO2 was lower during EOVAP: 23.5 versus 26.4 mmHg (p

Introduction Face and/or neck burn (FNB) exposes patients to the double respiratory risk of obstruction and hypoxia, and these risks may require a tracheal intubation. This study aims to describe the incidence and the characteristics of difficult intubation in FNB patients. Methods We conducted a 5-year retrospective, single-center study including all patients meeting the following criteria: 18 years of age or older, an FNB at least 1% of burned surface area with a severity equal to or greater than the superficial second degree, and intubation and a burn center admission within the first 24 hours after the burn. Patients were compared according to the difficulty of their intubation. Results Between January 2007 and December 2011, we included 134 patients. The incidence of difficult intubation was 11.2% but was greater in the burn center than in the pre–burn center: 16.9% vs 3.5% ( P = .02). The most important difference between patients with or without difficult intubation was the time between the burn injury and the intubation: 210 (105-290) vs 120 (60-180) minutes ( P = .047). After multivariate analysis, an intubation performed at a burn center was independently associated with difficult intubation: odds ratio=3.2; 95% confidence interval, 1.1-528. Conclusions This study underlines the high incidence of difficult intubation in FNB patients, greater than 11.2%, and demonstrates that intubation is more difficult when realized at a burn center, probably because it is performed later, allowing for development of cervical and laryngeal edema.

BackgroundMilitary anesthesia meets unique logistical, technical, tactical, and human constraints, but to date limited data have been published on anesthesia management during military operations.ObjectiveThis study aimed to describe and analyze French anesthetic activity in a deployed military setting.MethodsBetween October 2015 and February 2018, all patients managed by Sainte-Anne Military Hospital anesthesiologists deployed in mission were included. Anesthesia management was described and compared with the same surgical procedures in France performed by the same anesthesia team (hernia repair, lower and upper limb surgeries). Demographics, type of surgical procedure, and surgical activity were also described. The primary endpoint was to describe anesthesia management during the deployment of forward surgical teams (FST). The secondary endpoint was to compare anesthesia modalities during FST deployment with those usually used in a military teaching hospital.ResultsDuring the study period, 1547 instances of anesthesia were performed by 11 anesthesiologists during 20 missions, totaling 1237 days of deployment in nine different theaters. The majority consisted of regional anesthesia, alone (43.5%) or associated with general anesthesia (21%). Compared with France, there was a statistically significant increase in the use of regional anesthesia in hernia repair, lower and upper limb surgeries during deployment. The majority of patients were civilians as part of medical support to populations.ConclusionIn the context of an austere environment, the use of regional anesthesia techniques predominated when possible. These results show that the training of military anesthetists must be complete, including anesthesia, intensive care, pediatrics, and regional anesthesia.

Resume Objectifs La transfusion sanguine est un des elements majeurs du soutien medico-chirurgical des militaires en operation exterieure. Les moyens francais comportent : des concentres de globules rouges (CGR), du plasma lyophilise (PLYO), le sang total (ST), mais ni plaquettes, ni plasma frais congele. La strategie transfusionnelle francaise en operations militaires exterieures suit l’evolution des savoirs et des moyens. Nous decrivons ici les caracteristiques de la transfusion sanguine a l’hopital militaire de Kaboul. Patients et methodes Etude retrospective des dossiers des patients transfuses entre octobre 2010 et decembre 2011 a Kaboul, a partir du registre local de la transfusion sanguine. Les variables etudiees ont ete : les caracteristiques des patients, la biologie a l’admission, le type et la quantite des produits transfusionnels, l’evolution. Resultat Cent vingt-six patients ont ete transfuses : majoritairement Afghans (n = 97 ; 77 %), 49 militaires (39 %) dont 22 militaires francais (17 %), âge median 24 ans (3–66). Deux cents soixante-treize CGR provenant de France ont ete transfuses et 350, non utilises, ont ete detruits. Les pathologies ayant conduit a une transfusion ont ete : 76 blessures de guerre (60 %), 21 traumatismes (17 %) et 29 autres mecanismes (23 %). Dans les 24 premieres heures, les patients ont recu en mediane : deux CGR (0–12), un poche de ST (0–18) et deux PLYO (0–14). Le ratio PLYO/CGR etait de 1/1,6. Une transfusion massive (> 10 CGR ou ST) a concerne 9 % des patients. Vingt-sept pour cent des patients ont recu du ST. On note 17 deces (13,5 %). Conclusion L’utilisation du ST et du PLYO en substitution, respectivement, des concentres plaquettaires et des PFC, permet d’apporter des soins de qualite dans un contexte logistiquement contraint tout en maitrisant les risques et les couts.

Introduction Ebola Virus Disease (EVD) causes severe diarrhoea and vomiting, leading to dehydration and electrolyte abnormalities. Treatment remains supportive and often requires intravenous (IV) access. IV catheters are difficult to insert and maintain in this context. Our primary objective was to compare peripheral venous catheters (PVCs) and central venous catheters (CVCs) for volume resuscitation in patients with EVD. Material and methods We performed a prospective observational study between January and March 2015 at the Conakry Healthcare Workers Ebola Treatment Unit (ETU). The primary judgement criterion was the ratio of the daily infused volume of fluids to the prescribed volume (DIV/PV). Results Fourteen patients were admitted. Twenty-eight PVCs and 8 CVCs were inserted. CVCs had a longer survival time (96 ± 34 hours versus 33.5 ± 21 hours, P

Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient?s prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital.This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro.Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (p.001). The Bland-Altman plot showed a mean difference of 5.8% (95% confidence interval ?14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. RESULTS from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures.The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Introduction La reanimation ne peut se concevoir sans oxygene (2). L’approvisionnement, le transport et le stockage de l’O2 demandent des ressources importantes, rendant la disponibilite de celui-ci aleatoire dans les pays en voie de developpement [1] et sur les theâtres d’operations exterieures. Une alternative a l’O2 pressurise ou liquide est l’extraction de l’O2 de l’air par un extracteur d’oxygene (EO). Le couple EO/ventilateur dont nous disposons permet de delivrer [2] , [3] , une FiO2 de 80 %. Le but de cette etude est d’evaluer les situations necessitant le recours a l’O2 mural dans une reanimation ou la principale source d’O2 sont les EO. Materiel et methodes L’EO en dotation est le CO Integra 10™ (10 L/min a FiO2 92 %), les ventilateurs en dotation sont les LTV 1000 et 1200 (Pulmonetic system). Sont inclus tous les patients admis en reanimation necessitant une oxygenotherapie (ventilation spontanee au masque, ventilation non invasive en pression positive, ventilation mecanique invasive). Le suivi debute a l’admission du patient en reanimation et est realise quotidiennement jusqu’a sa sortie. Tous les patients inclus sont oxygenes par EO par defauts. L’echec d’oxygenation par EO est defini par la necessite de recours a l’O2 mural : – impossibilite technique de delivrer de l’O2 par le CO ; – un rapport PaO2/FiO2 Resultats Vingt patients ont ete inclus du 12/07/2014 au 17/10/2014. 65 % de femme et 35 % d’hommes âges en moyenne de 38,9 ans (13–70 ans). Les motifs d’admission etaient medicaux dans 50 % des cas, traumatologique dans 30 % des cas et chirurgicaux pour les 20 % restants. Les scores APACHE II etaient de 14,45 en moyenne (0–35) et IGS2 de 31,8 (0–74). La duree de sejour moyenne etait de 4,45 jour en moyenne (1–9). Le taux de patient traite pour une infection est de 66,9 %. Quatre patients (20 %) sont decedes dont 3 apres limitation et/ou arret des therapeutiques actives. Le nombre de jours d’oxygenotherapie sous EO etait au total de 112 (38 jours de ventilation invasive, 74 jours de VS ou VNI), avec 6 jours de recours a l’O2 mural (5,3 %). Les causes de recours a l’oxygene mural/bouteille etaient : – SDRA severe avec PaO2/FiO2 – les patients traumatises ou chirurgicaux de retour du bloc ou en partance pour le bloc ; – defaillance respiratoire aigue necessitant une intubation en extreme urgence. La FiO2 moyenne delivree etait de 44,6 % (25–75) pour des debit d’O2 moyen de 4,1 L/min (1–10) pour une ventilation minute de 8,3 L/min (5,2–12,1). Discussion Les EO permettent une economie d’O2 au sein d’une reanimation, l’utilisation d’O2 hyperbare est indispensable dans des situation urgente (arret respiratoire, intubation en urgence), pour les patients necessitant des FiO2 > 80 % ou le transports des patients. Il parait donc raisonnable d’utiliser les EO comme source principale d’O2 en reanimation dans les pays ou un acces fiable a l’oxygene est difficile, mais ceux ci ne permettent pas de s’affranchir de l’utilisation episodique d’une source d’O2 hyperbare.

Introduction Une epidemie de maladie a virus Ebola (MVE) touche actuellement l’Afrique de l’Ouest. Les patients infectes presentent une diarrhee abondante et des vomissements, responsables d’une deshydratation et de troubles ioniques [1] . Le traitement est symptomatique et necessite frequemment un abord intraveineux (IV). Les conditions de soins difficiles (equipements de protection individuels, climat, obstacles culturels et linguistiques a l’acceptation des soins) compliquent l’obtention et le maintien des abords vasculaires. L’objectif de cette etude est de comparer la voie veineuse peripherique (VVP) a la voie veineuse centrale (VVC) dans la prise en charge des patients avec MVE. Patients et methodes Il s’agit d’une etude prospective, realisee entre janvier et mars 2015 au centre de traitement Ebola pour soignants de Conakry. Les caracteristiques de l’ensemble des abords IV poses ont ete recueillies. Le critere de jugement principal etait le ratio volume de perfusion effectif/volume prescrit (VE/VP). Resultats Parmi les 14 patients admis, 13 ont eu au moins un abord vasculaire. L’indication majoritaire etait la rehydratation (87 %), suivie par l’administration de traitement IV. Vingt-huit VVP et 8 VVC ont ete posees avec un taux de succes a la premiere tentative de 86,7 % et 75 %. Il n’y a eu aucun accident d’exposition virale lie aux abords IV ; 37,5 % des VVC ont eu une complication mineure, il n’y a eu aucune complication majeure. La duree mediane de survie des VVC etait superieure (96 ± 34 vs 33,5 ± 21, p p = 0,12). Le VE/VP etait superieur dans le groupe VVC (moyenne 0,95 ± 0,08 vs 0,7 ± 0,27, p p = 0,002). Chaque VVC permettaient d’eviter une mediane de 4,5 (IC 95 % 2–5,5) ponctions vasculaires par patient ( Tableau 1 et Fig. 1 ). Discussion Aucune etude n’a compare les modalites d’abord IV pour les patients avec MVE. La VVP est cependant recommandee en premiere intention [2] . Le faible taux de survie observe pourrait compromettre la delivrance effective des volumes de perfusion prescrits, perennisant l’hypovolemie et majorant le risque de defaillance d’organe. La VVC a ete utilisee avec succes en conditions epidemiques [3] ou elle a montre une diminution de l’exposition des soignants au risque viral. Notre etude confirme qu’il s’agit d’une alternative fiable et sure a la VVP dans ce contexte. Elle suggere une amelioration de la delivrance du remplissage vasculaire, composante prioritaire de la prise en charge des patients avec MVE. Une evaluation prospective de l’impact clinique du type d’abord vasculaire dans cette pathologie est souhaitable.

Dear Editor, The actual outbreak of Ebola virus disease (EVD) started in December 2013 in West Africa, and spread from Guinea to Sierra Leone and Liberia. Organ dysfunctions during EVD have only been described through case reports managed in high income countries, and data are still lacking [1]. The Sepsis-related Organ Failure Assessment (SOFA) score has been developed to quantitatively describe the degree of organ dysfunction in intensive care unit septic patients [2]. We aimed to characterize the severity of Ebola patients admitted to our center by calculating the SOFA score on admission. After approval by the local ethics committee, SOFA score was calculated in Ebola-infected patients using the most abnormal values from the first 24 h after admission. Data were collected between January and April 2015. A total of 38 patients were admitted, of whom 22 were infected with Ebola. Results are expressed as mean ± standard deviation. The mean age of confirmed cases was 33 years (±9). Mean viral load expressed as cycle threshold (CT) at admission was 21.6 (±3.9). On the 22 patients, six died (mortality rate of 27.3 %). Mean SOFA score at admission was 2.6 (±1.7). SOFA score at admission was significantly higher in non-survivors than in survivors (4.8 ± 1.7 versus 1.7 ± 1, P = 0.001). Mean viral load was also higher in non-survivors (CT at 17.7 ± 3.8 versus 23 ± 3.1, P = 0.006). Renal dysfunction was the most frequent dysfunction on admission in non-survivors (Fig. 1). Relationships between admission patients’ conditions and outcome have never been explored during EVD, except for age and viral load [3]. A study analyzing the WHO case investigation form data of 3343 infected patients reported a high mortality rate above 70 %, but patients’ organ dysfunctions could not have been scored [4]. In this study, hemorrhage, coma, and ‘‘difficulty breathing’’ were not commonly reported in patients who died, suggesting that massive fluid loss due to gastrointestinal disorders may be the main factor of worse outcome. Another study reported a lower mortality rate of 43 % [3]. Risk of death was associated with an older age, but this study failed in identifying other factors, mainly because biological data on admission were also limited as no routine clinical laboratory testing was available. Presented data showed that patients were hemodynamically stable on admission and had no respiratory dysfunction (3 % of patients with oxygen therapy). Our results highlighted two main points. The first is that cardiovascular, respiratory, and neurological dysfunctions were not common on admission in Ebola patients, even in non-survivors. The second is the frequency of renal dysfunction. Acute kidney injury during EVD may be promoted by several factors: hypovolemia due to gastrointestinal fluid loss, inflammatory response, viral injury as suggested by histopathological examination of tissues from infected animals showing indications of interstitial nephritis [5]. Larger studies are needed to describe objectively organ dysfunction in Ebola patients and evolution during stay. It may also help to optimize the preparation of treatment facilities according to local available resources for the next outbreaks.

RESUME L’epidemie de maladie a virus Ebola sevit en Guinee depuis debut 2014. La Francea propose son aide a la Guinee dans le cadre de la lutte contre Ebola sous la forme d’un soutien de ses soignants durement touches par l’epidemie. Le Service de Sante des Armees a repondu a cette mission par la mise en œuvre d’un centre de traitement des soignants a Conakry, operationnel depuis janvier 2015.

Introduction L’epidemie a virus Ebola qui sevit en Guinee depuis 2013 a tue 101 soignants et contamine 76 autres. Premiere structure deployee par le service de sante des armees dans le cadre d’une mission de type risque « biologique », le centre de traitement des soignants (CTS) est operationnel depuis le 23 janvier 2015 a Conakry. Patients et methodes Tout soignant diagnostique ou suspect de maladie a virus Ebola (MVE) peut etre transfere au CTS sur demande d’une structure de soin luttant contre Ebola. Le patient/soignant sera admis en chambre individuelle en zone dediee aux cas confirmes ou probables. La biologie est realisee dans le CTS par un laboratoire P3 effectuant les PCR Ebola, des examens biologiques simples ainsi que des tests rapides VIH et paludisme. Le patient est traite par voie orale, ou intraveineuse en tenant compte des recommandations de l’OMS. En cas de MVE, un traitement par Favipiravir est propose dans le cadre d’un essai therapeutique national. Tous les soins sont faits en equipement de protection individuelle (EPI) etanche avec un niveau maximal de biosecurite. Resultats Trois patients guineens confirmes Ebola ont ete admis au CTS avec la notion de contact contaminant communautaire pour deux d’entre eux. Deux sur trois sont febriles, ils sont astheniques et presentent des signes digestifs et un syndrome algique diffus non specifique. Deux ont presente une injection conjonctivale isolee ; les signes d’hemorragie, complication specifique semble inconstante dans l’epidemie actuelle. Le bilan biologique initial montre des anomalies habituelles au cours de la MVE avec une augmentation predominante des ASAT, des CPK et des D-dimeres. Le bilan d’hemostase est normal. La PCR quantitative en temps reel a estime une viremie tres elevee pour un patient ( cycle treshold a 17 vs 25 et 34 pour les 2 autres). Les TDR VIH et paludisme sont negatifs. Tous sont traites par favipiravir, et traitements PO, avec necessite d’hydratation IV pour deux d’entre eux. Apres 15 jours, les 3 patients sortent gueris, sans sequelle immediate. Huit cas probables ont ete admis pour fievre associee a des signes digestifs ou ORL. Quatre ont eu un contact recent avec des patients contamines mais sous EPI et sans notion d’accident d’exposition virale. L’enquete clinico-biologique a conclu a des non-cas avec deux PCR Ebola negatives a 72 h d’intervalle. Les diagnostics differentiels retenus sont : une angine, un acces a P. falciparum , une pneumopathie, deux bronchites banales, trois gastro-enterites. La duree moyenne de sejour a ete de 2 ½ jours. Conclusion La prise en charge de ces 11 premiers cas a valide le concept du CTS. La planification stricte des tâches, la personnalisation des soins, l’acces au favipiravir, les conditions d’hospitalisation expliquent les excellents resultats obtenus pour les patients Ebola+ dans des contraintes de travail inedites et difficiles.

Objective Acute respiratory distress syndrome (ARDS) is a leading cause of mortality in burn patients. Smoke inhalation, pneumonia and inflammation process are the major causes of ARDS in burn patients. The American European Consensus Conference (AECC) definition proposed in 1994 has recently been revised by the Berlin definition. Our objective was to describe the epidemiology of ARDS comparing the Berlin definition with the AECC definition in a retrospective cohort of burn patients. Methods We reviewed admitted burn adult patients for a two year period, and investigated patient who received mechanical ventilation for more than 48 h and in whom pneumonia was diagnosed. Results 40 patients were analyzed. According to the AECC definition, 11 patients met criteria for ALI (27.5%), and 29 patients for ARDS (72.5%). According to the Berlin definition, all patients met criteria for ARDS: 4 (10%) for a severe ARDS, 25 (62.5%) for a moderate ARDS, 11 (27.5%) for a mild ARDS. Inhalation injury was diagnosed in 10 patients (25%). Categorizing patients with the Berlin definition showed statistically significative difference of mortality within the three groups, but not with the AECC definition. Conclusion The Berlin definition seems to be more accurate than the AECC definition to assess the severity of ARDS in term of outcome in burn patients. This definition may facilitate prompt recognition of ARDS in burn patients, and promote protective ventilation strategy to a larger number of patients.

Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients. This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded. We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p