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The COVID crisis has put hospitals under great stress over the past 2 years and some institutions came close to their breaking points. This has often forced decision makers and the entire institutions to change their practices and the organization of the hospitals in order to continue operating despite limited resources. It has also led some hospitals to develop and implement organizational innovations. This article is based on a qualitative case study analyzing the case of a crisis unit that has implemented various innovative medical and organizational actions in order to manage the flow of resuscitation Covid patients in a large group of hospitals in Paris. This team has implemented a new evaluation scale of resuscitation needs in order to better manage quantitatively and qualitatively the patients’ flow; it has defined medical criteria to select the patients eligible for transfer; it has organized one hundred patients transfers to other hospitals’ intensive care units, in and out of the region, involving private hospitals and private ambulances for a new collaboration. The case allows us to understand innovation in the midst of an extreme situation, when material and human resources are highly constrained, and with very strong time pressure. We highlight the importance of implementing flexible organizational processes and staffing the crisis team with physicians and nurses with specific and complementary skills and experience in flow management and crisis situations.

Introduction Non-operative management is currently the preferred approach in blunt liver trauma, including high grade liver lesions. However, hemodynamic instability imposes the need for an emergency laparotomy, with a perihepatic packing (PHP) to control liver bleeding in most cases. Our retrospective study aimed to assess the outcomes of liver trauma patients who underwent a shortened PHP. Methods All consecutive patients who underwent PHP for blunt liver trauma from 1998 to 2019 in our Level I trauma center were included in the study. Unstable patients with severe liver trauma were transferred to the operating room without any delay, and a collective decision was made to perform abbreviated laparotomy to pack the liver. Demographics, perioperative data, postoperative outcomes, and mortality were retrospectively collected, and survivors and deceased patients were compared with a paired t-test. Results Fifty-nine patients of 206 patients admitted with severe liver injuries were treated with shortened PHP. Thirty-four (57.6%) patients died, including 26 (76.5%) within the first 24 h. Twelve (20.3%) patients had a selective hepatic embolization and eight (13.6%) had an extrahepatic embolization. Forty-eight patients had an extra abdominal associated injury. This was not a predictive factor of mortality. The removal of packing was performed in 24 patients within 72 h after laparotomy, with an 80% survival rate in these patients. Conclusion Shortened PHP is an effective strategy for controlling liver bleeding in severe hepatic trauma. The mortality rate of these patients is high, but after the removal of packing, the survival is good.

Brain biopsy is a useful surgical procedure in the management of patients with suspected neoplastic lesions. Its role in neurologic diseases of unknown etiology remains controversial, especially in ICU patients. This study was undertaken to determine the feasibility, safety, and the diagnostic yield of brain biopsy in critically ill patients with neurologic diseases of unknown etiology. We also aimed to compare these endpoints to those of non-ICU patients who underwent a brain biopsy in the same clinical context.Monocenter, retrospective, observational cohort study.A French tertiary center.All adult patients with neurologic diseases of unknown etiology under mechanical ventilation undergoing in-ICU brain biopsy between January 2008 and October 2020 were compared with a cohort of non-ICU patients.None.Among the 2,207 brain-biopsied patients during the study period, 234 biopsies were performed for neurologic diseases of unknown etiology, including 29 who were mechanically ventilated and 205 who were not ICU patients. Specific histological diagnosis and final diagnosis rates were 62.1% and 75.9%, respectively, leading to therapeutic management modification in 62.1% of cases. Meningitis on prebiopsy cerebrospinal fluid analysis was the sole predictor of obtaining a final diagnosis (2.3 [1.4-3.8]; p = 0.02). ICU patients who experienced therapeutic management modification after the biopsy had longer survival (p = 0.03). The grade 1 to 4 (mild to severe) complication rates were: 24.1%, 3.5%, 0%, and 6.9%, respectively. Biopsy-related mortality was significantly higher in ICU patients compared with non-ICU patients (6.9% vs 0%; p = 0.02). Hematological malignancy was associated with biopsy-related mortality (1.5 [1.01-2.6]; p = 0.04).Brain biopsy in critically ill patients with neurologic disease of unknown etiology is associated with high diagnostic yield, therapeutic modifications and postbiopsy survival advantage. Safety profile seems acceptable in most patients. The benefit/risk ratio of brain biopsy in this population should be carefully weighted.

Resume Le College national des enseignants d’anesthesie et de reanimation (CNEAR) reunit les 181 professionnels hospitalo-universitaires de l’anesthesie-reanimation impliques dans l’enseignement et la recherche en anesthesie, reanimation et medecine perioperatoire. Les objectifs du CNEAR pour la discipline anesthesie-reanimation & medecine peri-operatoire sont avant tout pedagogiques, a destination des etudiants du troisieme et du deuxieme cycle des etudes medicales. Le CNEAR intervient ainsi dans l’organisation, l’evaluation et la validation de l’enseignement du troisieme cycle des specialites medicales. Il realise la publication d’un referentiel actualise de connaissances a destination des etudiants du deuxieme cycle des etudes medicales. Grâce a un partenariat fort avec l’universite numerique en sante et sport (UNESS), le CNEAR assure la mise en ligne de contenus pedagogiques sur la plateforme SIDES NG, la mise en place du livret electronique de l’interne et le suivi regulier du curriculum des internes. Les membres du CNEAR participent egalement a la representation de la discipline aupres des pouvoirs publics et des tutelles au sein du Conseil national professionnel d’anesthesie-reanimation et medecine peri-operatoire (CNP-ARMPO). Pour atteindre ces objectifs, le CNEAR travaille en etroite collaboration avec la sous-section 48-01 (Anesthesie-reanimation et medecine peri-operatoire) du Conseil national des universites et la Societe francaise d’anesthesie et de reanimation (SFAR). Il est par ailleurs membre de droit du CNP-ARMPO et de la Coordination nationale des colleges d’enseignants en medecine (CNCEM) et etend ses collaborations internationales grâce a un partenariat prometteur avec UNESS-International.

Background Mortality is high in older patients hospitalized with COVID-19. Previous studies observed lower mortality during the Omicron wave, yet no data is available on older patients. The objective was to compare in-hospital mortality between the Omicron and previous waves in older patients hospitalized with COVID-19. Methods This retrospective observational multicenter cohort study used the Greater Paris University Hospitals Group’s data warehouse (38 hospitals). Patients aged ≥ 75 years with a confirmed COVID-19 diagnosis and hospitalized from March 2020 to January 2022 were included. The study period was divided into five waves. The fifth wave (January 1st to 31st 2022) was considered as the Omicron wave as it was the predominant variant (≥ 50%), and was compared with waves 1 (March-July 2020), 2 (August-December 2020), 3 (January-June 2021) and 4 (July-December 2021). Primary outcome was in-hospital mortality. Secondary outcome was occurrence of ICU admission or in-hospital death. Multivariate logistic regression was performed, with a sensitivity analysis according to variant type. Results Of the 195,084 patients hospitalized with COVID-19, 19,909 patients aged ≥ 75 years were included (median age 85 [IQR 79–90] years, 53% women). Overall in-hospital mortality was 4,337 (22%), reaching 345 (17%) during wave 5. Waves 1 and 3 were significantly associated with increased in-hospital mortality in comparison with wave 5 (adjusted Odds Ratios aOR 1.42 [95%CI 1.21–1.66] and 1.56 [95%CI 1.33–1.83] respectively). Waves 1 to 3 were associated with an increased risk of occurrence of ICU admission or in-hospital death in comparison with wave 5: aOR 1.29 [95% CI 1.12 to 1.49] for wave 1, aOR 1.25 [95% CI 1.08 to 1.45] for wave 2 and aOR 1.56 [95% CI 1.36 to 1.79] for wave 3. Sensitivity analysis found that Omicron variant was associated with decreased mortality, in comparison with previous variants. Conclusions Mortality was lower during the 5th Omicron wave in the older population, but remained high, implying that this variant could be considered as “milder” but not “mild”. This persistently high mortality during the 5th Omicron wave highlights the importance of including older patients in clinical trials to confirm the benefit/risk balance of COVID-19 treatments in this fragile population.

BackgroundManagement of bowel traumatic injuries is a challenge. Although anastomotic or suture leak remains a feared complication, preserving bowel continuity is increasingly the preferred strategy. The aim of this study was to evaluate the outcomes of such a strategy.MethodsAll included patients underwent surgery for bowel traumatic injuries at a high volume trauma center between 2007 and 2017. Postoperative course was analyzed for abdominal complications, morbidity and mortality.ResultsAmong 133 patients, 78% had small bowel injuries and 47% had colon injuries. 87% of small bowel injuries and 81% of colon injuries were treated with primary repair or anastomosis, with no difference in treatment according to injury site (p = 0.381). Mortality was 8%. Severe overall morbidity was 32%, and abdominal complications occurred in 32% of patients. Risk factors for severe overall morbidity were stoma creation (p = 0.036), heavy vascular expansion (p = 0.005) and a long delay before surgery (p = 0.023). Fistula rate was 2.2%; all leaks occurred after repairing small bowel wounds.ConclusionPrimary repair of bowel injuries should be the preferred option in trauma patient, regardless of the site—small bowel or colon—of the injury. Stoma creation is an important factor for postoperative morbidity, which should be weighed against the risk of an intestinal suture or anastomosis.

En mars 2021, l’Île-de-France a connu une nouvelle vague de Covid-19. Face à une projection épidémique faisant craindre un dépassement des capacités, la cellule de crise de l’Assistance publique-Hôpitaux de Paris a validé la mise en oeuvre du projet Météor. Météor est la transformation d’un restaurant du personnel du CHU Pitié-Salpêtrière en réanimation d’accueil et d’orientation de patients Covid-19 avant qu’ils ne soient adressés à des réanimations plus pérennes sur site ou en dehors. Cette démarche n’ayant jamais été pensée auparavant, tout était à construire. Une équipe projet composée d’un cadre de santé, d’un médecin, d’un ingénieur et d’un directeur a piloté sa mise en oeuvre. Le projet s’est voulu modulable, démontable et intégré comme une ressource zonale. En à peine 15 jours, l’unité était opérationnelle. L’organisation des soins a été simplifiée et standardisée au maximum pour que chaque personnel puisse assurer sa mission en sérénité malgré un contexte et des lieux inhabituels. L’efficacité de la mise en oeuvre du projet est liée à l’expertise des équipes en place et au caractère multiprofessionnel de l’équipe projet. Le point de fragilité s’est avéré être les ressources humaines. La constitution d’un corps de réserve sanitaire de personnels de soins critiques est nécessaire pour anticiper la prochaine crise.

Resume Les hopitaux representent, de toute evidence, une cible sensible pour une agression collective a caractere terroriste. Le fonctionnement tres particulier associant une activite de soins permanents, milieu par definition ouvert, et une capacite a accueillir, a tout moment, un afflux de blesses va determiner la reponse strategique en cas d’intrusion. Cette reponse doit imperativement etre coordonnee entre, d’une part, la direction de l’hopital, l’equipe de soins et, d’autre part, les acteurs publics de la securite interieure et du secours. Cela demande une preparation specifique impliquant, en premier lieu, la cellule de crise, mais aussi l’ensemble du personnel hospitalier. L’elaboration d’un plan, regulierement remis a jour et connu de tous, sera indispensable pour reduire au mieux la phase initiale de chaos. Il est urgent d’introduire une culture de l’exercice dans les hopitaux. Sans monopoliser inutilement le personnel, mais en cherchant avant tout a evaluer sa capacite pour repondre a une intrusion. La coordination des equipes soignantes avec la police et les secours (pompiers et samu) est essentielle. Elle est la cle de la reussite. Elle doit donc etre travaillee, sans relâche, par les acteurs qui occuperont une place de decideur dans les differents postes de commandement ou cellule de crise. En outre, il faut imperativement se preparer a etre surpris et mis sous forte tension. La destabilisation de l’hopital agresse est logique, mais la poursuite de l’activite est un enjeu majeur. Les mouvements de foule spontanee, dans et autour de l’hopital, impacteront fortement la strategie de reponse. Ils sont, certes, difficiles a modeliser, mais ne pas les anticiper serait une erreur. Enfin, il est primordial d’anticiper un point de rupture pour garder un peu d’avance dans l’organisation de la reponse, meme s’il ne fait aucun doute qu’une acceptation de l’imprevu est obligatoire. Cela aussi doit s’apprehender.

Rationale: Sleep deprivation can alter endurance of skeletal muscles, but its impact on respiratory command is unknown.Objectives: We aimed to assess the effect of sleep deprivation on respiratory ...

International audience; Objective: Identify issues that are important to severe trauma survivors up to 3 years after the trauma. Background: Severe trauma is the first cause of disability-adjusted life years worldwide, yet most attention has focused on acute care and the impact on long-term health is poorly evaluated. Method: We conducted a large-scale qualitative study based on semi-structured phone interviews. Qualitative research methods involve the systematic collection, organization, and interpretation of conversations or textual data with patients to explore the meaning of a phenomenon experienced by individuals themselves. We randomly selected severe trauma survivors (abbreviated injury score ≥3 in at least 1 body region) who were receiving care in 6 urban academic level-I trauma centers in France between March 2015 and March 2018. We conducted double independent thematic analysis. Issues reported by patients were grouped into overarching domains by a panel of 5 experts in trauma care. Point of data saturation was estimated with a mathematical model. Results: We included 340 participants from 3 months to 3 years after the trauma [median age: 41 years (Q1-Q3 24-54), median injury severity score: 17 (Q1-Q3 11-22)].We identified 97 common issues that we grouped into 5 overarching domains: Body and neurological issues (29 issues elicited by 277 participants), biographical disruption (23 issues, 210 participants), psychological and personality issues (21 issues, 147 participants), burden of treatment (14 issues, 145 participants), and altered relationships (10 issues, 87 participants). Time elapsed because the trauma, injury location, or in-hospital trauma severity did not affect the distribution of these domains across participants' answers. Conclusions: This qualitative study explored trauma survivors' experiences of the long-term effect of their injury and allowed for identifying a set of issues that they consider important, including dimensions that seem overlooked in trauma research. Our findings confirm that trauma is a chronic medical condition that demands new approaches to post-discharge and longterm care.

New finding What is the central question of this study? Transition to supine posture induces an inspiratory load associated with cortical activation in awake healthy subjects. Some obstructive sleep apnoea patients exhibit this cortical activity in the sitting position contributing to the arousal-dependent compensation of their upper airway abnormalities. Does a transition to the supine posture in awake obstructive sleep apnoea patients increase this cortical activity? What is the main finding and its importance? The transition to supine posture induces a reduction in the cortical activity despite evidence of an increase in genioglossus activity, suggesting that genioglossus activation is not driven by cortical activity. Abstract The anatomy and mechanical properties of the upper airway (UA) depend on posture. Lying in a supine position causes cephalad fluid shift to the neck, thus narrowing the UA and predisposing the individual to obstructive sleep apnoea (OSA). Increased UA dilator muscle activity during wakefulness prevents the UA collapse but the underlying mechanism has not yet been elucidated. In the sitting position during wakefulness, some OSA patients exhibit preinspiratory cortical activity (preinspiratory potential, PIP) probably related to UA abnormalities. The aim of this study was to investigate changes in the preinspiratory cortical activity and UA dilator muscle in OSA patients during postural challenge. An electroencephalogram was used to detect PIP, and the genioglossus electromyographic activity and ventilation were analysed in 17 awake, male OSA patients while they were sitting, just after lying down, and then in response to leg positive pressure to enhance cephalad fluid shift. The prevalence of PIP decreased from 53% (sitting) to 12% (supine) (P = 0.002) in association with increased genioglossus activity (tonic from median (25th, 75th centiles) 2.3 (1.8, 2.8)% to 3.6 (1.7, 5.0)% of voluntary deglutition, P = 0.019; phasic from 2.3 (1.9, 2.8)% to 3.7 (2.0, 6.1)%, P = 0.024), and with increased transcutaneous carbon dioxide pressure (from 43.0 (42.4, 44.2) to 44.6 (43.5, 45.2) mmHg). No change was observed during leg-positive-pressure application. Moving from the sitting position to the supine position reduces respiratory-related premotor cortical activity in awake OSA patients. The concomitant increase in genioglossus activity, therefore, is not driven by cortical respiratory activity.

Resume Les besoins de formation en anesthesistes-reanimateurs (AR) sont eleves pour la valence anesthesie de la specialite. Ils sont moins bien identifies pour la reanimation (rea) et restent debattus. L’objectif de cette enquete pilotee par le College national des enseignants d’anesthesie et de reanimation (CNEAR) etait d’etayer, sur la base d’elements chiffres, les decisions des pouvoirs publics concernant la determination du nombre d’etudiants affectes a l’issue des ECN pour le Co-DESAR-MIR avec une vision nationale et regionale des besoins de sante publique. Dans ce but, une evaluation des besoins en medecins dans les unites de reanimation et les USC en France a ete conduite. Les coordonnateurs de subdivision du DESAR (n = 28), ont complete un questionnaire portant sur les unites de surveillance continue (USC) et de reanimation incluant les CHU, les CHG, les ESPIC et les structures liberales. Pour chaque unite de reanimation et d’USC en France quel qu’en soit le type (medical, chirurgical, mixte), les donnees suivantes etaient colligees : nombre de lits, de medecins y exercant (âge ≥ 58 ans, non-AR et non-MIR) et prevision d’ouverture de lits. Les resultats montrent un ratio lits/medecin de 2 en reanimation et de 4,3 en USC, considere comme satisfaisant aux regards des besoins fonctionnels. La proportion de medecins anesthesistes-reanimateurs âges de plus de 58 ans etait de 66 % en rea et de 69 % en USC. Les donnees demographiques objectives sur les besoins de formation de la filiere du Co-DESAR-DESMIR devront etre prises en compte par les pouvoirs publics pour determiner dans l’avenir les flux de formation dans ces deux disciplines dans une vision de sante publique.

La capacité à accueillir un afflux massif de victimes au sein d’un hôpital fait partie des obligations de tout établissement de santé (ES). Les modalités de cet accueil sont définies de façon réglementaire par le plan blanc d’établissement. Chaque ES doit s’entraîner. Les exercices sont un élément clé pour apprendre à mieux faire face à ces situations sanitaires exceptionnelles et inhabituelles. Ils permettent de tester les dispositifs et procédures en place, d’acquérir de l’expérience, de déterminer les points forts, les faiblesses et les axes d’amélioration. La conception d’un exercice nécessite avant tout la définition de ses grandes caractéristiques (contexte, type, objectifs), la détermination du cadre et du périmètre de l’exercice (convention d’exercice), la détermination des ressources humaines (animateurs, plastrons, évaluateurs, observateurs) et matérielles nécessaires. Il faudra aussi écrire le scénario (initial, cadence, évolutions prévues), organiser les conditions d’animation (dossier d’exercice) et d’observation, définir les modalités de briefing, de débriefing et les modalités d’évaluation (outils et critères). L’exercice devra mener à un retour d’expérience avec propositions de mesures correctrices si nécessaire. Il doit être piloté par un comité de pilotage multiprofessionnel sous l’égide du directeur d’établissement ou de son représentant. Il doit être conçu comme une étape dans un processus d’amélioration des pratiques professionnelles au profit des patients.

Blood transfusion is a mainstay of therapy for trauma-induced coagulopathy, but the optimal modalities for plasma transfusion in the prehospital setting remain to be defined.To determine whether lyophilized plasma transfusion can reduce the incidence of trauma-induced coagulopathy compared with standard care consisting of normal saline infusion.This randomized clinical trial was performed at multiple centers in France involving prehospital medical teams. Participants included 150 adults with trauma who were at risk for hemorrhagic shock and associated coagulopathy between April 1, 2016, and September 30, 2019, with a 28-day follow-up. Data were analyzed from November 1, 2019, to July 1, 2020.Patients were randomized in a 1:1 ratio to receive either plasma or standard care with normal saline infusion (control).The primary outcome was the international normalized ratio (INR) on arrival at the hospital. Secondary outcomes included the need for massive transfusion and 30-day survival. As a safety outcome, prespecified adverse events included thrombosis, transfusion-related acute lung injury, and transfusion-associated circulatory overload.Among 150 randomized patients, 134 were included in the analysis (median age, 34 [IQR, 26-49] years; 110 men [82.1%]), with 68 in the plasma group and 66 in the control group. Median INR values were 1.21 (IQR, 1.12-1.49) in the plasma group and 1.20 (IQR, 1.10-1.39) in the control group (median difference, -0.01 [IQR, -0.09 to 0.08]; P = .88). The groups did not differ significantly in the need for massive transfusion (7 [10.3%] vs 4 [6.1%]; relative risk, 1.78 [95% CI, 0.42-8.68]; P = .37) or 30-day survival (hazard ratio for death, 1.07 [95% CI, 0.44-2.61]; P = .89). In the full intention-to-treat population (n = 150), the groups did not differ in the rates of any of the prespecified adverse events.In this randomized clinical trial including severely injured patients at risk for hemorrhagic shock and associated coagulopathy, prehospital transfusion of lyophilized plasma was not associated with significant differences in INR values vs standard care with normal saline infusion. Nevertheless, these findings show that lyophilized plasma transfusion is a feasible and safe procedure for this patient population.ClinicalTrials.gov Identifier: NCT02736812.

Background Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. Methods We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. Results Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). Conclusion This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21–036.

Backround Triage is key in the management of mass casualty incidents. Objective The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack. Design setting and participant This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files. Outcomes measures and analysis The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category. Main result Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged. Conclusion A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.

We aimed to assess the incidence and the risk factors for secondary wound infections associated to high-energy ammunition injuries (HEAI) in the cohort of civilian casualties from the 2015 terrorist attacks in Paris.This retrospective multi-centric study included casualties presenting at least one HEAI who underwent surgery during the first 48 h following hospital admission. HEAI-associated infection was defined as a wound infection occurring within the initial 30 days following trauma. Risk factors were assessed using univariate and multivariate analysis.Among the 200 included victims, the rate of infected wounds was 11.5%. The median time between admission and the surgical revision for secondary wound infection was 11 days [IQR 9-20]. No patient died from an infectious cause. Infections were polymicrobial in 44% of the cases. The major risk factors for secondary wound infection were ISS (p 0.001), SAPS II (p 0.001), MGAP (p 0.001), haemorrhagic shock (p = 0.003), use of vasopressors (p 0.001), blood transfusion (p 0.001), abdominal penetrating trauma (p = 0.003), open fracture (p = 0.01), vascular injury (p = 0.001), duration of surgery (p = 0.009), presence of surgical material (p = 0.01). In the multivariate analysis, the SAPS II score (OR 1.07 [1.014-1.182], p = 0.019) and the duration of surgery (OR 1.005 [1.000-1.012], p = 0.041) were the only risk factors identified.We report an 11.5% rate of secondary wound infection following high-energy ammunition injuries. Risk factors were an immediately severe condition and a prolonged surgery.

Key Points Question Can electroencephalography (EEG), combined with clinical, biological, and magnetic resonance imaging (MRI) analyses, help to better characterize patients with neurologic coronavirus disease 2019 (COVID-19) and diagnose specific COVID-19–related encephalopathy? Findings Neurologic manifestations, biological findings, EEG findings, and brain MRI images were analyzed in a cohort study of 78 adult patients with COVID-19. Nine patients had no identified cause of brain injury, as revealed by biological and MRI findings; their injury was defined as COVID-19–related encephalopathy. Meaning This study suggests that, although neurologic manifestations, EEG findings, and MRI findings may appear heterogeneous and nonspecific, multimodal monitoring may better identify patients with COVID-19–related encephalopathy and guide treatment strategy., Importance There is evidence of central nervous system impairments associated with coronavirus disease 2019 (COVID-19) infection, including encephalopathy. Multimodal monitoring of patients with COVID-19 may delineate the specific features of COVID-19–related encephalopathy and guide clinical management. Objectives To investigate clinical, biological, and brain magnetic resonance imaging (MRI) findings in association with electroencephalographic (EEG) features for patients with COVID-19, and to better refine the features of COVID-19–related encephalopathy. Design, Setting, and Participants This retrospective cohort study conducted in Pitié-Salpêtrière Hospital, Paris, France, enrolled 78 hospitalized adults who received a diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) and underwent EEG between March 30 and June 11, 2020. Exposures Detection of SARS-CoV-2 from a nasopharyngeal specimen using a reverse transcription–polymerase chain reaction assay or, in the case of associated pneumonia, on a computed tomography scan of the chest. Main Outcomes and Measures Data on the clinical and paraclinical features of the 78 patients with COVID-19 were retrieved from electronic patient records. Results Of 644 patients who were hospitalized for COVID-19, 78 (57 men [73%]; mean [SD] age, 61 [12] years) underwent EEG. The main indications for EEG were delirium, seizure-like events, and delayed awakening in the intensive care unit after stopping treatment with sedatives. Sixty-nine patients showed pathologic EEG findings, including metabolic-toxic encephalopathy features, frontal abnormalities, periodic discharges, and epileptic activities. Of 57 patients who underwent brain MRI, 41 showed abnormalities, including perfusion abnormalities, acute ischemic lesions, multiple microhemorrhages, and white matter–enhancing lesions. Fifty-five patients showed biological abnormalities, including dysnatremia, kidney failure, and liver dysfunction, the same day as the EEG. The results of cerebrospinal fluid analysis were negative for SARS-Cov-2 for all tested patients. Nine patients who had no identifiable cause of brain injury outside COVID-19 were further isolated; their brain injury was defined as COVID-19–related encephalopathy. They represented 1% (9 of 644) of patients with COVID-19 requiring hospitalization. Six of these 9 patients had movement disorders, 7 had frontal syndrome, 4 had brainstem impairment, 4 had periodic EEG discharges, and 3 had MRI white matter–enhancing lesions. Conclusions and Relevance The results from this cohort of patients hospitalized with COVID-19 suggest there are clinical, EEG, and MRI patterns that could delineate specific COVID-19–related encephalopathy and guide treatment strategy., This cohort study investigates clinical, biological, and brain magnetic resonance imaging (MRI) findings in association with electroencephalographic (EEG) features for patients with coronavirus disease 2019 (COVID-19) and refines the features of COVID-19–related encephalopathy.

International audience; Background This study provides a detailed imaging assessment in a large series of patients infected with coronavirus disease 2019 (COVID-19) and presenting with neurologic manifestations. Purpose To review the MRI findings associated with acute neurologic manifestations in patients with COVID-19. Materials and Methods This was a cross-sectional study conducted between March 23 and May 7, 2020, at the Pitié-Salpêtrière Hospital, a reference center for COVID-19 in the Paris area. Adult patients were included if they had a diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with acute neurologic manifestations and referral for brain MRI. Patients with a prior history of neurologic disease were excluded. The characteristics and frequency of different MRI features were investigated. The findings were analyzed separately in patients in intensive care units (ICUs) and other departments (non-ICU). Results During the inclusion period, 1176 patients suspected of having COVID-19 were hospitalized. Of 308 patients with acute neurologic symptoms, 73 met the inclusion criteria and were included (23.7%): thirty-five patients were in the ICU (47.9%) and 38 were not (52.1%). The mean age was 58.5 years ± 15.6 [standard deviation], with a male predominance (65.8% vs 34.2%). Forty-three patients had abnormal MRI findings 2-4 weeks after symptom onset (58.9%), including 17 with acute ischemic infarct (23.3%), one with a deep venous thrombosis (1.4%), eight with multiple microhemorrhages (11.3%), 22 with perfusion abnormalities (47.7%), and three with restricted diffusion foci within the corpus callosum consistent with cytotoxic lesions of the corpus callosum (4.1%). Multifocal white matter-enhancing lesions were seen in four patients in the ICU (5%). Basal ganglia abnormalities were seen in four other patients (5%). Cerebrospinal fluid analyses were negative for SARS-CoV-2 in all patients tested (n = 39). Conclusion In addition to cerebrovascular lesions, perfusion abnormalities, cytotoxic lesions of the corpus callosum, and intensive care unit-related complications, we identified two patterns including white matter-enhancing lesions and basal ganglia abnormalities that could be related to severe acute respiratory syndrome coronavirus 2 infection. © RSNA, 2020 Online supplemental material is available for this article.

Preliminary clinical data indicate that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with neurological and neuropsychiatric illness. Responding to this, a weekly virtual coronavirus disease 19 (COVID-19) neurology multi-disciplinary meeting was established at the National Hospital, Queen Square, in early March 2020 in order to discuss and begin to understand neurological presentations in patients with suspected COVID-19-related neurological disorders. Detailed clinical and paraclinical data were collected from cases where the diagnosis of COVID-19 was confirmed through RNA PCR, or where the diagnosis was probable/possible according to World Health Organization criteria. Of 43 patients, 29 were SARS-CoV-2 PCR positive and definite, eight probable and six possible. Five major categories emerged: (i) encephalopathies (n = 10) with delirium/psychosis and no distinct MRI or CSF abnormalities, and with 9/10 making a full or partial recovery with supportive care only; (ii) inflammatory CNS syndromes (n = 12) including encephalitis (n = 2, para- or post-infectious), acute disseminated encephalomyelitis (n = 9), with haemorrhage in five, necrosis in one, and myelitis in two, and isolated myelitis (n = 1). Of these, 10 were treated with corticosteroids, and three of these patients also received intravenous immunoglobulin; one made a full recovery, 10 of 12 made a partial recovery, and one patient died; (iii) ischaemic strokes (n = 8) associated with a pro-thrombotic state (four with pulmonary thromboembolism), one of whom died; (iv) peripheral neurological disorders (n = 8), seven with Guillain-Barré syndrome, one with brachial plexopathy, six of eight making a partial and ongoing recovery; and (v) five patients with miscellaneous central disorders who did not fit these categories. SARS-CoV-2 infection is associated with a wide spectrum of neurological syndromes affecting the whole neuraxis, including the cerebral vasculature and, in some cases, responding to immunotherapies. The high incidence of acute disseminated encephalomyelitis, particularly with haemorrhagic change, is striking. This complication was not related to the severity of the respiratory COVID-19 disease. Early recognition, investigation and management of COVID-19-related neurological disease is challenging. Further clinical, neuroradiological, biomarker and neuropathological studies are essential to determine the underlying pathobiological mechanisms, which will guide treatment. Longitudinal follow-up studies will be necessary to ascertain the long-term neurological and neuropsychological consequences of this pandemic.

SARS-CoV-2 can cause severe pneumonia requiring invasive mechanical ventilation [2], in the context of atypical acute respiratory distress syndrome (ARDS) [3]. The magnitude of the epidemic places an unprecedented pressure on intensive care units (ICU), making avoidance of intubation a critical issue., COVID-19 pneumonia can be life-threatening. Given the unprecedented burden place on ICU resources by the epidemic, avoiding intubation is a major issue. This study suggests that CPAP can achieve this objective.