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Objectives: Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods: A scoping review was conducted on Medline database from inception to September 2021. Results: The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion: This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.

Introduction To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. Materials and Methods We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. Results The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). Conclusion Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.

International audience; Rationale: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown.Objectives: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2

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 The death rate in intensive care units (ICUs) can reach 20%. More than half occurs after a decision of care withholding/withdrawal. We aimed at describing and evaluating the experience of ICU physicians and nurses involved in the end-of-life (EOL) procedure. Primary objective was the evaluation of the experience of EOL assessed by the CAESAR questionnaire. Secondary objectives were to describe factors associated with a low or high score and to examine the association between Numeric Analogic Scale and quality of EOL. Methods Consecutive adult patients deceased in 52 ICUs were included between April and June 2018. Characteristics of patients and caregivers, therapeutics and care involved after withdrawal were recorded. CAESAR score included 15 items, rated from 1 (traumatic experience) to 5 (comforting experience). The sum was rated from 15 to 75 (the highest, the best experience). Numeric Analogic Scale was rated from 0 (worst EOL) to 10 (optimal EOL). Results Five hundred and ten patients were included, 403 underwent decision of care withholding/withdrawal, and among them 362 underwent effective care withdrawal. Among the 510 patients, mean CAESAR score was 55/75 (± 6) for nurses and 62/75 (± 5) for physicians (P P = 0.06). CAESAR score and Numeric Analogic Scale were significantly but weakly correlated. They were significantly higher for both nurses and physicians if the patient died after a decision of withholding/withdrawal. In multivariable analysis, among the 362 patients with effective care withdrawal, disagreement on the intensity of life support between caregivers, non-invasive ventilation and monitoring and blood tests the day of death were associated with lower score for nurses. For physicians, cardiopulmonary resuscitation the day of death was associated with lower score in multivariable analysis. Conclusion Experience of EOL was better in patients with withholding/withdrawal decision as compared to those without. Our results suggest that improvement of nurses’ participation in the end-of-life process, as well as less invasive care, would probably improve the experience of EOL for both nurses and physicians. Registration: ClinicalTrial.gov: NCT03392857.

Microvesicles (MVs) have previously been shown to exert profibrinolytic capacity, which is increased in patients with septic shock (SS) with a favorable outcome. We, therefore, hypothesized that the plasmin generation capacity (PGC) could confer to MVs a protective effect supported by their capacity to lyse a thrombus, and we investigated the mechanisms involved. Using an MV-PGC kinetic assay, ELISA, and flow cytometry, we found that granulocyte MVs (Gran-MVs) from SS patients display a heterogeneous PGC profile driven by the uPA (urokinase)/uPAR system. In vitro, these MVs lyse a thrombus according to their MV-PGC levels in a uPA/uPAR-dependent manner, as shown in a fluorescent clot lysis test and a lysis front retraction assay. Fibrinolytic activators conveyed by MVs contribute to approximately 30% of the plasma plasminogenolytic capacity of SS patients. In a murine model of SS, the injection of high PGC Gran-MVs significantly improved mouse survival and reduced the number of thrombi in vital organs. This was associated with a modification of the mouse coagulation and fibrinolysis properties toward a more fibrinolytic profile. Interestingly, mouse survival was not improved when soluble uPA was injected. Finally, using a multiplex array on plasma from SS patients, we found that neutrophil elastase correlates with the effect of high-PGC-capacity plasma and modulates the Gran-MV plasmin generation capacity by cleaving uPA-PAI-1 complexes. In conclusion, we show that the high PGC level displayed by Gran-MVs reduces thrombus formation and improves survival, conferring to Gran-MVs a protective role in a murine model of sepsis.

Multiloculated hydrocephalus constitutes a challenging pathology due to intracerebral haemorrhage or ventriculitis leading to iterative shunt revision frequently described in paediatric neurosurgery, but poorly reported in adults. Nevertheless, this potential complication of intraventricular haemorrhage, already drained in emergency, should be considered with special interest, as ideal management of cerebrospinal drainage remains debated in such situation. We thus report herein the case of intraventricular haemorrhage in an adult complicated of multiloculated hydrocephalus, as an illustrative plea for endoscopic surgery.

IntroductionAn amphibious assault ship was deployed on 22 March in Corsica to carry out medical evacuation of 12 critical patients infected with COVID-19. The ship has on-board hospital capacity and is the first time that an amphibious assault ship is engaged in this particular condition. The aim is to evaluate the feasibility and safety of prolonged medical evacuation of critical patients with COVID-19.MethodsWe included 12 patients with confirmed COVID-19 infection: six ventilated patients with acute respiratory distress syndrome and six non-ventilated patients with hypoxaemia. Transfer on an amphibious assault ship lasted 20 hours. We collected patients’ medical records: age, comorbidities, COVID-19 history and diagnosis, ventilation supply and ventilator settings, and blood gas results. We calculated oxygen consumption (OC).ResultsAll patients had a medical history. The median delay from onset of symptoms to hospitalisation was 8 (7–10) days. The median Sequential Organ Failure Assessment score on admission was 3 (2–5). There was no significant increase in oxygen during ship transport and no major respiratory complication. There was no significant increase in arterial oxygen pressure to fractional inspired oxygen ratio among ventilated patients during ship transport. Among ventilated patients, the median calculated OC was 255 L (222–281) by hours and 5270 L (4908–5616) during all ship transport. Among non-ventilated patients, the median calculated OC was 120 L (120–480) by hours and 2400 L (2400–9600) during all ship transport.ConclusionThe present work contributes to assessing the feasibility and safety condition of critical COVID-19 evacuation on an amphibious assault ship during an extended transport. The ship needs to prepare a plan and a specialised intensive team and conduct patient screening for prolonged interhospital transfers.

Hypocapnia induces cerebral vasoconstriction leading to a decrease in cerebral blood flow, which might precipitate cerebral ischemia. Hypocapnia can be intentional to treat intracranial hypertension or unintentional due to a spontaneous hyperventilation (SHV). SHV is frequent after subarachnoid hemorrhage. However, it is understudied in patients with severe traumatic brain injury (TBI). The objective of this study was to describe the incidence and consequences on outcome of SHV after severe TBI. We conducted a retrospective, observational study including all intubated TBI patients admitted in the trauma center and still comatose 24 h after the withdrawal of sedation. SHV was defined by the presence of at least one arterial blood gas (ABG) with both PaCO2 7.45. Patient characteristics and outcome were extracted from a prospective registry of all intubated TBI admitted in the intensive care unit. ABG results were retrieved from patient files. A multivariable logistic regression model was developed to determine factors independently associated with unfavorable outcome (defined as a Glasgow Outcome Scale between 1 and 3) at 6-month follow-up. During 7 years, 110 patients fully respecting inclusion criteria were included. The overall incidence of SHV was 69.1% (95% CI [59.9–77]). Patients with SHV were more severely injured (median head AIS score (5 [4–5] vs. 4 [4–5]; p = 0.016)) and exhibited an elevated morbidity during their stay. The proportion of patients with an unfavorable functional neurologic outcome was significantly higher in patients with SHV: 40 (52.6%) versus 6 (17.6%), p = 0.0006. After adjusting for confounders, SHV remains an independent factor associated with unfavorable outcome at the 6-month follow-up (OR 4.1; 95% CI [1.2–14.4]). SHV is common in patients with a persistent coma after a severe TBI (overall rate: 69%) and was independently associated with unfavorable outcome at 6-month follow-up.

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.

Background: Cocaine is one of the most widely used illicit drugs, and it is the most common cause of drug-related death. The association of cocaine use with acute heart failure is a rare occurrence. Case Report: We report the case of a 31 years-old woman who presented Takotsubo cardiomyopathy with severe cardiogenic shock after cocaine abuse. That required the use of high doses of positive inotropic amines and mechanical ventilation. The evolution was quickly favorable after the cessation of cocaine. Discussion: Takotsubo cardiomyopathy is often related to a stressful trigger, and several cases have been described with the use of several psychostimulants. As such, it is not surprising that cocaine use can be associated with the development of Takotsubo cardiomyopathy when it results in excess release of catecholamines and excitation of adrenergic receptors. Conclusion: In critical care unit, Takotsubo cardiomyopathy is a rare complication of cocaine abuse. This etiological diagnosis can be difficult especially in the absence of the concept of toxic intake as it was initially the case for our patient, but the treatment does not differ from other causes of cardiomyopathy and Cessation of cocaine use has been associated with improvement in cardiac function.

To the Editor: We read with interest the comments from Sarc et al[1][1] about our previous study on ![Formula][2] delivered by noninvasive ventilation (NIV) compared with long-term oxygen therapy at the same flow.[2][3] We want to give some precision in response to their comments. Sarc et al

Background Blood clot formation is a multifactorial process and has been related many times in intensive care units. Here is presented a multiple thrombosis formation in a rewarming patient. Case description A 68-year-old patient was admitted to our intensive care unit after lying on the floor for an unknown time. She presented a severe hypothermia at 26° and a severe cardiogenic shock. Because she was confused and was hypoxemic, she had been intubated at her admission. After intravascular warming, we could stop sedative medications. She presented a right hemiparesis and acute left leg ischemia. Computed tomography (CT) scan revealed a constituted left Sylvian stroke and a massive clot along the aorta. She required a surgical embolectomy and fasciotomy. She died after she presented a severe bowel ischemia on the third day after her admission. Conclusion Relevant hypothesis for blood clot formation in this patient may include prolonged lying position or blood temperature variation. Hypothermia and rewarming responsibilities may explain multiple thrombosis development. How to cite this article Schmitt J, Esnault P, Sartre M, Cungi PJ, Meaudre E. Severe Aortic Thrombosis and Profound Hypothermia: A Case Report. Indian J Crit Care Med 2021;25(5):588–589.

Resume Le concept de damage control (DC) se base sur une strategie therapeutique sequentielle visant a privilegier la restauration physiologique sur la reparation anatomique chez des patients polytraumatises hemorragiques dont le pronostic vital est immediatement engage. Initialement decrit sous le nom de damage control surgery (DCS) pour les blesses de guerre presentant des traumatismes abdominaux penetrants hemorragiques, ce concept s’articule en 3 temps : chirurgie de controle lesionnel (hemostase, coprostase), restauration physiologique puis chirurgie de reparation definitive. Ce concept a tres vite ete repris pour la prise en charge reanimatoire sous le nom de damage control resuscitation (DCR) qui designe les modalites de la reanimation hospitaliere conduite chez les patients en etat de choc hemorragique traumatique relevant d’une strategie de damage control (DC). Il repose principalement sur une reanimation hemodynamique specifique et une reanimation hemostatique precoce et agressive visant a lutter precocement contre la triade letale associant coagulopathie, hypothermie et acidose. L’integration des phases reanimatoires et chirurgicales de facon concomitante des l’admission du blesse a conduit au concept appele integrated approach DCR-DCS qui permet de debuter la reanimation hemostatique des l’accueil du blesse ameliorant les conditions physiologiques peroperatoires sans retarder l’acte chirurgical. En constante evolution, ce concept de DC a ete propose egalement des la prise en charge initiale du blesse pour demarrer au plus vite le controle de l’hemorragie et la reanimation hemostatique, realisant le concept de remote DCR (RDCR), mais a aussi ete etendu a la prise en charge radiologique, diagnostique et therapeutique sous le nom de DC radiologique (DCRad). Le DCS ne concerne que les traumatises les plus graves ou les situations d’afflux de blesse, sous peine de risquer d’infliger une surmorbidite non negligeable et inutile a des blesses pouvant etre traites de facon definitive d’emblee. Correctement applique, le DCS permet d’ameliorer significativement le taux de survie des blesses de guerre.

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.

Introduction France deployed to Afghanistan from 2001 to 2014 within the International Security and Assistance Force. A French role 3 hospital was built in 2009 in the vicinity of Kabul International Airport (KaIA). The objectives of this study were to describe the epidemiology, management, and outcome of war-related craniocerebral injuries during the Afghan campaign in a French role 3 hospital. Methods From March 1, 2010 to September 30, 2012, we conducted a retrospective descriptive study in Kabul, Afghanistan. All patients presenting with a ballistic craniocerebral injury to the KaIA role 3 hospital were included. Results We analyzed 48 records. Mean age was 21.9 years (1–46 years) with a 37:11 (male:female) sex ratio and a majority Afghan population ( n = 41). Civilians represented 64.6% ( n = 31) of casualties. On the battlefield, mean Glasgow Coma Scale score was 9.4 [3–15]. On arrival at the KaIA field hospital, 20 of the 48 patients were hemodynamically unstable. All patients underwent a full-body computed tomography scan. The majority of our casualties had associated injuries. Neurosurgery was indicated for 42 (87.5%) patients. The surgery consisted of wound debridement plane by plane associated with decompressive craniectomy ( n = 11), debridement craniectomy ( n = 19), and craniotomy ( n = 12). A total of 32.4% wounded died at the point of injury, 8.4% at the emergency department, and 16.9% after surgery. Conclusions War casualties with ballistic head injuries were predominantly multitraumatized patients with hemodynamic compromise requiring neurosurgical damage control management and multidisciplinary care. The neurosurgeon has thus an essential role to play.

BACKGROUND: Long-term home mechanical ventilation is increasingly used by patients with chronic respiratory failure. Storage of medical data in the cloud is expanding, and ventilation can be monitored remotely. The aim of this bench study was to determine whether tidal volume (VT) can be affected by the location of supplemental oxygen placement. METHODS: We tested 4 home ventilators in a bench test using a dual-chamber test lung to test the addition of supplemental oxygen placement via a connector in the circuit (ie, front intake port) versus via the manufacturer9s rear intake port, with different oxygen supply flows of 2, 4, 6, and 8 L/min. We compared the effectively delivered VT as measured with a pneumotachograph (ie, measured VT) versus the VT reported by each home ventilator (ie, monitored VT). RESULTS: For all of the home ventilators, the monitored VT and measured VT were comparable when the rear oxygen intake was used, regardless of oxygen flow. However, when the front oxygen intake was used, the monitored VT as measured by the ventilators was significantly lower than the measured VT, with the greatest difference reaching 29% for the highest oxygen flow tested (8 L/min). CONCLUSIONS: The monitored VT may be inaccurate if oxygen is added with a connector in the circuit, which may have consequences on both the individual level and collective level (ie, big data analysis). Physicians who analyze data from home ventilators should be aware of the site of oxygen supplementation and promote use of only the rear oxygen intake.

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: Optimal surgical management of spinal injuries as part of life-threatening multiple traumas remains challenging. We provide insights into the surgical management of spinal injuries in polytrauma patients. Methods: All patients from our polytrauma care network who both met at least one positive Vittel criteria and an injury severity score (ISS) >15 at admission and who underwent surgery for a spinal injury were included retrospectively. Demographic data, clinical data demonstrating the severity of the trauma and imaging defining the spinal and extraspinal number and types of injuries were collected.Results: Between January 2012 and December 2016, 302 (22.2%) patients suffered from spinal injury (143 total injuries) and 83 (6.1%) met the inclusion criteria. Mean ISS was 36.2 (16-75). Only 48 (33.6%) injuries led to neurological impairment involving the thoracic (n = 23, 16.1%) and lower cervical (n = 15, 10.5%) spine. The most frequent association of injuries involved the thoracic spine (n = 42). 106 spinal surgeries were performed. The 3-month mortality rate was 2.4%.Conclusions: We present data collected on admission and in the early postoperative period referring to injury severity, the priority of injuries, and development of multi-organ failure. We revealed trends to guide the surgical support of spinal lesions in polytrauma patients.

Rationale: Nocturnal noninvasive ventilation (NIV) is now recommended for hypercapnic chronic pulmonary obstructive disease (COPD) patients (GOLD 2017). Long-term oxygen therapy (LTOT) improve survival in hypoxemic COPD patients. Leaks with NIV should decrease FiO2. Aims and Objectives: Compare nocturnal FiO2 under NIV to day time pharyngeal FiO2 with nasal cannula oxygen therapy (with the same O2 flow) in COPD patient at home. Methods: In an observational study, 14 COPD patients were enrolled at home. In the evening a naso-pharyngeal probe allowed to analyze pharyngeal FiO2 with LTOT. The usual O2 flow was adjusted with a precision flowmeter. Then patient NIV parameters were transcribed on the study home ventilator (Vivo 50 Breas) with the same O2 flow. The all-night non-invasive ventilation parameters were registered in a pressure support mode with single limb leaking circuit. Daytime and night-time FiO2 were compared. Results: The overall results of all 14 patients showed that the measured FiO2 was much lower during the nighttime compared to the daytime measurement: 25,1+-1,1 % versus 30,8+-2,6 % (P Conclusion: With modern pattern of NIV, pressure target and intentional leaks, nighttime FiO2 decrease. This partial removing of O2 therapy should be harmful. It might explain poor results of all but two randomized controlled trial about long term NIV in COPD.

International audience; No abstract available

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.

BACKGROUND: Nocturnal noninvasive ventilation is recommended for patients with hypercapnic COPD. Long-term oxygen therapy improves survival in patients with hypoxemic disease. However, leaks during noninvasive ventilation are likely to reduce the fraction of inspired oxygen. OBJECTIVES: To compare nocturnal inspired O2 fractions during noninvasive ventilation with daytime pharyngeal inspired O2 fractions during nasal cannula oxygen therapy (with the same O2 flow) in patients with COPD at home (ie, real-life conditions). METHODS: This single-center prospective observational study included 14 subjects with COPD who received long-term O2 therapy. We analyzed pharyngeal inspired O2 fractions in the evening, with a nasopharyngeal probe (sidestream gas analyzer). The O2 flow was measured with a precision flow meter, at the usual flow. Then, the same O2 flow was implemented for noninvasive ventilation with a study’s home ventilator. The all-night noninvasive ventilation parameters were delivered in pressure mode with a single-limb leaking circuit. Daytime and nighttime inspired O2 fractions were compared. RESULTS: The mean ± SD daytime pharyngeal inspired O2 fraction, measured with normobaric basal O2 flow, 0.308 ± 0.026%, was significantly higher than the mean ± SD nighttime inspired O2 fraction, measured during noninvasive ventilation (0.251 ± 0.011; P CONCLUSIONS: The nighttime inspired O2 fraction decreased with a modern noninvasive ventilation pattern, pressure target, and intentional leaks. This partial lack of O2 therapy is likely to be harmful. It might explain the poor results in all but 2 randomized controlled trials on long-term noninvasive ventilation in COPD. (ClinicalTrials.gov registration NCT02599246.)

Resume Decrire les caracteristiques des evenements indesirables de novembre 2009 a decembre 2013 declares par systeme informatique, et en discuter l’apport pour la mise en place des comites de retour d’experience. Etude retrospective monocentrique. L’analyse des evenements indesirables a porte sur les caracteristiques du patient, l’heure, le lieu de survenue, la nature et les consequences de l’evenement. Sur la periode de l’etude, 268 evenements etaient declares. Le taux d’evenements indesirables declares etait de 1,1 %. L’âge median des patients etait de 61 ans, le score ASA median etait de 2. Les declarations etaient faites dans 53,3 % des cas par les medecins, et le plus souvent entre 8 h et 14 h (57,4 %). Les evenements declares survenaient le plus souvent en salle d’intervention (70 % des cas), et etaient lies a un defaut d’organisation dans 29,1 % des cas. Ils etaient consideres graves dans 7,8 % des cas. Le score ASA des patients chez lesquels un evenement indesirable grave survenait etait significativement plus eleve. Les evenements indesirables declares sont le plus souvent des evenements porteurs de risque qui surviennent en heure ouvrable. La mise en place des comites de retour d’experience s’inscrit dans une politique de securite des soins dont l’objectif est d’analyser ces evenements puis d’en faire le retour d’experience au profit de l’equipe. Leur travail repose sur un signalement efficace et exhaustif de ces evenements. Le recueil informatise des EI peut etre une aide pour ces comites en favorisant le processus de declaration.

Resume Introduction L’arthroplastie du genou occasionne d’importantes pertes sanguines. Differentes techniques d’epargne transfusionnelle existent dont la retransfusion de sang epanche de redon. Certaines etudes remettent en cause la qualite de ce sang et notamment sa capacite a coaguler. Elles utilisent des tests d’hemostase « statiques » qui refletent de maniere tres incomplete la realite, contrairement aux methodes viscoelastiques. L’objectif principal de cette etude etait d’evaluer le profil thromboelastometrique par ROTEM ® du sang epanche en le comparant au sang veineux du patient. Patients et methodes Il s’agissait d’une etude observationnelle, prospective et monocentrique effectuee sur 3 mois en 2013. L’accord du CPP et le consentement des patients ont ete obtenus au prealable. Tous les patients majeurs ayant beneficie d’une arthroplastie totale primaire du genou avec mise en place d’un redon recuperateur ont ete inclus. Un profil thromboelastometrique et un bilan biologique standard (hemoglobine, plaquette, TP, TCA, fibrinogene) ont ete realises sur le sang veineux du patient et sur le sang epanche du redon recuperateur en SSPI. Resultats Vingt patients ont ete inclus. La duree mediane de chirurgie etait de 93 minutes. Treize patients (65 %) ont recu de l’acide tranexamique en peroperatoire. Le volume median de sang epanche a ete de 225 mL. Deux patients (10 %) ont beneficie d’une retransfusion. L’analyse du sang epanche a montre un deficit majeur en facteurs de coagulation en biologie standard (TP ® , Ex-tem ® , Fib-tem ® ou Ap-tem ® ). Par rapport au sang veineux, le sang du redon avait un taux d’hemoglobine significativement plus bas : 8,8 vs 13,5 g/dL ( p Discussion Dans ce travail, nous avons confirme que le sang de redon etait incoagulable probablement en relation avec un mecanisme multifactoriel associant un deficit en facteur et une activation de la fibrinolyse.

The aims of this study were to review and quantify the types of anesthetic procedures performed by anesthesiologists assigned to the forward surgical team (FST) deployed in Abidjan, Ivory Coast. The study includes all patients undergoing surgery by the FST from July 2012 through July 2016. The activity was retrospectively analyzed and divided according to demographics, surgical specialties, emergency versus elective surgery, types of anesthetic and post-operative analgesic procedures, and transfusion aspects. Over this period, surgeons performed 1520 operations, 98 % as medical support to the population (MSP). Elective surgery accounted for 96 % of this activity, and emergencies for only 4 %. The main surgical activities were visceral (74 %) and orthopedic (26 %). Anesthetic procedures were general anesthesia for 62 % and locoregional anesthesia in 38 %. Our study showed that the FST contributed to MSP. Anesthetic procedures for MSP required limited resources, standardization of the procedures, and specific skills beyond the original specialties of military anesthesiologists to fulfill the needs of the local population.

Background While spontaneous spinal epidural hematomas are rare, 1 of the identified risk factors is vitamin K antagonist therapy. Case Description We present a case of a spontaneous spinal epidural hematoma occurring in a patient under treatment with dabigatran, a non–vitamin K oral anticoagulant. The initial hemiparesis symptom was misleading and was retrospectively identified as Brown-Sequard syndrome. Immediate dabigatran antagonism with idarucizumab followed by posterior cervical laminectomy permitted a complete neurologic recovery at day 4. Conclusions This is the first description of a spontaneous spinal epidural hematoma under non−vitamin K antagonist oral anticoagulant therapy that has been successfully antagonized and emphasizes the importance of specific antidote development.

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.

Duret hemorrhage has always been reported during an episode of increased intracranial pressure with transtentorial herniation. We reported a Duret hemorrhage occurring during an episode of intracranial hypotension resulted in sinking skin flap syndrome which was responsible for acute paradoxal descending transtentorial herniation and Duret hemorrhage, 10 days after large hemicraniectomy which could indicate early cranioplasty.

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

Blunt cerebrovascular injuries (BCVI) have been increasingly recognized in the past decade due to the initiation of different screening protocols. We present the case of an anterior cerebral artery rupture with free contrast extravasation following a severe traumatic brain injury. Epidemiology, modalities of screening and treatment of BCVI are discussed. This report reminds that the screening of BCVI may be essential after a severe traumatic brain injuries (TBI). How to cite this article Mathais Q, Esnault P, Joubert C, Dragone C, Meaudre E. Post-traumatic Anterior Cerebral Artery Rupture after a Severe Traumatic Brain Injury. Indian Journal of Critical Care Medicine, January 2019;23(1):54-55.

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.

Takotsubo cardiomyopathy is characterized by the sudden onset of reversible left ventricular dysfunction. Associated refractory cardiogenic shock is a rare occurrence and may require extracorporeal membrane oxygenation (ECMO). We report a case of a patient who, following the inadvertent injection of 1 mg of epinephrine, presented with reverse Takotsubo cardiomyopathy and refractory cardiogenic shock that required the implementation of a percutaneous ECMO. A 49-yr-old female patient presented with reverse Takotsubo cardiomyopathy in the operating room after an inadvertent injection of epinephrine. The development of refractory cardiogenic shock required emergent use of a mobile percutaneous ECMO system. It was possible to wean this support after four days, and the patient was later discharged without cardiac or neurological sequelae. The investigations performed confirmed the iatrogenic nature of this reverse Takotsubo cardiomyopathy. Takotsubo cardiomyopathy following an injection of epinephrine remains a rare but increasingly described occurrence. The severity of the symptoms appears to be patient dependent, but refractory cardiogenic shock may occur and require significant circulatory support. If this situation occurs in a hospital where this necessary equipment is lacking, a mobile ECMO unit appears to be a viable solution to optimize the patient’s chances of survival.

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.

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

Management of critically ill patients in austere environments is a logistic challenge. Availability of oxygen cylinders for the mechanically ventilated patient may be difficult in such a context. One solution is to use a ventilator able to function with an oxygen concentrator (OC).We tested two Elisée™ 350 ventilators paired with SeQual Integra 10-OM oxygen concentrators (OC) (Chart Industries, http://www .chartindustries.com) and evaluated the delivered fraction of inspired oxygen (Fio2). Ventilators were connected to a test lung and Fio2 was measured and indicated by the ventilator. Continuous oxygen was generated by the OC from 0.5L/min to 10L/min, and administered by the specific inlet port of the ventilator. Several combinations of ventilator settings were evaluated to determine the factors affecting the delivered Fio2.The Elisée 350 turbine ventilator is able to deliver a high Fio2 when functioning with an OC. However, modifications of the ventilator settings such as an increase in minute ventilation, inspiratory-to-expiratory ratio, and positive end-expiratory pressure affect delivered Fio2 despite steady-state oxygen flow from the concentrator.OCs provide an alternative to oxygen cylinders for delivering high Fio2 with a turbine ventilator. Nevertheless, Fio2 must be monitored continuously, since it decreases when minute ventilation is increased.