Analyse de la prise en charge des patients traumatisés sévères dans le contexte français : processus de triage et processus de soin

In France, the third most frequent cause of disability adjusted life years lost is trauma, an observation that makes trauma a public health challenge. However, investment in trauma care and specific research fails to meet this challenge and to acknowledge the associated societal and economic impact.The purpose of this research was to explore the core of the pathway of a major trauma patient and bring to light key issues and question and to find answers. The data used in this research were mainly extracted from a regional and national trauma registry, the Traumabase®. The registry collects epidemiological, clinical, paraclinical and therapeutic variables for patients with severe trauma admitted to participating trauma centres. The first project focused on the effects of triage on patients with severe trauma following a road traffic accident in the Ile de France region. Patients who were initially under triaged and then transferred to regional trauma centres did not have a worse prognosis than patients who were transported directly. The emergency medical system as a whole ensured that they would have an equivalent outcome. A population analysis carried out by a probabilistic data chainage using the accident records of the National Road Safety Observatory made it possible to approach the undertriage rate leading to death in the region (0.15%) and to reveal that 60% of deaths occurred before any hospital admission. The second project developed a pragmatic pre-alert tool based on simple, clinical prehospital criteria to predict acute hemorrhage in trauma patients. This tool is meant to increase the performance of the receiving hospital trauma team of these critically sick patients and activate a specific hemorrhage pathway. The study identified five variables (shock index>1, mean blood pressure 1, pression artérielle moyenne <70mmHg, hémoglobine capillaire < 13g/dL, bassin instable et intubation), dont la présence de deux ou plus d’entre-elles permettait d’activer l’alerte pour l’hôpital receveur. Cet outil devra être évalué en prospectif pour confirmer ses performances et évaluer son impact sur l’organisation et le devenir des patients.Le troisième projet de recherche ciblait plus spécifiquement une des thérapeutiques de la coagulopathie aigue du traumatisé sévère en choc hémorragique. Il a tenté de quantifier l’impact de l’administration de concentré de fibrinogène à la phase précoce du choc hémorragique traumatique (6 premières heures) sur la mortalité toutes causes confondues des 24 premières heures par une approche d’inférence causale (score de propension et méthode d’estimation double robuste). Il n’a pas été retrouvé d’effet significatif sur la mortalité, un manque de puissance pouvant être responsable de ce résultat (différence de risque observée : -0,031, Intervalle de confiance 95% [-0,084 ; 0,021]).Ainsi l’ensemble de ces 3 projets de recherche ont permis de répondre à des problématiques ciblées du parcours du patient traumatisé sévère, générant par la même de nouvelles perspectives d’analyse pour mieux circonscrire les réponses de terrain

Analysis of Severe Trauma Patients Management : Triage and Care Process

La traumatologie est un problème de santé publique au troisième rang des années de vie perdues ajustées sur l’incapacité en France. L’investissement sanitaire et le volume de recherche qu’elle génère sont en deçà de ce que représente son impact sociétal. L’objet de ce travail de recherche était de plonger au cœur du parcours du patient traumatisé sévère pour en cibler trois problématiques clefs et tenter de répondre aux interrogations qu’elles génèrent.Les données utilisées provenaient essentiellement d’un observatoire de traumatologie lourde hospitalier (Traumabase®), régional et national, qui collige un ensemble de variables épidémiologiques, cliniques, paracliniques, et thérapeutiques des patients traumatisés sévères admis en centre de traumatologie.Le premier projet a ciblé l’orientation initiale (triage) des patients traumatisés sévères suite à un accident de la circulation au sein de la région Île de France et son effet sur la mortalité. Les patients initialement mal triés, transférés secondairement dans les centres de traumatologie régionaux, ne présentaient pas un pronostic plus sombre que les patients qui étaient transportés directement. Le système de soin dans son ensemble permettait de leur assurer un devenir équivalent. Une analyse en population réalisée par un chainage probabiliste des données avec les fiches d’accident de l’observatoire national de la sécurité routière a permis d’approcher le taux de sous triage conduisant au décès dans la région (0,15%) et d’objectiver que 60% des décès survenaient avant toute admission hospitalière.Le second projet visait l’optimisation de la jonction entre l’équipe médicalisée préhospitalière et l’équipe intrahospitalière. Il s’est attelé à développer un outil de prédiction de la sévérité des patients hémorragiques pour permettre l’anticipation de l’admission des patients les plus graves. Cet outil, le Red Flag, avait pour cahier des charges d’être simple et pragmatique, et de ne pas nécessiter de dispositif externe pour l’utiliser. Il a identifié cinq caractéristiques (shock index>1, pression artérielle moyenne 1, mean blood pressure <70mmHg, capillary hemoglobin <13g/dL, unstable pelvis and intubation). If two or more variables were present, the tool identified patient with acute hemorrhage and the corresponding pathway should be activated. This tool requires prospective validation and assessment of its impact on care provision and patient outcome.The third research project focused on a therapeutic component of trauma induced coagulopathy. The study attempted to quantify the effect of fibrinogen concentrate administration at the early phase of traumatic hemorrhagic shock (first 6 hours) on 24 hours all-cause mortality using a causal inference approach (propensity score and double robust estimator). The research did not demonstrate any impact on mortality (observed risk difference: -0.031, 95% confidence interval [-0.084; 0.021]);  a lack of power might be responsible for this result

Trauma reloaded: Trauma registry in the era of data science

International audienc

Cangrelor for cardiopulmonary bypass in patients with heparin-induced thrombocytopenia: it is not so easy

International audienceAnticoagulation management for cardiopulmonary bypass (CPB) is challenging in patients with acute heparin-induced thrombocytopenia (HIT). The strategy of combining cangrelor intraoperatively with heparin for CPB anticoagulation is of increasing interest but exposes to specific unresolved problems.We report the case of a patient requiring surgical pulmonary embolectomy for pulmonary embolism at the very acute phase of HIT, with a high titre of anti-PF4/heparin antibodies and severe thrombocytopenia. For CPB management, cangrelor was administered in combination with heparin prescribed and monitored as usual. Surgery was successfully performed, but postoperatively, the patient developed a new thrombotic event. We discussed the specific problems associated with such strategy, including the dose of cangrelor and its monitoring, the management of the cell-saver, the risk of heparin rebound and the risk of platelet transfusion. These issues must be addressed before considering the combination of cangrelor and unfractionated heparin as a standard of care for CBP

Direct transport vs secondary transfer to level I trauma centers in a French exclusive trauma system: Impact on mortality and determinants of triage on road-traffic victims.

BackgroundTransporting a severely injured patient directly to a trauma center (TC) is consensually considered optimal. Nevertheless, disagreement persists regarding the association between secondary transfer status and outcome. The aim of the study was to compare adjusted mortality between road traffic trauma patients directly or secondarily transported to a level 1 trauma center (TC) in an exclusive French trauma system with a physician staffed prehospital emergency medical system (EMS).MethodsA retrospective cohort study was performed using 2015-2017 data from a regional trauma registry (Traumabase®), an administrative database on road-traffic accidents and prehospital-EMS records. Multivariate logistic regression models were computed to determine the role of the modality of admission on mortality and to identify factors associated with secondary transfer. The primary outcome was day-30 mortality. Results: During the study period, 121.955 victims of road-traffic accident were recorded among which 4412 trauma patients were admitted in the level 1 regional TCs, 4031 directly and 381 secondarily transferred from lower levels facilities. No significant association between all-cause 30-day mortality and the type of transport was observed (Odds ratio 0.80, 95% confidence interval (CI) [0.3-1.9]) when adjusted for potential confounders. Patients secondarily transferred were older, with low-energy mechanism and presented higher head and abdominal injury scores. Among all 947 death, 43 (4.5%) occurred in lower-level facilities. The population-based undertriage leading to death was 0.15%, 95%CI [0.12-0.19].ConclusionIn an exclusive trauma system with physician staffed prehospital care, road-traffic victims secondarily transferred to a TC do not have an increased mortality when compared to directly transported patients

Effect of Fibrinogen concentrate administration on early mortality in traumatic hemorrhagic shock

International audienc

Cardiometabolic Disorders and the Risk of Critical COVID-19 as Compared to Influenza Pneumonia

International audienceWe aimed to compare the influence of cardiometabolic disorders on the incidence of severe COVID-19 vs. non-COVID pneumonia. We included all consecutive patients admitted with SARS-CoV-2-positive pneumonia between 12 March 2020 and 1 April 2020 and compared them to patients with influenza pneumonia hospitalized between December 2017 and December 2019 at the same tertiary hospital in Paris. Patients with COVID-19 were significantly younger and more frequently male. In the analysis adjusted for age and sex, patients with COVID-19 were more likely to be obese (adjOR: 2.25; 95% CI 1.24–4.09; p = 0.0076) and receive diuretics (adjOR: 2.13; 95% CI 1.12–4.03; p = 0.021) but were less likely to be smokers (adjOR: 0.40; 95% CI 0.24–0.64; p = 0.0002), have COPD (adjOR: 0.25; 95% CI 0.11–0.56; p = 0.0008), or have a previous or active cancer diagnosis (adjOR: 0.54, 95% CI 0.32–0.91; p = 0.020). The rate of ICU admission was significantly higher in patients with COVID-19 (32.4% vs. 5.2% p < 0.0001). Obesity was significantly associated with the risk of direct ICU admission in patients with COVID-19 but not in patients with influenza pneumonia. Likewise, pre-existing hypertension was significantly associated with mortality in patients with COVID-19 but not in patients with influenza pneumonia. Cardiometabolic disorders differentially influenced the risk of presenting with severe COVID-19 or influenza pneumonia

Impact of High-Dose Prophylactic Anticoagulation in Critically Ill Patients With COVID-19 Pneumonia

International audienceBACKGROUND: Because of the high risk of thrombotic complications (TCs) during SARS-CoV-2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation, although arguments in favor of this strategy are inconsistent. RESEARCH QUESTION: What is the incidence of TC in critically ill patients with COVID-19 and what is the relationship between the dose of anticoagulant therapy and the incidence of TC? STUDY DESIGN AND METHODS: All consecutive patients referred to eight French ICUs for COVID-19 were included in this observational study. Clinical and laboratory data were collected from ICU admission to day 14, including anticoagulation status and thrombotic and hemorrhagic events. The effect of high-dose prophylactic anticoagulation (either at intermediate or equivalent to therapeutic dose), defined using a standardized protocol of classification, was assessed using a time-varying exposure model using inverse probability of treatment weight. RESULTS: Of 538 patients included, 104 patients experienced a total of 122 TCs with an incidence of 22.7% (95% CI, 19.2%-26.3%). Pulmonary embolism accounted for 52% of the recorded TCs. High-dose prophylactic anticoagulation was associated with a significant reduced risk of TC (hazard ratio, 0.81; 95% CI, 0.66-0.99) without increasing the risk of bleeding (HR, 1.11; 95% CI, 0.70-1.75). INTERPRETATION: High-dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill patients with COVID-19 without an increased risk of hemorrhage. Randomized controlled trials comparing prophylaxis with higher doses of anticoagulants are needed to confirm these results