Jean-Stéphane David

Thrombocytopenia contributes to trauma-induced coagulopathy and may require platelet transfusion. Viscoelastic assays can provide rapid surrogates of platelet count, but thresholds may be influenced by physiological derangements. We compared ROTEM-derived parameters for diagnosing thrombocytopenia and tested their robustness across selected conditions. We performed a retrospective registry-based cohort study in a level 1 trauma center (2011–2021). Severely injured adults were included if they had at least one paired ROTEM and platelet count measurement within 24 hours of admission; patients receiving anticoagulants were excluded. Thrombocytopenia was defined as platelets <100 G/L. Associations between platelet count and ROTEM parameters were assessed with Spearman correlation. Diagnostic accuracy was evaluated using ROC and precision–recall (PR) analyses; optimal thresholds were chosen by maximal F1-score. For the best parameter, performance was explored across hemoglobin level, acidosis, and hypocalcemia. Of 4,395 admissions, 865 patients were included with 1,395 paired measurements; thrombocytopenia occurred in 213 samples (15.3%) and was present at admission in 35 (4%). Platelet count correlated with clot amplitude/elasticity (p < 0.001). The platelet component of clot amplitude at 5 minutes (A5 PLAT) had the best discrimination (AUC 0.929; AUPRC 0.627). The optimal PR-based threshold was A5 PLAT ≤21 mm. Performance was mainly affected by severe acidosis and severe hypocalcemia. In severe trauma, ROTEM-derived A5 PLAT accurately identifies platelet count <100 G/L and outperforms other ROTEM parameters, supporting its use for rapid platelet-related decision-making. Hypocalcemia and acidosis may reduce precision and should be considered when applying ROTEM-based thresholds during early trauma resuscitation.

L’étude des propriétés viscoélastiques du caillot est apparue à la fin des années 40 mais ce n’est que depuis une vingtaine d’années que leur utilisation s’est développée en pratique clinique. Ces techniques vont permettre de réaliser une analyse globale de l’hémostase mais également de diagnostiquer précisément les déficits acquis. L’aspect global de cette analyse prend également en compte les phénomènes intercurrents tels que l’inflammation ou l’anémie. L’utilisation de ces techniques dans des situations variées telles que la traumatologie, les hémorragies du post partum ou digestive et la chirurgie cardiaque, va permettre un diagnostic précoce des troubles de l’hémostase. L’effet sur l’administration des produits sanguins et sur le pronostic reste à confirmer dans de futurs travaux idéalement randomisés.

Background: Prehospital trauma triage tools are not tailored to identify severely injured older adults. Our trauma triage protocol based on a three-tier trauma severity grading system (A, B, and C) has never been studied in this population. The objective was to assess its accuracy in predicting in-hospital mortality among older adults (≥65 years) and to compare it to younger patients. Methods: A retrospective multicenter cohort study, from 2011 to 2021. Consecutive adult trauma patients managed by a mobile medical team were prospectively graded A, B, or C according to the initial seriousness of their injuries. Accuracy was evaluated using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Results: 8888 patients were included (14.1% were ≥65 years). Overall, 10.1% were labeled Grade A (15.2% vs. 9.3% among older and younger adults, respectively), 21.9% Grade B (27.9% vs. 20.9%), and 68.0% Grade C (56.9% vs. 69.8%). In-hospital mortality was 7.1% and was significantly higher among older adults regardless of severity grade. Grade A showed lower sensitivity (50.5 (43.7; 57.2) vs. 74.6 (69.8; 79.1), p < 0.0001) for predicting mortality among older adults compared to their younger counterparts. Similarly, Grade B was associated with lower sensitivity (89.5 (84.7; 93.3) vs. 97.2 (94.8; 98.60), p = 0.0003) and specificity (69.4 (66.3; 72.4) vs. 74.6 (73.6; 75.7], p = 0.001) among older adults. Conclusions: Our prehospital trauma triage protocol offers high sensitivity for predicting in-hospital mortality including older adults.

Purpose To assess the incidence of undertriage in major trauma, its determinant, and association with mortality. Methods A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011–2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage. Results A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51–65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36). Conclusions In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.

Objectives: Describe prehospital tranexamic acid (TXA) use and appropriateness within a major trauma pediatric population, and identify the factors associated with its use. Design: Multicenter, retrospective study, 2014–2020. Setting: Data were extracted from a multicenter French trauma registry including nine trauma centers within a physician-led prehospital emergency medical services (EMS) system. Patients: Patients less than 18 years old were included. Those who did not receive prehospital intervention by a mobile medical team and those with missing data on TXA administration were excluded. Interventions: None. Measurements and Main Results: Nine-hundred thirty-four patients (median [interquartile range] age: 14 yr [9–16 yr]) were included, and 68.6% n = 639) were male. Most patients were involved in a road collision (70.2%, n = 656) and suffered a blunt trauma (96.5%; n = 900). Patients receiving TXA (36.6%; n = 342) were older (15 [13–17] vs 12 yr [6–16 yr]) compared with those who did not. Patient severity was higher in the TXA group (Injury Severity Score 14 [9–25] vs 6 [2–13]; p < 0.001). The median dosage was 16 mg/kg (13–19 mg/kg). TXA administration was found in 51.8% cases (n = 256) among patients with criteria for appropriate use. Conversely, 32.4% of patients (n = 11) with an isolated severe traumatic brain injury (TBI) also received TXA. Age (odds ratio [OR], 1.2; 95% CI, 1.1–1.2), A and B prehospital severity grade (OR, 7.1; 95% CI, 4.1–12.3 and OR, 4.5; 95% CI, 2.9–6.9 respectively), and year of inclusion (OR, 1.2; 95% CI, 1.1–1.3) were associated with prehospital TXA administration. Conclusions: In our physician-led prehospital EMS system, TXA is used in a third of severely injured children despite the lack of high-level of evidence. Only half of the population with greater than or equal to one criteria for appropriate TXA use received it. Conversely, TXA was administered in a third of isolated severe TBI. Further research is warranted to clarify TXA indications and to evaluate its impact on mortality and its safety profile to oversee its prescription.