Traumatic pneumothorax is a potentially life-threatening condition requiring timely diagnosis and management, particularly in the prehospital setting where diagnostic tools are limited. This study aimed to evaluate the diagnostic performance of clinical signs used by emergency physicians in the field to identify traumatic pneumothorax requiring early thoracic decompression. We conducted a retrospective observational study in a French level I trauma center from January 2015 to August 2022. All patients with CT-confirmed pneumothorax managed by prehospital emergency physicians were included. The primary endpoint was the diagnostic performance of prehospital clinical assessment to identify pneumothorax requiring early decompression (prehospital or within four hours of admission). Statistical analysis was focused on predictive performance of three clinical signs (asymmetric lung auscultation, thoracic expansion asymmetry, and subcutaneous emphysema) in identifying cases requiring early decompression, using univariable analyses and the construction of a composite predictive score by logistic regression. Among 280 included patients, 115 (41

BACKGROUND:Hyponatremia is common in traumatic brain injury (TBI) population, and is associated with poor outcomes. The main mechanisms are the syndrome of inappropriate antidiuresis (SIAD) and cerebral salt wasting syndrome (CSW). This study aimed to assess hyponatremia prevalence and time of onset in patients with TBI and assess differences between SIAD and CSW. METHOD:This retrospective cohort study was conducted between 2015 and 2018 in our level 1 trauma center. Patients admitted to the intensive care unit with TBI were included. Three subgroups were determined using urinary clinical and biological criteria: SIAD, CSW, and Undetermined. Predictive factors were assessed for each subgroup, especially the influence of free water, sodium, or fluid intake. RESULTS:Among 351 trauma patients with TBI, 57 (16 % [95 %CI 12 %20 %]) developed hyponatremia within 30 days. 30 (9 % [95 %CI 6 %12 %]) developed a SIAD, 13 (4 % [95 %CI 2 %6 %]) a CSW, 14 (4 % [95 %CI 2 %6 %]) an undetermined form. CSW subgroup had higher Simplified Acute Physiology Score II (SAPS II), Injury severity score ISS, more cerebral injuries, intracranial pressure monitoring, mechanical ventilation than the SIAD subgroup. Fluid, sodium and free water intake in the 48 h preceding hyponatremia did not influence CSW or Undetermined hyponatremia development, whereas excessive free water intake in the 48 h preceding hyponatremia was associated with SIAD development. CONCLUSION:Hyponatremia prevalence was 16 %, half were SIAD and one quarter were CSW. Patients with CSW were more severely injured than those who developed SIAD. Excessive free water intake could induce more SIAD-related hyponatremia due to impaired urine dilution. LEVEL OF EVIDENCE:III, prognostic/epidemiological.

INTRODUCTION:The specialized care of acute trauma patients is increasingly organized within networks, with the most critical patients referred to level 1 trauma centers (TC1). This French national survey aimed to evaluate the organizational and structural characteristics of these centers. MATERIAL AND METHODS:A 195-item survey was conducted across 40 centers classified as TC1 according to consensual criteria. It included a general analysis of the hospital, followed by an internal analysis of each department, specifically admitting severe acute trauma patients. The survey collected data on the architectural, human, and functional organization, activity, and general satisfaction regarding each department. RESULTS:All surveyed centers responded, 65% (26/40) of them were integrated into a trauma network. These TC1 admitted 409 (±332) severe trauma patients/year, including 90 (±75) grade A/very severe and 138 (±120) grade B/severe. Across the 40 TC1, a total of 46 reception areas were identified with a mean of 2.9 (±1.7) beds/area, and a surface of 20.4 (±8.9) m²/area. Their distances from the CT-scanner and operating room were 81 (±90) and 82 (±76) m, respectively. For grade A (unstable despite prehospital medical care) and B (stabilized after prehospital medical care and/or specific anatomic lesion) patients, the trauma team leader was an anesthesiologist-intensivist in 97.5% and 90.5% of admissions, respectively. Eleven (23.9%) reception areas reported multiple medical specialties involved in the admission of severe trauma patients, and 19 (41.3%) reported having dedicated nurses. CONCLUSION:This survey highlights the variability of the functional, architectural, and human resource organization of French TC1.

External lumbar drainage (ELD) of cerebrospinal fluid may help control intracranial pressure following a traumatic brain injury. We aimed to assess the efficacy and safety of ELD in post-traumatic intracranial hypertension (IH). This retrospective monocentric cohort study was conducted in the trauma critical care unit of the regional Level-I trauma centre between January 2012 and December 2022. All traumatic brain injury patients with IH (≥ 22 mmHg despite optimal sedation) were included. Data collection focused on the duration and management of IH, complications related to ELD, and outcomes (6-month Glasgow Outcome Scale [GOS]). The influence of ELD on the duration of IH was assessed using a multivariable Cox regression analysis, while its impact on the 6-month GOS (“unfavourable outcome” GOS 1–3, “good outcome” GOS 4–5) was evaluated using a multivariable logistic regression analysis. Ninety patients (mean age 37 [SD, 16], injury severity score [ISS] 29 [IQR, 24–34]) were analyzed during the study period. Of these, 50 (56

BACKGROUND:Pain control is key to the management of patients with multiple rib fractures. We compared the impact of posterior extrathoracic fascial plane block (PEFB) with paravertebral block (PVB) and systemic analgesia on morphine consumption, pain relief, and improvement in respiratory parameters. METHODS:Trauma patients with multiple rib fractures who were not mechanically ventilated were randomised into three groups: PEFB, PVB, and systemic analgesia. The primary endpoint was morphine consumption at 24 h. The secondary endpoints (pain at rest and when coughing, morphine consumption in the first 72 h, rescue thoracic epidural analgesia, sniff nasal inspiratory pressure [SNIP], and maximal expiratory pressure [MEP]) were analysed using linear mixed models. RESULTS:Of the 90 patients included in the study, 77.7% were male; median (interquartile range) Injury Severity Score was 14 (10-19), chest Abbreviated Injury Scale was 3 (3-4), and number of ribs fractured was 4.5 (5-9). Morphine consumption at 24 h in the PEFB group was noninferior to that in the PVB group (17 [11-29] mg and 22 [14-31] mg, respectively; P<0.001). Thirty percent of patients in the control and PEFB groups and 6.7% in the PVB group (P=0.043) had thoracic epidural analgesia during the study. In the per-protocol analysis, morphine consumption at 72 h was higher in the control group but with no significant difference between intervention groups: control, 45 (36-72) mg; PEFB, 30 (16-44) mg; and PVB, 38 (22-62) mg (P=0.051). Pain scores were higher during coughing in all groups (β=3.89, P<0.0001), but scores were lower with a significant interaction in the PVB group (β=-0.58, P=0.010). Over 72 h, SNIP values increased significantly from baseline (β from 7.2 to 14.9; P=0.002) in all groups, and MEP values showed a difference with higher values in the PVB group (β=12.71, 95% confidence interval 2.73-22.77; P=0.012). CONCLUSIONS:Posterior extrathroacic fascial plane block promoted a noninferior effect on morphine consumption at 24 h compared with paravertebral block in patients with multiple rib fractures. However, although PEFB has merit as a first-line treatment for rib fracture analgesia, it is more likely than PVB to require thoracic epidural anaesthesia rescue. Pain relief during coughing and respiratory parameters improved more in the PVB group. CLINICAL TRIAL REGISTRATION:NCT03396692.

L’usage de plus en plus répandu du garrot dit « tactique » en préhospitalier s’intègre dans la stratégie de « Damage Control »bien que pourvoyeur de nombreuses complications. Ainsi un usage inadapté du garrot en pré hospitalier risque d’alourdir le pronostic initial d’autant plus que sa morbidité en pré hospitalier reste peu étudiée dans la littérature Le taux de complications du garrot en pré hospitalier aux membres inférieurs varie de 0 % à 25 % selon les auteurs. Une série de patients au sein de notre unité ayant développé des complications post garrot, nous a amené à reconsidérer sa balance bénéfice risque. Ce travail porte sur une revue de cas chez qui l’utilisation du garrot a été responsable de complications importantes mettant en jeu la récupération fonctionnelle. Entre octobre et janvier 2021, 5 cas de traumatismes graves du membre supérieur chez lesquels l’utilisation d’un garrot en pré-hospitalier a été responsables de complications importantes ont été rapporté. Les données préhospitalières, les antécédents, les lésions associées, l’examen clinique d’admission, le temps total de garrot ainsi que les examens paracliniques ont été consignés. Les constations per opératoires et les complications post opératoires ont également été relevées. En préhospitalier, aucun des patients ne présentaient des signes de choc hémodynamique. Le saignement était dans la plupart des cas absent ou modéré. Deux patients présentait des lésions cutanée uniquement. Nous avons noté des complications graves telles qu’une paralysie du nerf musculo-cutané chez un patient, un syndrome des loges, une rhabdomyolyse et un syndrome d’ischémie-reperfusion chez un autre. Le rôle d’un garrot préhospitalier prolongé dans l’infection postopératoire a également été suspecté chez deux patients. Le temps moyen de garrot en préhospitalier était de 2h10 un relai efficace par pansement compressif a été réalisé seulement dans un cas. À notre connaissance il n’existe pas d’études dans la littérature recensant spécifiquement la morbidité et l’efficacité du garrot pré hospitalier dans les traumatismes sévères au membre supérieur. L’utilisation inadaptée du garrot pneumatique en phase pré-hospitalière dans les traumatismes sévères du membre supérieur en termes de pression utilisée, de durée ou d’absence d’indication peut aggraver les conséquences des lésions traumatiques initiales et compromettre le pronostic de conservation du membre ou sa fonction. Cette série de cas, bien que restreinte, suggère que le rapport bénéfice/risque du garrot préhospitalier doit être réévalué. Des études complémentaires devraient être menées pour étudier la morbidité spécifique du garrot au membre supérieur et cibler ses indications.

Background: The goal of the present national survey was to describe the practices and use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in France in level-1 trauma centers. Methods: Between January and December 2023, the ACUTE SFAR (Société Française d’Anesthésie et de Réanimation) committee sent a numeric survey to each French level-1 trauma center. This survey was focused on REBOA in trauma management including: use, protocol (indications, placement, aortic occlusion durations), aortic occlusion location (Zone 1/Zone 3), partial occlusion (pREBOA), device characteristics, operator, specific complications. Results: Among the 41 French level-1 trauma centers, 18 (44%) had incorporated REBOA in their algorithm. In 2022, 78% (14/18) of these centers had experienced between 1 and 5 REBOA placements, 11% (2/18) between 6 and 10, and 6% (1/18) 10 or more placements. The frequency of REBOA procedures increased with the duration of REBOA availability at the center. A protocol for REBOA placement was present in 28% (5/18) of centers. An anesthesiologistintensivist was the operator in 50% (9/18), a surgeon in 28% (5/18), and a radiologist in 22% (4/18) of centers. The proportion of centers using REBOA in Zone 1 was 39% (7/18), and pREBOA 33% (6/18). The maximum duration of complete aortic occlusion was specified in 50% of centers for Zone 1 and 78% for Zone 3. Conclusions: Use of REBOA is modestly spread among the French trauma centers, and in less than half of centers. Specific protocols are present. Anesthesiologist-intensivists are the operators in only half of these centers.

BACKGROUND:Indications for Veno-venous (VV) or veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) after trauma rely on poor evidence. The main aims were to describe the population of trauma patients requiring either VV or VA ECMO and report their clinical management and outcomes. METHODS:An observational multicentre retrospective study was conducted in 17 Level 1 trauma centres in France between January 2010 and December 2021. All patients admitted for major trauma were screened for inclusion, and those receiving either VV ECMO or VA ECMO were included. The primary outcome was in-hospital mortality. RESULTS:Among the 52,851 patients screened, 179 were included, with 143 supported by VV ECMO (median [Q1-Q3] age 32 years [24-48]; men 83.5%; injury severity score [ISS] 33 [25-43] and 76 (53.6%) with a traumatic brain injury [TBI]) and 36 supported by VA ECMO (median age 39 years [25-55]; men 88.9%; ISS 36 [25-56] and 23 (63.9%) with a TBI). In the VV ECMO group, three indications for ECMO implementation were chest injuries (n = 68, 47.6%), ventilator-associated pneumonia (VAP; n = 57, 39.9%), and extra-respiratory acute respiratory distress syndrome (ARDS; n = 57, 39.9%). In the VV ECMO group, 45.8% (n = 65) died in the hospital, with 33 (48.5%) deaths following cannulation for chest injuries, 22 (39.3%) following cannulation for VAP, and 10 (55.6%) following cannulation for extrapulmonary ARDS. In the VA ECMO group, 75.0% (n = 27) died during their hospital stay. CONCLUSIONS:In-hospital mortality of trauma patients requiring ECMO for refractory ARDS varied according to indications. The best prognosis was observed in the subgroup of pneumonia-induced ARDS patients.

INTRODUCTION:The widespread pre-hospital use of tourniquets, particularly in the upper limb, raises questions about associated morbidity, which has been little studied and may have serious consequences for functional prognosis. METHODS:A review of 9 patients was carried out, analyzing pre-hospital tourniquet use in terms of complications affecting recovery. RESULTS:There were serious complications: musculocutaneous nerve palsy in 1 patient, and compartment syndrome, rhabdomyolysis and ischemia-reperfusion syndrome in another. A role of prolonged pre-hospital tourniquet application in postoperative infection was also suspected in 2 patients. DISCUSSION:The risk-benefit ratio and indications for using a tourniquet on the upper limb in the pre-hospital setting need to be reconsidered.

Background: The present study investigated an institutional multidisciplinary strategy for managing traumatic haemorrhagic shock by integrating the placement of REBOA (resuscitative endovascular balloon occlusion of the aorta) by anaesthesiologist-intensivists. Methods: All severe trauma patients who received percutaneous REBOA placement between January 2013 and December 2022 in our level 1 trauma centre were retrospectively analysed. The data collected included the clinical context, indications and location of REBOA, durations of aortic occlusion (AO), choice of haemostatic procedures and surgical teams, and specific complications. Results: In total, 38 trauma patients were included in the present study (mean age = 41 years [standard deviation = 21 years], 31 [82 %] were male, and median injury severity score was 62.5 [inter-quartile range (IQR) = 45-75]). REBOA was always placed by anaesthesiologist-intensivists, who comprised 68 % of the senior physicians (13/19) in our trauma team over the period. Twenty-eight AOs (74 %) were performed in zone 1 and 10 (26 %) in zone 3. Twelve patients (32 %) received REBOA upon circulatory arrest. Routes following REBOA placement comprised: computed tomography scan = 47 %, operating room = 34 %, angiography = 3 %, emergency room thoracotomy = 5 %, and prematurely died = 11 %. Duration of AO was 38 min (IQR = 32-44 min) in zone 1 and 78 min (IQR = 48-112 min) in zone 3. Mortality rate was 66 % (95 % CI 51-81 %) and higher in cases of AO in zone 1 (79 % versus 30 %, p = 0.018) or concomitant with circulatory arrest (92 % versus 54 %, p = 0.047). No ischemic limb needed an intervention and three endothelial injuries required delayed endovascular stenting. Conclusions: Percutaneous REBOA placement by anaesthesiologist-intensivists included in the multidisciplinary management of traumatic haemorrhagic shock was associated with acceptable time of AO and local complications similar to those observed in other series.

BACKGROUND:Few studies investigated the outcome of patients admitted to intensive care unit (ICU) for gunshot wounds (GSW). The purpose of this study was to determine the 28-day mortality, and to analyze the impact of variables on the mortality of patients admitted to ICU with GSW in four French University Hospitals level-1 regional trauma centers. METHOD:All medical files of adult patients (above fifteen years old) admitted to four French University Hospitals level-1 regional trauma centers for GSW were retrospectively analyzed from January 1st 2015 to June 30th 2021. The primary aim was to determine 28-day death rate of patients admitted in ICU for GSW. The secondary aim was to describe biological parameters, injuries and management of patients admitted to our ICUs, and to identify the variables associated with the 28-day mortality rate. A multivariate analysis allowed determining independent mortality factors. A Kaplan-Meier analysis compared mortality according to head injury. RESULTS:Among 17,262 patients screened, 173 (1 %) were admitted for GSW and 162 were analyzed. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h after ICU admission, and 87.5 % of deaths within three days of ICU admission. The 28-day death rate of patients with head injury was significantly higher as compared to patients without head injury (p < 0.001). Out of forty deaths, twenty-three (57.5 %) were due to head injury, and nine (22.5 %) were due to bleeding. The mechanisms were assault (45.1 %), suicide (34.6 %), accident (4.9 %) and unidentified (15.4 %). In a multivariate analysis, variables associated with the 28-day death rate were age, pre-hospital Glasgow coma score, and Injury Severity Score. CONCLUSION:GSW represented 1 % of ICU admission. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h due to head injuries and bleeding. Head injuries were associated with significantly higher mortality rate.

Our objective was to assess the relationship between the pre-/post-oxygenator gradient of the partial pressure of carbon dioxide (triangle EC PCO2; dissolved form) and CO2 elimination under extracorporeal respiratory support. All patients who were treated with veno-venous extracorporeal membrane oxygenation and high-flow extracorporeal CO2 removal in our intensive care unit over 18 months were included. Pre-/post-oxygenator blood gases were collected every 12 h and CO2 elimination was calculated for each pair of samples (pre-/post-oxygenator total carbon dioxide content in blood [ctCO(2)] x pump flow [extracorporeal pump flow {QEC}]). The relationship between triangle EC PCO2 and CO2 elimination, as well as the origin of CO2 removed. Eighteen patients were analyzed (24 oxygenators and 293 datasets). Each additional unit of triangle EC PCO2 x QEC was associated with an increase in CO2 elimination of 5.2 ml (95% confidence interval [CI], 4.7-5.6 ml; p < 0.001). Each reduction of 1 ml STPD/dl of CO2 across the oxygenator was associated with a reduction of 0.63 ml STPD/dl (95% CI, 0.60-0.66) of CO2 combined with water, 0.08 ml STPD/dl (95% CI, 0.07-0.09) of dissolved CO2, and 0.29 ml STPD/dl (95% CI, 0.27-0.31) of CO2 in erythrocytes. The pre-/post-oxygenator PCO2 gradient under extracorporeal respiratory support is thus linearly associated with CO2 elimination; however, most of the CO2 removed comes from combined CO2 in plasma, generating bicarbonate. ASAIO Journal 2024; 70:417-426

Les blocs tronculaires ou distaux des branches du nerf trijumeau, des premiers nerfs cervicaux ou du plexus cervical superficiel sont indiqués pour l’anesthésie, l’analgésie et l’algologie de la face et du scalp. Ces blocs sont largement sous-utilisés, probablement en raison de l’anatomie un peu complexe de la région, et de la zone imprécise de recouvrement entre les nerfs, justifiant souvent d’associer plusieurs blocs pour une anesthésie/analgésie efficace. Une standardisation des procédures, permettant de bloquer plusieurs nerfs à partir d’un même point de ponction, optimise la pratique de ces blocs. L’échographie autorisant le repérage de la majorité nerfs ou de leurs foramens facilite la réalisation de ces blocs et devrait permettre d’en généraliser l’utilisation. Le bloc des branches du nerf ophtalmique (V1) assure l’anesthésie-analgésie du tiers supérieur de la face jusqu’à la suture coronale. Les blocs tronculaires des nerfs maxillaire (V2) et mandibulaire (V3) bénéficient considérablement de l’apport de l’échoguidage, d’autant que ces nerfs sont satellites de vaisseaux profonds. Les blocs de leurs branches distales sont faciles mais ne couvrent que les territoires tégumentaires. Les deux premières branches du plexus cervical, les nerfs grand auriculaire et petit occipital, qui sont concernées par les incisions latérales en neurochirurgie, peuvent être bloquées par un point de ponction unique. Enfin, la branche sensitive de C2, le nerf d’Arnold, impliquée dans la névralgie homonyme et les incisions postérieures en neurochirurgie, est accessible à un bloc échoguidé.Distal or truncal blocks of the trigeminal nerve, first cervical nerves, or superficial cervical plexus are indicated for face and scalp anesthesia, analgesia, and algology. They are largely under-used, given the complex regional anatomy, and the imprecise overlap of the nerves, thus justifying the association between several blocks for an efficient anesthesia-analgesia. Standardization of the procedure to simultaneously block the different nerves from a single punction point allows the optimization of their use. Echography enables the detection of most of the nerves or their foramina and eases the blocks. This should broaden the use of those blocks. Ophthalmic nerve (V1) branches block ensures the anesthesia-analgesia from the upper tier of the face to the coronal suture. Maxillary (V2) and mandibular (V3) nerve truncal blocks benefit from the echo guidance use, them being satellites of deep vessels. Distal blockade of their branches is easy but circumscribed to integumental territories. The first two branches of the cervical plexus, the greater auricular and lesser occipital nerves, which are recruited in lateral incision for neurosurgery, can be blocked by a single punction point. Finally, the sensitive branch of nerve C2, Arnold's nerve, involved in the homonym neuralgia and posterior incisions in neurosurgery, can be blocked through echo guidance.

Background: Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA).Methods: Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management.Results: Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0- 41.0]. The consumption of sufentanil at 48h was 725 [465-960] mu g/48h versus 670 [510-940] mu g/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] mu g vs. 480 [352-535] mu g (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints.Conclusions: CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.(c) 2022 Published by Elsevier Masson SAS on behalf of Socie acute accent te acute accent franc , aise d'anesthe acute accent sie et de re acute accent animation (Sfar).

BACKGROUND:The COVID-19 pandemic abruptly increased the inflow of patients requiring intensive care units (ICU). French health institutions responded by a twofold capacity increase with temporary upgraded beds, supplemental beds in pre-existing ICUs, or newly created units (New-ICU). We aimed to compare outcomes according to admission in expert pre-existing ICUs or in New-ICU. METHODS:This multicenter retrospective observational study was conducted in two 20-bed expert ICUs of a University Hospital (Expert-ICU) and in one 16-bed New-ICU in a private clinic managed respectively by 3 and 2 physicians during daytime and by one physician during the night shift. All consecutive adult patients with COVID-19-related acute hypoxemic respiratory failure admitted after centralized regional management by a dedicated crisis cell were included. The primary outcome was 180-day mortality. Propensity score matching and restricted cubic spline for predicted mortality over time were performed. RESULTS:During the study period, 165 and 176 patients were enrolled in Expert-ICU and New-ICU respectively, 162 (98%) and 157 (89%) patients were analyzed. The unadjusted 180-day mortality was 30.8% in Expert-ICU and 28.7% in New-ICU, (log-rank test, p =  0.7). After propensity score matching, 123 pairs (76 and 78%) of patients were matched, with no significant difference in mortality (32% vs. 32%, OR 1.00 [0.89; 1.12], p = 1). Adjusted predicted mortality decreased over time (p < 0.01) in both Expert-ICU and New-ICU. CONCLUSIONS:In COVID-19 patients with acute hypoxemic respiratory failure, hospitalization in a new ICU was not associated with mortality at day 180.

Importance Optimal transfusion strategies in traumatic hemorrhage are unknown. Reports suggest a beneficial effect of 4-factor prothrombin complex concentrate (4F-PCC) on blood product consumption. Objective To investigate the efficacy and safety of 4F-PCC administration in patients at risk of massive transfusion. Design, Setting, and Participants Double-blind, randomized, placebo-controlled superiority trial in 12 French designated level I trauma centers from December 29, 2017, to August 31, 2021, involving consecutive patients with trauma at risk of massive transfusion. Follow-up was completed on August 31, 2021. Interventions Intravenous administration of 1 mL/kg of 4F-PCC (25 IU of factor IX/kg) vs 1 mL/kg of saline solution (placebo). Patients, investigators, and data analysts were blinded to treatment assignment. All patients received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1) and were treated according to European traumatic hemorrhage guidelines. Main Outcomes and Measures The primary outcome was 24-hour all blood product consumption (efficacy); arterial or venous thromboembolic events were a secondary outcome (safety). Results Of 4313 patients with the highest trauma level activation, 350 were eligible for emergency inclusion, 327 were randomized, and 324 were analyzed (164 in the 4F-PCC group and 160 in the placebo group). The median (IQR) age of participants was 39 (27-56) years, Injury Severity Score was 36 (26-50 [major trauma]), and admission blood lactate level was 4.6 (2.8-7.4) mmol/L; prehospital arterial systolic blood pressure was less than 90 mm Hg in 179 of 324 patients (59%), 233 patients (73%) were men, and 226 (69%) required expedient hemorrhage control. There was no statistically or clinically significant between-group difference in median (IQR) total 24-hour blood product consumption (12 [5-19] U in the 4F-PCC group vs 11 [6-19] U in the placebo group; absolute difference, 0.2 U [95% CI, -2.99 to 3.33]; P = .72). In the 4F-PCC group, 56 patients (35%) presented with at least 1 thromboembolic event vs 37 patients (24%) in the placebo group (absolute difference, 11% [95% CI, 1%-21%]; relative risk, 1.48 [95% CI, 1.04-2.10]; P = .03). Conclusions and Relevance Among patients with trauma at risk of massive transfusion, there was no significant reduction of 24-hour blood product consumption after administration of 4F-PCC, but thromboembolic events were more common. These findings do not support systematic use of 4F-PCC in patients at risk of massive transfusion. Trial Registration ClinicalTrials.gov Identifier: NCT03218722.

Background: Optimal decarboxylation dose under extracorporeal respiratory support to ensure sufficient reduction of mechanical ventilation stress remains unclear and understudied. The aim of this study was to assess the interdependence of blood flow (BF) and gas flow (GF) in predicting CO 2 removal and mechanical ventilation reduction (MVR) under extracorporeal respiratory support. Methods: All patients who benefited from veno-venous ECMO (HLS-maquet 7.0, 1.8 m²) and high-flow ECCO 2 R (HLS-maquet 5.0, 1.3 m²) in our intensive care unit over a period of 18 months were included. CO 2 removal was calculated from inlet/outlet blood gases performed in clinical practice during the first 7 days of oxygenator use. The relationship between the BF × GF product and CO 2 removal or MVR was studied using linear regression models. Results: Eighteen patients were analysed, corresponding to 24 oxygenators and 261 datasets. CO 2 removal was 393 mL/min (IQR, 310–526 mL/min) for 1.8 m 2 oxygenators and 179 mL/min (IQR, 165–235 mL/min) for 1.3 m 2 oxygenators. The decarboxylation index was associated linearly with CO 2 removal (R 2 = 0.62 and R 2 = 0.77 for the two oxygenators, respectively) and MVR (R 2 = 0.72 and R 2 = 0.62, respectively). Values in the range 20−30L 2 /min 2 were associated with an MVR ratio between 38% and 58% for 1.8 m 2 oxygenators, and between 37% and 55% for 1.3 m 2 oxygenators. Conclusion: The decarboxylation index is a simple parameter to predict CO 2 removal and MVR under extracorporeal respiratory support. A BF of 2 L 2 /min 2 or more may be necessary to obtain a significant reduction of mechanical convection. Trial Registration: Being a retrospective study, no trial registration was made.