While volume–outcome relationships for non-traumatic out-of-hospital cardiac arrest have been reported in hospital settings, the impact of prehospital exposure, particularly for the rare and clinically complex entity of traumatic cardiac arrest (TCA), remains uncertain and may influence emergency medical services (EMS) proficiency and survival. The study aimed to assess the relationship between exposure of emergency medical services to traumatic cardiac arrest cases and patients’ survival. We conducted a multicentre retrospective cohort study using data from the French nationwide out of hospital cardiac arrest registry (RéAC) from July 2011 to March 2023. EMS volume was defined by the number of traumatic cardiac arrests managed by physician-staffed EMS per year of participation in the registry. The primary outcome was survival upon hospital admission. Secondary outcomes included return of spontaneous circulation (ROSC), 30-day survival, and 30-day survival with a favourable neurological outcome. We also investigated key prehospital management variables such as epinephrine administration, intubation, haemorrhage control procedures, fluid resuscitation, blood transfusion, thoracostomy, on-scene time and transport time. A multivariable mixed model was used to account for differences in baseline characteristics. Among 151,658 out-of-hospital cardiac arrest, 6,263 were identified as TCA (age 45 years [IQR 29;63]; 77

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.

INTRODUCTION:Pelvic fractures complicated by hemorrhagic shock represent a major challenge in trauma management, particularly in the absence of active arterial bleeding (e.g., contrast extravasation or "blush") on computed tomography (CT). In this context, some teams advocate for non-selective arterial embolization, whereas others favor a watchful waiting strategy. The aim of this study was to compare, in patients with severe pelvic trauma and hemorrhagic shock, the impact of two strategies (i.e., non-interventional management versus systematic embolization) on red blood cell transfusion requirements within the first 24 h following admission. MATERIALS AND METHODS:This multicenter retrospective cohort study included adult patients (≥18 years) admitted to the trauma resuscitation unit of three level-1 trauma centers. Patients were included in the study if they received at least two units of packed red blood cells (PRBCs) within 4 h of admission and if they had surrogates of shock (a lactate level > 5 mmol/L at admission or if they required vasopressor support within 4 h of injury). The exclusion criterion was the presence of arterial contrast extravasation ("blush") on CT. The primary outcome was the number of PRBC units transfused within the first 24 h. Secondary outcomes included 48-hour mortality, 30-day mortality, length of stay in the intensive care unit, total hospital length of stay, and duration of vasopressor therapy. RESULTS:A total of 165 patients were included between January 2015 and September 2022. In multivariable analysis, no significant difference was observed in the median number of PRBC units transfused within 24 h between the two strategies (3.0 [2.0; 6.5] vs. 3.0 [2.0;4.0]; p = 0.872). Similarly, no difference in 30-day mortality was identified (odds ratio 0.62, 95% confidence interval 0.25-1.67; p = 0.310). No significant differences were found in the duration of shock, vasopressor support, or early mortality. CONCLUSION:In patients with pelvic fractures complicated by hemorrhagic shock and without evidence of active arterial bleeding on CT, this study did not demonstrate the superiority of systematic embolization over a non-interventional management in terms of transfusion requirements or clinical outcomes.

Propofol is the most frequently used hypnotic during rapid sequence induction in patients at risk of pulmonary aspiration of gastric contents worldwide. Its most common side effect is to induce hypotension due to dose-dependent vasoplegia. Ketamine is an alternative with pharmacological hemodynamic stability but a higher risk of postoperative delirium. Ketofol, an equimolar combination of these two hypnotics, has recently been proposed in this setting. The objective of this study is to demonstrate the superiority of ketamine (or ketofol) compared to propofol, in association with a neuromuscular blocking agent, for achieving tracheal intubation without hypotension in patients undergoing surgery under general anesthesia and at risk of pulmonary aspiration of gastric contents. The HyPnotiKs study is a multicenter, open-labeled, superiority, randomized controlled trial comparing ketamine (2 mg/kg), propofol (2 mg/kg), and ketofol (1 mg/kg each) for rapid sequence induction in 1218 adult surgical patients requiring tracheal intubation during general anesthesia. Enrollment started in April 2025 in 20 French anesthesia units. The expected date of the final follow-up is May 2027. The primary outcome is the proportion of successful tracheal intubation at the first attempt and without major hypotension. A hierarchical procedure is planned to compare the three arms. Intention-to-treat principle will be applied. The HyPnotiKs study protocol has been approved by the ethics committee of the Comité de Protection des Personnes Sud Méditerranée V and will be carried out in accordance with the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentations at scientific conferences and publications in peer-reviewed journals. The HyPnotiKs study is the first randomized controlled trial powered to investigate whether ketamine, ketofol, or propofol is the hypnotic of first choice for rapid sequence induction of anesthesia in patients with a full stomach, considering successful tracheal intubation without hypotension. ClinicalTrials.gov NCT06733129. Registered on December 2024.

The association between ionized calcium (iCa²⁺) levels at admission and mortality in trauma patients remains controversial, with prior studies suggesting increased mortality in both hypocalcemic and hypercalcemic states. This study aimed to characterize the relationship between admission iCa²⁺ and key clinical outcomes, including mortality, and to clarify the contribution of acidosis—particularly among patients presenting with elevated iCa²⁺ levels. We performed a retrospective multicenter cohort study using a trauma registry (2011–2021). Adult trauma patients admitted to a level-1 trauma center with measured admission iCa²⁺ were included. Hypocalcemia and hypercalcemia were defined as iCa²⁺ <1.10 mmol/L and > 1.20 mmol/L, respectively. The primary outcome was mortality at hospital discharge (MHD); secondary outcomes were massive transfusion and trauma-induced coagulopathy (TIC). Associations were evaluated using multivariable logistic regression. We additionally assessed whether incorporating pH-adjusted iCa²⁺ improved the predictive performance of the mortality model. Among 977 patients (93

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.

Le bénéfice de la transfusion pré-hospitalière de plasma lyophilisé à la phase initiale d’un choc hémorragique chez un traumatisé sévère est débattu. La transfusion de plasma apporte des facteurs de la coagulation et permet une restauration partielle du glycocalyx. Cependant, les conclusions des trois principales études prospectives, randomisées, contrôlées divergent et ne permettent pas de conclure sur le bénéfice d’une transfusion précoce de plasma. En effet, les patients inclus ne sont pas tous en état de choc hémorragique. À l’opposé, les études observationnelles menées à grande échelle, pour la plupart en zone de combats, plaident pour un apport précoce de plasma mais sont critiquables car rétrospectives et associées à des facteurs confondants (réduction du délai d’admission hospitalier, pose de garrots).

Survival rates for trauma cardiac arrest (TCA) routinely range from 2 to 5% and have not improved in high-income countries over the past two decades, unlike those for medically induced cardiac arrests. This persisting low TCA survival rates have led to debates, about the value of resuscitating TCA patients, considering the significant risks and costs involved compared to the low chances of favorable outcomes. As well, TCA patients are frequently excluded from large randomized controlled trials on cardiac arrest management, with most research consisting of retrospective studies and clinical case series. The causes of cardiac arrest following injury are diverse, and hypovolemia, particularly from hemorrhagic shock, is a significant cause of early death. Direct cardiac or large vessel injuries, such as myocardial contusions or tamponade, can also lead to TCA. While TCA from severe brain or spinal injuries are less frequent, survival rates in these cases can be slightly better if return of spontaneous circulation (ROSC) is achieved. The presence of bystander CPR, shockable initial rhythms, and rapid identification and treatment of reversible causes are associated with favorable outcomes. A few strategies should be applied systematically, such as early bleeding source control, oxygen supplementation, hypovolemia correction, and diagnosing and treating compressive pleural or pericardial effusions. Emerging techniques are suggested for the management of refractory hemorrhagic shock and cardiac arrest, such as the REBOA (Resuscitative Balloon Occlusion of the Aorta), but further research is needed to determine the most effective approaches to prehospital and in-hospital TCA management.

Aim:Out-of-hospital traumatic cardiac arrests (TCA) are associated with a poor prognosis, yet limited research focuses on paediatric TCA. This study aimed to compare outcomes following TCA between children and adults. Methods:We conducted a retrospective cohort study using data from the French cardiac arrest registry (RéAC) between July 2011 and March 2023. We included all patients under 65 years who suffered a TCA managed by a mobile medical team. Patients were categorized as children (<18 years) and adults (18-65 years). The primary endpoint was the 30-day survival, and secondary endpoints were: return of spontaneous circulation (ROSC), survival at hospital admission and survival with a favourable neurological outcome (Cerebral Performance Categories 1-2) at 30 days. Results:Among 5,030 included patients, 396 were children (median age 13 [IQR 4-16] years; 73.2% male) and 4,634 were adults (median age 39 [IQR 27-51] years; 80.4% male). Paediatric patients had significantly higher rates of ROSC (25.5% vs. 20.6%, p = 0.02), survival to hospital admission (21.2% vs. 14.7%, p < 0.001), and 30-day survival (3.5% vs. 1.6%, p < 0.01). However, the proportion of patients achieving a favourable neurological outcome at 30 days did not differ significantly between groups (0.8% vs. 0.9%, p = 0.80). Conclusions:Paediatric patients with out-of-hospital TCA demonstrate higher rates of ROSC and survival compared to adults, although neurological outcomes remain poor in both populations. These findings underscore age-related disparities in TCA prognosis and highlight the need for age-specific research in TCA patients.

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.

Crystalloid-based fluid resuscitation has long been a cornerstone in the initial management of trauma-induced hemorrhagic shock. However, its benefit is increasingly questioned as it is suspected to increase bleeding and worsen coagulopathy. The emergence of alternative strategies like permissive hypotension and vasopressor use lead to a shift in early trauma care practices. Critical appraisal of current evidence is necessary to guide clinicians and outline research perspectives. Current guidelines for managing trauma-induced hemorrhagic shock suggest titrating fluids and using vasopressors to achieve minimal blood pressure targets until hemorrhage is controlled. In case of traumatic brain injury with severe hemorrhage, blood pressure target increases. The scientific literature supporting these recommendations is limited, and several aspects remain the subject of ongoing scientific debate. The aim of this review is to evaluate the existing evidence on low-volume fluid resuscitation during the first hours of trauma management, with an emphasis on its integration with permissive hypotension, vasopressor use and cerebral perfusion pressure in traumatic brain injury. The review also highlights the limitations of current guidelines, particularly the lack of robust evidence supporting specific type of fluid, volumes and administration protocols tailored to specific trauma scenarios and populations. Emerging technologies such as point-of-care diagnostics, integrated monitoring systems, and machine learning hold promise for enhancing clinical decision-making in trauma care. These innovations could play a crucial role, ultimately helping clinicians address critical unanswered questions in trauma management and improve patient survival. Crystalloid-based resuscitation remains relevant in early trauma care, but its application must be reassessed considering recent evidence and evolving practices. Further research is essential to refine fluid resuscitation guidelines, particularly in defining safe fluid volumes and the role of vasopressors. The integration of advanced monitoring technologies may offer new opportunities to optimize trauma care and improve outcomes.

Background: Despite systematic thromboprophylaxis, 30% of the COVID-19 patients in intensive care units develop thrombosis. This occurrence is associated with a hypo fibrinolytic state measured by thromboelastometry when adding tissue plasminogen activator (tPA) to citrated whole blood for a further run for EXTEM (ROTEM). Objectives: Because hydroxyethyl starches (HESs) affect fibrin polymerization, we have assessed its potential effect on in vitro tPA-induced fibrinolysis. Methods: Fifteen successive COVID-19 patients from the local intensive care units were selected for tPA resistance occurrence. HES was added to whole blood samples with proportion similar to the pharmacologic recommendations. Samples were run for EXTEM on a ROTEM delta device after further addition of tPA. Paired controls were whole blood samples with the same volume of saline added. To assess the impact of HES on coagulation, thrombin generation was measured in 10 COVID-19 patients in the presence of either HES or saline; then, the clots obtained were used to generate electron microscope images. Results: Clot firmness at 5 minutes and the lysis index at 30 minutes were decreased in presence of HES compared with saline (Wilcoxon test, P < .01 for HES vs saline and HES vs untreated). However, no statistically signi ficant difference was observed for all thrombin generation assay parameters studied (endogenous thrombin potential, peak thrombin, and time to peak). With HES, fibrin fibers of either COVID-19 patients or control subjects were thicker than those of saline-treated samples. Conclusion: These results highlight that HES increased apparent in vitro tPA-induced fibrinolysis in case of severe COVID-19 disease. Use of this plasma volume expander may translate as a potential help against COVID-19 -induced thrombosis occurrence.

Critically injured patients need rapid and appropriate hemostatic treatment, which requires prompt identification of trauma-induced coagulopathy (TIC) upon hospital admission. We developed and validated the performance of a clinical score based on prehospital resuscitation parameters and vital signs at hospital admission for early diagnosis of TIC. The score was derived from a level-1 trauma center registry (training set). It was then validated on data from two other level-1 trauma centers: first on a trauma registry (retrospective validation set), and then on a prospective cohort (prospective validation set). TIC was defined as a PTratio > 1.2 at hospital admission. Prehospital (vital signs and resuscitation care) and admission data (vital signs and laboratory parameters) were collected. We considered parameters independently associated with TIC in the score (binomial logistic regression). We estimated the score’s performance for the prediction of TIC. A total of 3489 patients were included, and among these a TIC was observed in 22

Background Anaemia and blood transfusion are associated with poor outcomes after hip fracture. We evaluated the efficacy of intravenous iron and tranexamic acid in reducing blood transfusions after hip fracture surgery.Methods In this double-blind, randomised, 2 x 2 factorial trial, we recruited adults hospitalised for hip fractures in 12 medical centres in France who had preoperative haemoglobin concentrations between 95 and 130 g/dL. We randomly allocated participants (1:1:1:1), via a secure web-based service, to ferric derisomaltose (20 mg/kg intravenously) and tranexamic acid (1 g bolus followed by 1 g over 8 h intravenously at inclusion and 3 g topically during surgery), iron plus placebo (normal saline), tranexamic acid plus placebo, or double placebo. Unmasked nurses administered study drugs; participants and other clinical and research staff remained masked to treatment allocation. The primary outcome was the percentage of patients transfused during hospitalisation (or by day 30). The primary analysis included all randomised patients. This study is registered on ClinicalTrials.gov (NCT02972294) and is closed to new participants.Findings Of 413 patients (51-104 years old, median [IQR] 86 [78-91], 312 [76%] women, 101 [24%] men), 104 received iron plus tranexamic acid, 103 iron plus placebo, 103 tranexamic acid plus placebo, and 103 double placebo between March 31, 2017 and June 18, 2021 (study stopped early for efficacy after the planned interim analysis done on the first 390 patients included on May 25, 2021). Data for the primary outcome were available for all participants. Among patients on double placebo, 31 (30%) were transfused versus 16 (15%) on both drugs (relative risk 051 [983% CI 027-097]; p=0012). 27 (26%) participants on iron (081 [050-129]; p=028) and 28 (27%) on tranexamic acid (085 [054-133]; p=039) were transfused. 487 adverse events were reported with similar event rates among the groups; among prespecified safety endpoints, severe postoperative anaemia (haemoglobin <8 g/dL) was more frequent in the double placebo group. Main common adverse event were sepsis, pneumonia, and urinary infection, with similar rates among all groups. Interpretation In patients hospitalised for hip fracture surgery with a haemoglobin concentration 95-130 g/dL, preoperative infusion of ferric derisomaltose plus tranexamic acid reduced the risk of blood transfusion by 50%. Our results suggest that combining treatments from two different pillars improves patient blood-management programmes. Either treatment alone did not reduce transfusion rates, but we might not have had the power to detect it.

Background To accelerate the diagnosis and treatment of trauma-induced coagulopathy (TIC), viscoelastic haemostatic assays (VHA) are increasingly used worldwide, although their value is still debated, with a recent randomised trial showing no improvement in outcome. The objective of this retrospective study was to compare 2 cohorts of injured patients in which TIC was managed with either a VHA-based algorithm or a conventional coagulation test (CCT)-based algorithm. Methods Data were retrieved from 2 registries and patients were included in the study if they received at least 1 unit of red blood cell in the first 24 h after admission. A propensity score, including sex, age, blunt vs. penetrating, systolic blood pressure, GCS, ISS and head AIS, admission lactate and PT ratio , tranexamic acid administration, was then constructed. Primary outcome was the proportion of subjects who were alive and free of massive transfusion (MT) at 24 h after injury. We also compared the cost for blood products and coagulation factors. Results From 2012 to 2019, 7250 patients were admitted in the 2 trauma centres, and among these 624 were included in the study (CCT group: 380; VHA group: 244). After propensity score matching, 215 patients remained in each study group without any significant difference in demographics, vital signs, injury severity, or laboratory analysis. At 24 h, more patients were alive and free of MT in the VHA group (162 patients, 75%) as compared to the CCT group (112 patients, 52%; p < 0.01) and fewer patients received MT (32 patients, 15% vs. 91 patients, 42%, p < 0.01). However, no significant difference was observed for mortality at 24 h (odds ratio 0.94, 95% CI 0.59–1.51) or survival at day 28 (odds ratio 0.87, 95% CI 0.58–1.29). Overall cost of blood products and coagulation factors was dramatically reduced in the VHA group as compared to the CCT group (median [interquartile range]: 2357 euros [1108–5020] vs. 4092 euros [2510–5916], p < 0.001). Conclusions A VHA-based strategy was associated with an increase of the number of patients alive and free of MT at 24 h together with an important reduction of blood product use and associated costs. However, that did not translate into an improvement in mortality.

Importance It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent. Objective To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation. Design, Setting, and Participants Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021. Interventions Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 μg/kg; n = 575) immediately after injection of a hypnotic. Main Outcomes and Measures The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%. Results Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%). Conclusions and Relevance Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference. Trial Registration ClinicalTrials.gov Identifier: NCT03960801.