The respective weights of head and extra-head injuries to the occurrence of coagulopathy following traumatic brain injury (TBI) remain unclear. We hypothesized that the severity of extra-head injuries would be the main contributor to coagulopathy following TBI. This was a retrospective study from a multicenter, prospective trauma registry. All adult patients directly admitted following TBI (Abbreviated Injury Score [AIS]) head ≥1) from 2012 to 2021 were included. Coagulopathy was defined as a prothrombin time ratio (PTr) >1.2, platelets <100 G.L-1, or fibrinogen level <1.5 g.L-1 on hospital admission. TBI severity was assessed by the Glasgow Coma Scale (GCS). Severe extracranial injuries were defined by at least one of the extra-head AIS scores ≥3 (AISextra-head ≥3). Incidences of coagulopathy were determined and compared according to TBI severity in patients with or without severe extracranial injuries. Risk factors for coagulopathy were identified using bivariate analysis and then multivariable analysis. In 9,610 TBI patients analyzed, the overall incidence of coagulopathy was 28.5% (n = 2,738). The incidence of coagulopathy increased gradually with TBI severity, from 8% for GCS 14-15% to 42% for GCS 3 in patients without severe extracranial injuries, and from 27% for GCS 14-15% to 70% for GCS 3 in patients with severe extracranial injuries. In multivariable analysis, AISextra-head ≥3 (odds ratio = 2 [1.8-2.3], p < 0.001) and GCS ≤8 (odds ratio = 1.3 [1.1-1.6], p = 0.001) were independent risk factors for coagulopathy. Coagulopathy was associated with both head and extra-head injury severities, yet to a greater extent with severe extracranial injuries.

Following severe trauma, activation of the autonomic and neuroendocrine systems is key in the response to hemorrhage by triggering vasopressor secretion, sodium and water reabsorption to maintain blood pressure and organ perfusion. However, these adaptative mechanisms remain not yet well described in this setting. The main goal of this study was to explore hypothalamic-posterior-pituitary-vasopressin, hypothalamic–pituitary–adrenal and renin–angiotensin–aldosterone system responses to severe trauma. This is a single-centre prospective observational study among adult severe trauma patients (Injury Severity Score (ISS) ≥ 9) in a French level-1 trauma center. Sixty-five patients were included with a mean age of 46 (± 20) years old and a median ISS of 25 (19–30). Twenty-eight (43

Abstract Background Veno-arterial carbon dioxide tension difference (ΔPCO2) and mixed venous oxygen saturation (SvO2) have been shown to be markers of the adequacy between cardiac output and metabolic needs in critical care patients. However, they have hardly been assessed in trauma patients. We hypothesized that femoral ΔPCO2 (ΔPCO2 fem) and SvO2 (SvO2 fem) could predict the need for red blood cell (RBC) transfusion following severe trauma. Methods We conducted a prospective and observational study in a French level I trauma center. Patients admitted to the trauma room following severe trauma with an Injury Severity Score (ISS) > 15, who had arterial and venous femoral catheters inserted were included. ΔPCO2 fem, SvO2 fem and arterial blood lactate were measured over the first 24 h of admission. Their abilities to predict the transfusion of at least one pack of RBC (pRBCH6) or hemostatic procedure during the first six hours of admission were assessed using receiver operating characteristics curve. Results 59 trauma patients were included in the study. Median ISS was 26 (22–32). 28 patients (47%) received at least one pRBCH6 and 21 patients (35,6%) had a hemostatic procedure performed during the first six hours of admission. At admission, ΔPCO2 fem was 9.1 ± 6.0 mmHg, SvO2 fem 61.5 ± 21.6% and blood lactate was 2.7 ± 1.9 mmol/l. ΔPCO2 fem was significantly higher (11.6 ± 7.1 mmHg vs. 6.8 ± 3.7 mmHg, P = 0.003) and SvO2 fem was significantly lower (50 ± 23 mmHg vs. 71.8 ± 14.1 mmHg, P < 0.001) in patients who were transfused than in those who were not transfused. Best thresholds to predict pRBCH6 were 8.1 mmHg for ΔPCO2 fem and 63% for SvO2 fem. Best thresholds to predict the need for a hemostatic procedure were 5.9 mmHg for ΔPCO2 fem and 63% for SvO2 fem. Blood lactate was not predictive of pRBCH6 or the need for a hemostatic procedure. Conclusion In severe trauma patients, ΔPCO2 fem and SvO2 fem at admission were predictive for the need of RBC transfusion and hemostatic procedures during the first six hours of management while admission lactate was not. ΔPCO2 fem and SvO2 fem appear thus to be more sensitive to blood loss than blood lactate in trauma patients, which might be of importance to early assess the adequation of tissue blood flow with metabolic needs.

L’hématome intracérébral spontané est fréquent avec un taux de mortalité élevé. Il survient dans un contexte de « maladie des petits vaisseaux cérébraux », représentée par l’artériolo-sclérose et l’angiopathie amyloïde. Son diagnostic impose une enquête diagnostique exhaustive reposant principalement sur l’imagerie cérébrale injectée. Le transfert dans une unité de neuroréanimation pour traitement spécifique s’impose en cas de lésion macrovasculaire sous-jacente ; il se discute en cas de trouble de conscience dans l’éventualité d’une intervention neurochirurgicale ou d’un neuromonitorage. Le traitement consiste à éviter le développement de lésions cérébrales secondaires en contrôlant le niveau de pression artérielle, en arrêtant les agents antiplaquettaires et en neutralisant les anticoagulants. La réanimation doit être maximaliste à la phase initiale en prenant en compte l’autonomie antérieure, les directives anticipées et/ou les souhaits du patient rapportés par la personne de confiance.

Abstract Background Following traumatic brain injury (TBI), coagulopathy on hospital admission is reported in 25–35% of patients and associated with increased morbimortality. The respective contributions of intracranial injury and concomitant extracranial lesions to coagulopathy have been poorly investigated. We hypothesized that the occurrence of post-TBI coagulopathy would not only be related to head injury severity, but also and to a greater extent to the presence and severity of the associated extra-cranial injuries.Methods Observational study from a multicenter prospective French trauma registry (Traumabase®). All adult patients directly admitted to one of the participating centers from January 2012 to December 2021 following TBI (AIS (Abbreviated Injury score) head ≥ 1) were included. Post-TBI coagulopathy was defined by at least 1 of the following criteria: prothrombin ratio (Quick %) < 70% or platelet count < 100 G.L− 1 or fibrinogenemia < 1.5 g.L− 1 on hospital admission. Severe associated extracranial lesions were defined by at least 1 of the extra-head AIS scores ≥ 3.Results Among 33875 patients admitted to 22 trauma centers, 9610 patients had TBI and were analyzed. The overall incidence of admission coagulopathy was 28.5%. Coagulopathic patients were significantly more severely injured and especially more severely head-injured, when compared to non-coagulopathic patients. The higher the AIShead, the higher the proportion of patients exhibiting coagulopathy (P < 0.001), whatever the presence of extracranial lesions. When compared to patients with AIShead = 1, the increased incidence of coagulopathy with TBI severity was observed at an earlier stage of TBI severity when severe extracranial lesions were present. In multivariable analysis, severe extracranial injury was independently associated with the risk of post-TBI coagulopathy (OR 2.0 (1.8–2.3), P < 0.001).Conclusions A continuously graded association between the severity of head injury and coagulopathy at hospital admission was observed, and this increased incidence of coagulopathy was observed at an earlier stage of TBI severity when severe extracranial lesions were present. The presence of severe extracranial injuries was one of the most important risk factors for coagulopathy following TBI. Intracranial and extra-cranial injury severity could be used to timely identify TBI patients most likely to present post-traumatic coagulopathy, that could benefit from early specific hemostatic resuscitation.

Editor, Anaesthesiology and intensive care residency is challenging with long hours, night calls and a high level of stress and its consequences on physical and mental health has become a major concern.1 Connected devices are increasingly involved in everyday practice. The amount of data collected, so-called big data, permits us to uncover unknown correlations or trends in large data sets of populations. The iFAR study (Impact de la Formation en Anesthésie-Réanimation), is a prospective longitudinal study describing sleep patterns, physical activity and stress using connected wristbands in real-life conditions in a cohort of 20 French residents working in an anaesthesiology, surgical ICU or medical ICU. They wore a connected wristband during 2 consecutive months allowing real-time monitoring of sleep, physical activity and heart rate (HR) 24 h a day, during working days (including on-call days) and holidays. Residents also responded to the Perceived Stress Scale 10 (PSS-10) questionnaire and self-evaluated their sleep duration needs. We studied sleep duration, sleep debt by comparing actual sleep duration and sleep needs, physical activity and HR during working days, on-call days and holidays, each participant being its own control. The connected wristbands used were CHARGE HR manufactured by Fitbit (Fitbit Inc., San Francisco, California, USA) due to their ability to monitor HR, physical activity and sleep duration continuously with a real time synchronisation between the wristband and the manufacturer's web platform. The devices were synchronised with residents’ smartphones and an account was created on the manufacturer's website using an anonymised login. The study was approved by the national CERAR (comité d’éthique de la recherche en Anesthésie-Réanimation) ethics committee 74 rue Raynouard, Paris, France, under the reference IRB 000102542015012, on 19 February 2015, and consent forms were signed by all participating residents. Quantitative variables were expressed as median [interquartile range], while qualitative variables were expressed as a percentage. Nonparametric tests were analysis of variance (ANOVA) Friedman test and parametric tests were one way ANOVA and Student's t test. The alpha risk was set to 0.05. Analyses were performed using Prism Software (GraphPad Software, La Jolla, California, USA). We collected 1027 data items per resident during the study period. Participants’ characteristics are described in Table 1. In total, 1320 days were analysed, including 189 on-call days, representing a median of 9 [8.75 to 11] on-call days per resident during the 2 months study period, 302 days of holidays and 829 working days excluding on-call days.Table 1: Participants’ characteristicsMedian sleep time was 6.5 h [5.3 to 7.6] on working days compared to 3.8 h [2.7 to 5.3] during on-call days (P < 0.0001) and 7.5 h [6.3 to 8.6] on holidays (P < 0.0001) (Fig. 1). Ninety percent of residents had a nap on the day after a night call with a median duration of 59 min [0 to 150]. By subtracting actual sleep duration from estimated sleep needs, the median sleep debt was 49.8 min [34.8 to 79.3] for each night. Cumulated sleep debt was 64.7 h [28.7 to 82.5] per resident during the 2 months period. Forty percent of residents presented a cumulated sleep debt of more than 72 h, corresponding to 10 nights.Fig. 1: Hours of sleep on regular, on-call days and holidays.Daily walking distance per resident was 8.3 km [6.3 to 10.8] corresponding to 11 888 steps [9109 to 15 755]. Physical activity more than three metabolic equivalents of tasks was significantly longer during on-call days compared with regular days, 6.4 h [5.5 to 7.3] versus 5.4 h [4.2 to 6.5], respectively (P < 0.0001) (Fig. 2) and longer during working days than during holidays, 5.6 h [4.4 to 6.8] versus 5.0 h [3.9 to 6.0], respectively (P < 0.0001).Fig. 2: Physical activity more than three metabolic equivalents of tasks in hours on regular, on-call days and holidays.HR did not vary significantly between regular (65 bpm [62 to 69]), on-call days (65 bpm [62 to 69]) and holidays (66 bpm [58 to 70]). Median PSS-10 score was 21 points [20 to 26] corresponding to the threshold above which respondents are emotionally troubled by their professional environment. Five residents (25%) presented a PSS-10 score superior to 27 points corresponding to a strong feeling of powerlessness facing professional situations, at risk of burnout according to PSS-10 scale interpretation.2 PSS-10 was not different between ICU and anaesthesiology residents, with a median of 21 points [20 to 34] and 23.5 points [19 to 22.5] (P = 0.15), respectively. While it is not surprising to observe that residents sleep less during night calls, the tremendous sleep debt accumulated during the 2 months period is alarming, since it is demonstrated that the effects of sleep deprivation are cumulative.3 In addition, despite a debate on individual sleep needs, current guidelines recommend 7 to 9 h of sleep per night to promote optimal health,4 and sleeping more than 9 h might be appropriate for young adults and individuals recovering from sleep debt.5 On top of that, connected wristbands use actigraphy to monitor sleep thus giving no information on sleep quality. Indeed, if sleep is possible during night calls, it is often limited and fragmented,6 so that the sleep debt might have been underestimated. The results of this study performed in France can hardly be generalised to other countries where duty regulations, schedules and activities may be significantly different. Among the solutions to deal with professional stress, combining these new measure technologies with high fidelity medical simulation seems a possibly attractive approach. Furthermore, measures could be taken to withstand stressful situations (simulation for the most stressful situations, regular evaluation, anonymous help call numbers, psychological support in and outside medical wards). To conclude, using connected wristbands, an innovative method to quantify sleep and physical activity, this prospective preliminary study (iFAR) observed that anaesthesiology and intensive care residents sleep less during work periods than during holidays, accumulate sleep debt (64.7 h in 2 months), are highly active and present high levels of stress when compared with the general population.7