L'Université d'Angers

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.

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.

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.

This survey highlights the variability of the functional, architectural, and human resource organization of French TC1.

Metformin is the most commonly used drug in the treatment of type 2 diabetes mellitus and appears as a promising drug for several other conditions. While generally well-tolerated and relatively safe, metformin can cause serious side effects, and intoxication cases have been reported. Classically, the severity of metformin intoxications is better assessed by measuring lactate blood concentration and/or blood pH than by directly determining blood drug concentration. However, such an approach is more complicated in postmortem investigation. Indeed, biochemistry changes occur after death, affecting both lactate concentration and pH. In this context, the authors report a case of a metformin-related fatality for which toxicological and biochemical analyses have been integrated in order to better understand pathophysiological mechanisms and/or circumstances surrounding such fatalities. Metformin was quantified in femoral blood (FB) (45 mg/L), heart blood (HB) (39 mg/L), urine (464 mg/L), vitreous (18 mg/L) and gastric content (202 mg/L) using liquid chromatography-tandem mass spectrometry (LC-MS/MS). β-hydroxybutyrate (BHB) was also quantified in FB (491 mg/L) and vitreous (473 mg/L) using LC-MS/MS. Vitreous sodium (122 mmol/L), chloride (102 mmol/L), glucose (<0.10 mmol/L), creatinine (277 µmol/L) and lactate (13 mmol/L) concentrations were determined in vitreous on an Atellica® CH 930 analyzer. Glycated hemoglobin (HbA1C) was assessed in FB (7.7 %) using a Tosoh® G8 HPLC analyser. Overall, only few cases of metformin-related fatalities have been described. Here, the metformin FB concentration appeared particularly high, in agreement with other reported cases. Similarly, the results of the postmortem biochemistry analysis were also consistent with those reported in other metformin-related fatalities. Interestingly, BHB concentrations were notably elevated in both FB and vitreous humor. Furthermore, creatinine was determined in vitreous humor at a particularly high concentration. This case highlights the importance of combining postmortem toxicological and biochemical analyses in deaths involving antidiabetics. Indeed, such fatalities are quite complex and both drug toxicity and metabolic disorders may overlap with regard to mechanisms of death.