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16/02/2017

TMT tourniquet: Un nouveau venu

Un nouveau venu qui fait aussi bien que la référence US, à savoir le CAT, sans apporter plus (1). Ne pas confondre ce garrot dont le distributeur est connu et dont la fabrication parfaitement tracée. Sans aucune comparaison avec nombre de copies qui ne bénéficie pas des mêmes contrôle de qualité distribués à moins de 10 Euros et qui peuvent faire illusion.

TMT-Header-Graphic-Image.jpg

| Tags : tourniquet

08/02/2017

Tourniquets contrefaits = DANGER

DANGER

 

Les événements récents ont mis en avant l'importance de l'application précoce de garrot. L'approvisionnement en garrot est un véritable challenge et un marché où la guerre commerciale fait maintenant rage. Si le nombre de fabricants historiques de garrot était relativement restreint  (CAT, SOFT-T, TK4, RATS, MAT, SWAT), on voit fleurir nombre de copies essentiellement chinoises dont il est relativement aisé de se procurer des exemplaires, notamment sur le marché de l'AIRSOFT. Deux fabricants sont particulièrement la cible de ces contrefacteurs CAT ressources et TACMED solutions, car ce sont les deux garrots validés par les US dans le cadre du TCCC. Ces deux fabricants diffusent leurs produits pour une 20aines d'euros. Le garrot en service dans l'armée française depuis une dizaine d'année est le SOFT-T de la société TACMED, garrot dont il existe une version adaptée pour l'enfant. Les contrefacteurs chinois affichent des tarifs parfois 10 fois moindres. Les produits proposés par ces sociétés ne peuvent pas disposer des qualités techniques de même niveau que ceux détenus par les originaux. Un aspect important des garrots est leur résistance au vieillissement, aux intempéries, au froid, aux UV. Il a été démontré que ces caractéristiques sont très importantes en terme d'efficacité après quelques mois de port du garrot en ambiance opérationnelle vraie. Il serait étonnant que ces copies de garrot, dont les matières premières et les circuits de fabrication sont pour le moins opaques offrent les mêmes garanties de sécurité que ceux de fabricants historiques maîtrisant tous les process de fabrication de leur production.

Par ailleurs il semblerait que les conditions des certifications CE et ISO 134 (1,2,3)85 soit sujettes à caution car en partie relevant d'une autocertification.

Les autorités américaines ne sont saisies de ce problème et rappellent l'importance de ne s'approvisionner que chez les forunisseurs des garrots validés dans le T3C, à savoir les garrots produits apr CAT ressources et TacMed Solutions en excluant toute autre production au prétexte de tarifs à première vue (tro) alléchants. Lire le rapport de la FDA

Je vous propose dans le lien suivant quelques exemples concernant le garrot SOFT-T

Matériel Tourniquet Contrefaçons.pdf

Certains modèles de tourniquet s'inspirent très fortement de ces produits et en particulier du SOF-T (notamment le wide) mais avec une démarche d' innovation réelle. Aussi ces tourniquets sont ils différents de simples copies et très probablement de bonne qualité. Ils ne sont pas produits en chine mais dans des pays de l'Est européen, voire en Russie (a,b). On manque néanmoins de recul d'expertise technique de ces derniers. 

Dans l'état actuel des choses, à moins de s'équiper pour de l'airsoft, la prudence est de rester à l'écart des ces garrots et de continuer à utiliser les produits distribués par les fournisseurs reconnus des fabricants historiques (4, 5,6)

| Tags : tourniquet

04/02/2017

QuikClot: Du nouveau, pour l'hôpital

La gamme quikclot s'agrandit avec toute une proposition de pansement adapté à l'usage hospitalier, que ce soit peropératoire ou en soins critiques.

 

Quikclot_Radial_Hemostatic_Bandage_interventional_bandage.jpg

image-prod-188-20151019.png?width=591&height=800&ext=.png

 

| Tags : hémorragie

22/01/2017

Du sang qui descend du ciel

Nous ne sommes pas les seuls à avoir à faire face au contexte d'isolement. Il est particulièrement intéressant de regarder comment ces problèmes sont abordés par les pays en voie de construction. L'exemple rwandais devrait nous interpeller. Le recours à des drones de livraison en contexte militaire n'est pas une utopie car ce mode de ravitaillement a été utilisé en afghanistan.

 



| Tags : transfusion

11/11/2016

15 ans d'emploi du tourniquet: Que dire ?

Battlefield Tourniquets: Lessons Learned in Moving Current Care Toward Best Care in an Army Medical Department at War

Kragh JF Jr et Al. US Army Med Dep J. 2016 Apr-Sep;(2-16):29-36.

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Un point d'étape qui insiste sans surprise sur l'apport d'une pose précoce d'un garrot. Précoce mais aussi rapide:  25 secondes sont nécessaires aux plus entraînés mais c'est 20 secondes de trop. Plus on s'entraîne et plus vite ET mieux on pose ce garrot.  

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Bleeding prevention and control by tourniquet use by out-of-hospital caregivers is a major breakthrough in military medicine of current wars. The present review documents developments in tourniquet practices since 2001 among the US military services for aid in improving doctrine, policy, and especially care in wars to come. Tourniquets are an adjunct for resuscitation in self-care and buddy aid and today are issued to all military service persons who deploy into a combat zone. In the US Army, virtually every Soldier is trained in first aid tourniquet use; since 2009 they are instructed early and often to use them early and often. Despite substantial knowledge gains among the services in tourniquet use and resulting improvements in casualty survival, current evidence shows persistent diffi culties in achieving best care with tourniquet use for individual trauma patients. Nevertheless, contemporary tourniquet use incorporates key lessons learned over the last 14 years of war that include: (1) tourniquet use reliably stops bleeding from limb wounds and prevents mortality in prehospital settings; and (2) brief tourniquet use appears to be safe. These 2 lessons have become so evident that civilian emergency medical systems have begun using them, albeit unevenly. Collection and interpretation of data of casualties with tourniquet use have showed that such intervention has lifesaving benefit through 2 mechanisms: control of both ongoing hemorrhage and shock severity. The next generation of interventions in bleeding control involves developing the skill sets, education, and standards of tourniquet users which may improve hemorrhage control in wars to come

 

tourniquet

 

 

| Tags : tourniquet

30/09/2016

Nustat: Un nouveau venu ?

Controlling intraoperative hemorrhage during burn surgery: A prospective, randomized trial comparing NuStat® hemostatic dressing to the historic standard of care.

Butts CC et Al. Burns.  2016 Sep 19. pii: S0305-4179(16)30329-1. [Epub ahead of print]

INTRODUCTION:

One of the primary intraoperative challenges during burn surgery is to adequately excise the burn while avoiding massive hemorrhage. This has become increasingly important, as we see more burn patients that are older and with more medical comorbidities. While adequate excision down to healthy tissues for deep burns is essential for skin graft to take, it also leads to active bleeding that can be a challenge to control. Good hemostasis is imperative as a hematoma is the most common cause of graft loss. Several new products have become available to help control intraoperative hemorrhage. A new hemostatic dressing, NuStat®, is available and approved by FDA in United States.

METHODS:

A single institution prospective randomized control trial was completed at Regional Burn Center of the University of South Alabama comparing NuStat® with the institutional historic standard of care. Twenty such patients were included in our study. A cost analysis was also completed as part of the study retrospectively.

RESULTS:

For dressings used to treat the burn site, blood loss on the side treated with NuStat® was on average less (27g/100cm2) than the side treated with our historic standard of care (31g/100cm2), though it was not statistically significant (p=0.81). Similarly, on the donor site, blood loss on the side treated with NuStat® was on average less (14g/100cm2) than the side treated with our historic standard of care (15g/100cm2), but it was also not statistically significant (p=0.92). Average total blood loss from both excision and donor sites was also less with NuStat®(10g/100cm2) compared to the historic standard of care (12g/100cm2), but it was also not significant (p=0.77). There was no difference in the number of cycles required to achieve hemostasis for either the burn (1.15 NuStat® vs. 1.1 for historic standard of care, p=0.70) or the donor site (1 vs. 1, p=1.0). When comparing the cost of NuStat® versus the historic standard of care, the actual costs incurred for the wounds was less for the portion treated with NuStat® ($148.43) when compared to the historic standard of care ($186.45) (p<0.001).

CONCLUSIONS:

Based on these findings, NuStat® hemostatic action should be comparable to the historic standard of care, and these newerhemostatic agents evaluated further in burn surgery and bleeding during other procedures such as trauma surgery.

24/09/2016

Tourniquet: Entretien 3/mois mieux qu'1/mois

Does practice make perfect? Prospectively comparing effects of 2 amounts of practice on tourniquet use performance

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L'entretien des compétences et en particulier des gestes apparaît fondamentale et nécessite un suivi chiffré pour garantir un niveau suffisant d'expertise pour une projection opérationnelle. Ceci est parfaitement mis en avant dans le travail de schaeur et Al. (1) qui porte sur des gestes de réanimation préhospitalière. Le document proposé à votre lecture porte sur un geste essentiel: La pose du garrot. Une pratique plus régulière limite le désapprentissage.

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Although a lifesaving skill, currently, there is no consensus for the required amount of practice in tourniquet use. We compared the effect of 2 amounts of practice on performance of tourniquet use by nonmedical personnel.

METHODS:

Israeli military recruits without previous medical training underwent their standard tactical first aid course, and their initial performance in use of the Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC) was assessed. The educational intervention was to allocate the participants into a monthly tourniquet practice program: either a single-application practice (SAP) group or a triple-application practice (TAP) group. Each group practiced according to its program. After 3 months, the participants' tourniquet use performance was reassessed. Assessments were conducted using the HapMed Leg Tourniquet Trainer (CHI Systems, Fort Washington, PA), a mannequin which measures time and pressure.

RESULTS:

A total of 151 participants dropped out, leaving 87 in the TAP group and 69 in the SAP group. On initial assessment, the TAP group and the SAP group performed similarly. Both groups improved their performance from the initial to the final assessment. The TAP group improved more than the SAP group in mean application time (faster by 18 vs 8 seconds, respectively; P = .023) and in reducing the proportion of participants who were unable to apply any pressure to the mannequin (less by 18% vs 8%, respectively; P = .009).

CONCLUSION:

Three applications per monthly practice session were superior to one. This is the first prospective validation of a tourniquet practice program based on objective measurements.

| Tags : tourniquet

21/09/2016

Trauma Jonctionnel: Quels dispositifs appliquables ?

 PrehOSP JuncHem Control.jpg

14/09/2016

X stat: Magique ? Et bien NON

Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges: TCCC Guidelines Change 15-03.

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Le recours à de petites éponges comprzsées et recouvertes de chitosan apparaît fortement séduisant à tel point que l'XStat fait partie du TCCC. Cependant les bases scientifiques qui pourraient permettre de recommander ce produit paraissent très faibles. La lecture attentive du document proposé permet de s'en rendre compte. D'une part une application sur un cochon dans des conditions de laboratoire par un expert ne reproduit pas les conditions de combat. Ce produit apparaît ne pass être  adapté pour un emploi intra-thoracique, abdominal ou cervical  et il est prévu pour une durée d'application de 04h, ce qui ne permet pas de couvrir un certain nombre de missions vraiment spéciales ou certaine régions comme le cou (1). On comprend bien dès lors toute la prudence à avoir avec ces produits que l'industrie nous présente comme "magique". Ils le sont peut être, et ceci concerne tous les pansements hémostatiques (2),  mais il faut le prouver et ne pas céder aux sirènes effrénées du marketing des laboratoires. En la matière bien réaliser un packing de plaie, ne serait qu'avec une gaze standard doit rester un objectif fondamental, le reste étant un plus mais pas le fondamental.

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Exsanguination from wounds in the so-called junctional regions of the body (i.e., the neck, the axilla, and the groin) was responsible for 19% of the combat fatalities who died from potentially survivable wounds sustained in Afghanistan or Iraq during 2001 to 2011. The development of improved techniques and technology to manage junctional hemorrhage has been identified in the past as a high-priority item by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Army Surgeon General's Dismounted Complex Blast Injury (DCBI) Task Force. Additionally, prehospital care providers have had limited options with which to manage hemorrhage resulting from deep, narrow-track, penetrating trauma. XStat™ is a new product recently approved by the US Food and Drug Administration as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat has now been recommended by the CoTCCC as another tool for the combat medical provider to use in the management of junctional hemorrhage. The evidence that supports adding XStat to the TCCC Guidelines for the treatment of external hemorrhage is summarized in this paper.

04/09/2016

Garrot: Mais l'occlusion dans le temps ?

Different Width and Tightening System: Emergency Tourniquets on Distal Limb Segments

Wall PL et Al. J Spec Oper Med. 2015 Winter;15(4):28-38
 
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On s'interesse le plus souvent lors de la mise en place d'un tourniquet à son efficacité immédiate. Mais que se passe-t-il dans les minutes qui suivent ? Il est montré et notamment par ce travail que la pression sous le garrot diminue très rapidement. aussi le risque de resaignement est il grand et oblige à recontr^pler l'efficacité du garrot très régulièrement. C'est un des principes du garrot tactique. Ce travail suggère également que cette baisse de pression d'occlusion est moindre avec une bande de compression élastique. ceci milite pour l'adjonction d'une telle bande à peu près systématiquement soit du moins quand une réévaluation s'avère difficile à conduire dans de bonnes conditions. Ceci est connu (1) mais souvent non appliqué; De telles bandes sont représentées par la SWAT tourniquet, des bandes spécifiques, le pansement OALES Modular bandage et depuis peu par un produit très intéressant le Battle Wrap
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BACKGROUND:

Tourniquets are used on distal limb segments. We examined calf and forearm use of four thigh-effective, commercial tourniquetswith different widths and tightening systems: 3.8 cm windlass Combat Application Tourniquet® (CAT, combattourrniquet.com) and Special Operations Forces® Tactical Tourniquet-Wide (SOFTTW, www.tacmedsolutions.com), 3.8 cm ratchet Ratcheting Medical Tourniquet - Pediatric (RMT-P, www.ratchetingbuckles. com), and 10.4 cm elastic Stretch-Wrap-And-Tuck Tourniquet® (SWATT, www.swattourniquet.com).

METHODS:

From Doppler-indicated occlusion, windlass completion was the next securing opportunity; ratchet completion was one additional tooth advance; elastic completion was end tucked under a wrap.

RESULTS:

All applications on the 16 recipients achieved occlusion. Circumferences were calf 38.1±2.5 cm and forearm 25.1±3.0 cm (p<.0001, t-test, mean±SD). Pressures at Occlusion, Completion, and 120-seconds after Completion differed within each design (p<.05, one-way ANOVA; calf: CAT 382±100, 510±108, 424±92 mmHg; SOFTT-W 381±81, 457±103, 407±88 mmHg; RMT-P 295±35, 350±38, 301±30 mmHg; SWATT 212±46, 294±59, 287±57 mmHg; forearm: CAT 301±100, 352±112, 310±98 mmHg; SOFTT-W 321±70, 397±102, 346±91 mmHg; RMT-P 237±48, 284±60, 256±51 mmHg; SWATT 181±34, 308±70, 302±70 mmHg). Comparing designs, pressures at each event differed (p<.05, one-way ANOVA), and the elastic design had the least pressure decrease over time (p<.05, one-way ANOVA). Occlusion losses differed among designs on the calf (p<.05, χ²; calf: CAT 1, SOFTT-W 5, RMT-P 1, SWATT 0; forearm: CAT 0, SOFTT-W 1, RMT-P 2, SWATT 0).

CONCLUSIONS:

All four designs can be effective on distal limb segments, the SWATT doing so with the lowest pressures and least pressure losses over time. The pressure change from Occlusion to Completion varies by tourniquet tightening system and can involve a pressure decrease with the windlass tightening systems. Pressure losses occur in as little as 120 seconds following Completion and so can loss of Occlusion. This is especially true for nonelastic strap tourniquet designs.

| Tags : tourniquet

2 garrots: Côte à côte SVP, mais attention

Pressures Under 3.8cm, 5.1cm, and Side-by-Side 3.8cm-Wide Tourniquets

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Plus un garrot est large et plus efficace il est. parmi les garrots en dotation le Garrot Delfi est le plus performant en terme d'occlusion. Néanmoins son emploi en première intention et hors un vecteur d'évacuation est difficilement envisageable. Aussi l'association de deux garrots apparaît elle très pertinente surtout si ces derniers sont posés côte à côte. Ce n'est pas pour autant une sécurité car en permettant l'obtention d'une pression d'occlusion plus basse, cette méthode expose à une occlusion insuffisante . Cette publication  a par ailleurs comme intérêt de montrer que la pression d'occlusion baisse avec le temps et ce dès les premières minutes. Il est fondamental d'apprécier TRES régulièrement  l'efficacité du garrot. Donc plutôt un garrot large d'emblée mais si l'on doit compléter poser le second à côté du premier. A noter que le garrot utilisé n'est pas en dotation dans l'armées US mais qu'il s'agit d'un des meilleurs garrots de dernière génération.

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BACKGROUND:

Applications of wider tourniquet are expected to occlude arterial flow at lower pressures. We examined pressures under 3.8cm-wide, 5.1cm-wide, and side-by-side-3.8cm-wide nonelastic strap-based tourniquets.

METHODS:

Ratcheting Medical Tourniquets (RMT) were applied mid-thigh and mid-arm for 120 seconds with Doppler-indicated occlusion. The RMTs were a Single Tactical RMT (3.8cm-wide), a Wide RMT (5.1cm-wide), and Paired Tactical RMTs (7.6cm-total width). Tightening completion was measured at one-tooth advance past arterial occlusion, and paired applications involved alternating tourniquet tightening.

RESULTS:

All 96 applications on the 16 recipients reached occlusion. Paired tourniquets had the lowest occlusion pressures (ρ < .05). All pressures are given as median mmHg, minimum-maximum mmHg. Thigh application occlusion pressures were Single 256, 219-299; Wide 259, 203-287; Distal of Pair 222, 183-256; and Proximal of Pair 184, 160-236. Arm application occlusion pressures were Single 230, 189-294; Wide 212, 161-258; Distal of Pair 204, 193-254, and Proximal of Pair 168, 148-227. Pressure increases with the final tooth advance were greater for the 2 teeth/cm Wide than for the 2.5 teeth/cm Tacticals (ρ < .05). Thigh final tooth advance pressure increases were Single 40, 33-49; Wide 51, 37-65; Distal of Pair 13, 1-35; and Proximal of Pair 15, 0-30. Arm final tooth advance pressure increases were Single 49, 41-71; Wide 63, 48-77; Distal of Pair 3, 0-14; and Proximal of Pair 23, 2-35. Pressure decreases occurred under all tourniquets over 120 seconds. Thigh pressure decreases were Single 41, 32-75; Wide 43, 28-62; Distal of Pair 25, 16-37; and Proximal of Pair 22, 15-37. Arm pressure decreases were Single 28, 21-43; Wide 26, 16-36; Distal of Pair 16, 12-35; and Proximal of Pair 12, 5-24. Occlusion losses before 120 seconds occurred predominantly on the thigh and with paired applications (ρ < .05). Occlusion losses occurred in six Paired thigh applications, two Single thigh applications, and one Paired arm application.

CONCLUSIONS:

Side-by-side tourniquets achieve occlusion at lower pressures than single tourniquets. Additionally, pressure decreases undertourniquets over time; so all tourniquet applications require reassessments for continued effectiveness.

| Tags : tourniquet

27/06/2016

Albumine 20% plutôt que fibrinogène ?

Influences of limited resuscitation with plasma or plasma protein solutions on hemostasis and survival of rabbits with noncompressible hemorrhage

Kheirabadi BS et Al. J Trauma Acute Care Surg. 2016;81: 42–49

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Dans ce travail et alors que l'albumine diluée n'est pas recommandée, les auteurs évoquent la possibilité que les effets favorables d'une réanimation basée sur l'apport de plasma serait lié à l'apport de protéine et en particulier d'albumine qui aurait un effet tampon élevé, réduisant l'acidose métabolique, un des facteurs de la triade létale.

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BACKGROUND:

Plasma infusion with or without red blood cells is the current military standard of care for prehospital resuscitation of combat casualties. We examined possible advantages of early and limited resuscitation with fresh plasma compared with a single plasma protein or crystalloid solutions in an uncontrolled hemorrhage model in rabbits.

METHODS:

Anesthetized spontaneously breathing rabbits (3.3 ± 0.1 kg) were instrumented and subjected to a splenic uncontrolled hemorrhage. Rabbits in shock were resuscitated at 15 minutes with Plasma-Lyte (PAL; 30 mL/kg), PAL + fibrinogen (PAL + F; 30 mL + 100 mg/kg), fresh rabbit plasma (15 mL/kg), or 25% albumin (ALB; 5 mL/kg) solution, all given in two bolus intravenous injections (15 minutes apart) to achieve a mean arterial pressure of 65 mm Hg, n = 8 to 9/group. Animals were monitored for 2 hours or until death, and blood loss was measured. Blood samples and tissues were collected and analyzed.

RESULTS:

There were no differences among groups in baseline measures and their initial bleeding volume at 15 minutes. At 60 minutes after injury, mean arterial pressure was higher with ALB than with crystalloids (PAL or PAL + F), but shock indices were not different despite the large differences in resuscitation volumes. Fibrinogen addition to PAL only increased clot strength. Plasma resuscitation increased survival rate (75%) without significant improvement in coagulation measures. Albumin administration replenished total plasma protein and increased survival rate to 100% (p < .05 vs. crystalloids). No histological adverse events were identified in the vital organs.

alb25.jpg

CONCLUSIONS:

Fibrinogen administration added to a compatible crystalloid did not improve hemostatic outcomes. Plasma resuscitation increased survival rate; however, its effects did not differ from those obtained with 25% ALB at one-third of the volume. The ALB advantage was consistent with our previous findings in which 5% ALB was used at a volume equal to plasma. The benefit of plasma for resuscitation may be mostly due to its ALB content rather than its coagulation proteins

17/06/2016

Comprimez à distance: Avec le genou +++

Optimization of indirect pressure in order to temporize lifethreatening haemorrhage: a simulation study

Douma MJ et Al.  http://dx.doi.org/10.1016/j.injury.2016.06.010

 ----------------------------------------------------
Pour arrêter/limiter un saignement non garrotable, pensez à comprimer en amont et le plus efficace pour cela est le genou. Cela limitera le signement, le temps d emettre en place le dispositif adhoc comme par exemple un garrot jonctionnel.
 
Lire aussi 1, 2
 
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Background

Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, specifically external aortic compression (EAC). Indirect pressure has great potential for temporizing bleeds not amenable to direct tamponade i.e. abdominal-pelvic, junctional, and multi-site trauma. However, it is currently unclear how to optimize this technique.

Methods

We designed a model of central vessel compression using the Malbrain intraabdominal pressure monitor and digital weigh scale. Forty participants performed simulated external aortic compression on the ground, on a stretcher mattress, and with and without a backboard.

Results

The greater the rescuer’s bodyweight the greater was their mean compression (Pearson’s correlation 0.93). Using one-hand, a mean of 28% participant bodyweight (95% CI, 26% - 30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased the percentage of rescuer bodyweight transmission 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p <0.001). Adding a backboard increased transmission of rescuer bodyweight 7%-15% (p < 0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4%-9% (p < 0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p < 0.001).

Conclusions

Efficacy is maximized with larger-weight rescuers who use both hands, position themselves atop victims, and compress on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). Our work quantifies methods to optimize indirect pressure as a temporizing measure following life-threatening haemorrhage not amenable to direct compression, and while expediting compression devices or definitive treatment.

04/06/2016

European guideline on management of major bleeding / Trauma

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

Rossaint et al. Critical Care (2016) 20:100 

 Background: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

Methods: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

Results: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

Conclusions: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally

11/04/2016

PROPPR Study: 1-1-2 aussi bien !

Damage-control resuscitation and emergency laparotomy: Findings from the PROPPR study

Undurraga VJ et AL. J Trauma Acute Care Surg. 2016 Apr;80(4):568-75

BACKGROUND:

The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial has demonstrated that damage-controlresuscitation, a massive transfusion strategy targeting a balanced delivery of plasma-platelet-red blood cell in a ratio of 1:1:1, results in improved survival at 3 hours and a reduction in deaths caused by exsanguination in the first 24 hours compared with a 1:1:2 ratio. In light of these findings, we hypothesized that patients receiving 1:1:1 ratio would have improved survival after emergency laparotomy.

METHODS:

Severely injured patients predicted to receive a massive transfusion admitted to 12 Level I North American trauma centers were randomized to 1:1:1 versus 1:1:2 as described in the PROPPR trial. From these patients, the subset that underwent an emergency laparotomy, defined previously in the literature as laparotomy within 90 minutes of arrival, were identified. We compared rates and timing of emergency laparotomyas well as postsurgical survival at 24 hours and 30 days.

coagulopathie

RESULTS:

Of the 680 enrolled patients, 613 underwent a surgical procedure, 397 underwent a laparotomy, and 346 underwent an emergency laparotomy. The percentages of patients undergoing emergency laparotomy were 51.5% (174 of 338) and 50.3% (172 of 342) for 1:1:1 and 1:1:2, respectively (p = 0.20). Median time to laparotomy was 28 minutes in both treatment groups. Among patients undergoing an emergency laparotomy, the proportions of patients surviving to 24 hours and 30 days were similar between treatment arms; 24-hour survival was 86.8% (151 of 174) for 1:1:1 and 83.1% (143 of 172) for 1:1:2 (p = 0.29), and 30-day survival was 79.3% (138 of 174) for 1:1:1 and 75.0% (129 of 172) for 1:1:2 (p = 0.30).

CONCLUSION:

We found no evidence that resuscitation strategy affects whether a patient requires an emergency laparotomy, time to laparotomy, or subsequent survival.

18/02/2016

Stabilisation pelvienne: Les genoux sont importants

Pelvic pressure changes after a fracture: A pilot cadaveric study assessing the effect of pelvic binders and limb bandaging

Morris R et Al. Injury  http://dx.doi.org/10.1016/j.injury.2015.12.009

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Stabiliser un bassin pour lequel il existe une suspicion de fracture est une des composantes majeures du sauvetage au combat. Ceci vise à réduire la mortalité par hémorragie non garrotable ou non comprimable. Il existe des ceintures spécifiques pour cela. Ce travail est intéressant car il illustre la complémentarité des ceintures pelviennes ET de l'immobilisation des genoux. Cette dernière permet à elle seule d'augmenter la pression intra-abdominale et partant probablement de réduire le saignement. Donc n'oublier pas d'immobiliser les genoux. Que vous disposez ou pas de ceinture pelvienne, cela sert.

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Objectives: Pelvic binders are a life-saving intervention for hypovolaemic shock following displaced pelvic fractures, thought to act through increasing intra-pelvic pressure to reduce venous bleeding. This cadaveric study assesses changes in intra-pelvic pressure with different binders augmented by bandaging the thighs to recruit the femora as levers to close the pelvis. Access to femoral vessels via an in situ binder was also assessed.

Methods: Two embalmed cadavers were used with unstable pelvic injuries (OA/OTA 61-C1) created through disrupting the pelvic ring anteriorly and posteriorly. To measure intravesical pressure, which reflects intra-pelvic pressure, a supra-pubic catheter was inserted and connected to a water manometer whilst a spigot was placed in a urethral catheter to reduce leakage of fluid. The common and superficial femoral arteries were dissected in the left groin for each specimen prior to any intervention to allow inspection following binder application. A SAM pelvic sling II, Trauma Pelvic Orthotic Device (T-POD), Prometheus pelvic splint and an improvised pelvic binder were used on each cadaver, with each applied following lower limb bandaging with the knees slightly flexed. The groins were then inspected to assess if the femoral vessels were visible. Statistical analysis was performed in SPSS using a paired samples t test to determine if any difference existed between initial pelvic pressure in specimens compared to pressures with bandaging on and binders applied.

Results: Bandaging the lower limbs alone produced a significant increase in both peak and steady mean intra-pelvic pressure, 15.69 cmH2O and 12.38 cmH2O, respectively, compared to the baseline pressure, 8.73 cmH2O (p = 0.002 and p = 0.001, respectively). Applying the pelvic binder with the bandaging in place increased intra-pelvic pressure compared to the baseline (peak pressure of 25.38 cmH2O (p < 0.001) and steady pressure of 15.13 cmH2O (p = 0.003)). Steady mean pressures between bandaging alone and bandaging with the binder applied were not significantly different (p = 0.09), whilst the peak pressures were significantly greater when the binder was applied (p = 0.005). The improvised binder and T-POD both required cutting to access the femoral vessels which resulted in decreasing efficacy.

Conclusions: Intra-pelvic pressure was significantly increased through bandaging the lower limbs alone, and this represents a simple measure to increase intra-pelvic pressure and therefore efficacy of the binder. Access to the femoral vessels varied with binder type and represents an important consideration in polytrauma patients.

21/01/2016

Le graal plaquettaire hémostatique ?

Thrombosomes: a platelet-derived hemostatic agent for control of noncompressible hemorrhage

Fitzpatrick GM et Al. Transfusion. 2013 Jan;53 Suppl 1:100S-106S

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Un thrombosome est en quelque sorte une plaquette lyophilisée dans laquelle l'eau est remplacée par un sucre particulier: le trehalose. Ré exposé à une atmosphère humide, il se réhydrate pour retrouver toutes ses propriétés. Cela ne semble pas être une simple théorie car il initierait une génération de thrombine permettant la formation d'un caillot de manière satisfaisante. Des thrombosmes, du fibrinogène et du PLyo, on peut espérer !

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BACKGROUND: Uncontrolled hemorrhage is responsible for ~80% of the potentially survivable deaths in combat and over 40% of early mortality in the under 65 age group in the United States. Providing an easily used infusible hemostatic agent to first responders could significantly reduce these fatalities. We report on an infusible lyophilized platelet-derived hemostatic agent stabilized with trehalose and polysucrose prior to and during lyophilization.

STUDY DESIGN AND METHODS: Characterization included determining the particle population size range, surface marker expression GPIb, GPIIbIIIa, and Annexin V binding. Function was assessed by aggregation, thromboelastography, and thrombin generation. Pharmacokinetics, biodistribution, and immunogenicity established using Indium111 labeled Thrombosomes in healthy New Zealand white rabbits (NZWRs), efficacy in thrombocytopenic NZWR, and safety in NZWRs, canines, and nonhuman primates.

RESULTS: Thrombosomes retained GPIIbIIIa expression (98.71% 0.18 of the rehydrated particles), a reduced expression of GPIb (47.77% 6.65), and Annexin V binding (86.05% 2.65). Aggregation to all agonists except thrombin in buffer (78.15% 2.5) was <50%. Thrombin generation and thromboelastography results demonstrated a concentration gradient that was consistent from lot to lot. There were no observed adverse events in any safety study and blood loss was reduced by >80% in the thrombocytopenic ear bleed model.

CONCLUSION: Our in vitro characterization studies in conjunction with preclinical animal safety and efficacy studies demonstrated lot consistency in manufacturing, maintenance of hemostatic functions of Thrombosomes, safety at high dose concentrations, and the potential to provide an effective hemostatic agent at the site of injury.  

09/01/2016

1/1/1 ou 1/1/2 ?

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

Holcomb JB et All. JAMA Surg. 2013 Feb;148(2):127-36

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La reconnaissance et la mise en place de la meilleure stratégie thérapeutique du choc hémorragique traumatique sont des enjeux fondamentaux qui se posent aux équipes de réanimation préhospitalières et hospitalières. L'application du concepts du damage control resuscitation (1) vise par la mise en place d'un stratégie raisonnée d'arrêt des hémorragies (2), d'un remplissage vasculaire mesuré (3) et d'une politique transfusionnelle spécifique (4). Parmi ces mesures, il apparaît important de garantir l'apport équilibré de plasma, de plaquettes et de CGR dans un ration  élevé 1/1/1 ou 1/1/2. Deux études se sont attachées à ce point: L'étude PROMMTT et l'étude PROPPR ici présentée. La première confirme le bénéfice d'une telle stratégie avec une moindre mortalité chez les patients bénéficiant de rapport élevé supérieur mais uniquement dans les 6 premières heures. L'étude PROPPR semble confirmer ces données avec une moindre mortalité précoce par hémorragie mais ne réussit pas à confirmer l'intérêt d'un ratio 1/1/1 par rapport à un ratio 1/1/2 sur la mortalité à long terme.

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IMPORTANCE:

Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials.

OBJECTIVE:

To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio.

DESIGN, SETTING, AND PARTICIPANTS:

Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013.

INTERVENTIONS:

Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled).

MAIN OUTCOMES AND MEASURES:

Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status.

RESULTS:

No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.

CONCLUSIONS AND RELEVANCE:

Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups.

| Tags : hémorragie

25/12/2015

Transfusion de CGR: Les + graves seulement

Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study

Perel P et Al. PLoS Med. 2014 Jun 17;11(6):e1001664

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Les données qui suivent sont extraites de la cohorte des patients inclus dans l'étude CRASH2. Cette réinterprétation des données a pour objectif d'analyser le lien entre la mortalité à 28 jours et la transfusion de CGR. Les auteurs retrouvent un effet délétère de la transfusion de CGR pour les patients les moins à risque de mortalité. Ceci est en faveur des démarches de stratégies transfusionnelles sinon restrictives du moins raisonnées en fonction du contexte notamment préhospitalier où cette pratique associée à l'apport de fractions coagulantes semble être d'un grand intérêt(1).

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Background:

Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.

Methods and Findings:

A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: ,6%, 6%–20%, 21%–50%, and .50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction ,0.0001). Transfusion was associated with an increase in all-cause mortality among patients with , 6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p,0.0001, and OR 2.31, 95% CI 1.96–2.73, p,0.0001, respectively), but with a decrease in all-cause mortality in patients with .50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p,0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p,0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (,6%) predicted risk of death (p-value for interaction ,0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.

pmed.1001664.g001.jpg


Conclusions:

The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.

| Tags : hémorragie

22/12/2015

Tourniquet: Contrefaçons=Danger

Le regain d'intérêt pour la mise en place de garrot en cas d'hémorragie massive des membres ne doit pas faire oublier deux choses: Avoir appris correctement et utiliser un matériel adhoc.

Concernant ce dernier point apparaissent sur le marché nombre de garrots qui soit n'ont pas été validés soit sont des contrefaçons de ce dernier, soit des garrots proposés dans le cadre d'activité de type Softball.

Plutôt que d'utiliser un garrot de piêtre qualité, il vaut probablement mieux avoir recours à un garrot artisanal dont l'efficacité n'est pas remise en cause sous réserve d'une technique de pose maîtrisée.

On rappelle que les 3 seuls garrots validés par l'armée américaine sont le CAT, le SOFTT  et le Delfi EMT. Les SEULS garrots en service dans l'armée française sont le SOFTT et le Delfi EMT. Ces garrots sont produits par des industriels au terme de travaux de recherche et de démarche d'évolution et de politique qualité aboutis, toutes démarches absentes chez les copieurs et les contrefacteurs.

Tous les autres garrots n'ont pas suivis les mêmes process de développement, ce qui ne permet pas de garantir ni leur efficacité dans le temps, ni leur fiabilité.

Un exemple de copie du SOFTT est ici présenté

rotating-compression-tactical-black-tourniquet-for-hemorrhage.jpg

 

Un point d'alerte majeur aux USA


 

| Tags : tourniquet