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24/09/2016

Transfusion en vol: Sécurité assurée

Risk Management Analysis of Air Ambulance Blood Product Administration in Combat Operations

 

BACKGROUND:

Between June-October 2012, 61 flight-medic-directed transfusions took place aboard U.S. Army Medical Evacuation (medevac) helicopters in Afghanistan. This represents the initial experience for pre-hospital blood product transfusion by U.S. Army flight medics.

METHODS:

We performed a retrospective review of clinical records, operating guidelines, after-action reviews, decision and information briefs, bimonthly medical conferences, and medevac-related medical records.

RESULTS:

A successful program was administered at 10 locations across Afghanistan. Adherence to protocol transfusion indications was 97%. There were 61 casualties who were transfused without any known instance of adverse reaction or local blood product wastage. Shock index (heart rate/systolic blood pressure) improved significantly en route, with a median shock index of 1.6 (IQR 1.2-2.0) pre-transfusion and 1.1 (IQR 1.0-1.5) post-transfusion (P < 0.0001). Blood resupply, training, and clinical procedures were standardized across each of the 10 areas of medevacoperations.

DISCUSSION:

Potential risks of medical complications, reverse propaganda, adherence to protocol, and diversion and/or wastage of limited resources were important considerations in the development of the pilot program. Aviation-specific risk mitigation strategies were important to ensure mission success in terms of wastage prevention, standardized operations at multiple locations, and prevention of adverse clinical outcomes. Consideration of aviation risk mitigation strategies may help enable other helicopter emergency medical systems to develop remote pre-hospital transfusion capability. This pilot program provides preliminary evidence that blood product administration by medevac is safe.

| Tags : transfusion

22/09/2016

SmO2: Utile ?

Muscle Oxygen Saturation Improves Diagnostic Association Between Initial Vital Signs and Major Hemorrhage: A Prospective Observational Study.

 
 

L'hémorragie reste la cause principale des décès évitable et l'importance de la mise en oeuvre d'une stratégie transfusionnelle précoce est actée. Mais sur quels critères. Au delà des critères cliniques simples, on peut citer le recours au suivi des lactates. Le suivi de paramètres d'oxygénation tissulaire simple est maintenant possible. Ce qu'évoque ce document est l'emploi de la SmO2, élément déjà utilisé en médecine du sport. Le recours à un tel paramètre est donc potentiellement très intéressant si cette pertinence était confirmée et sa mesure valide avec des outils simples.

OBJECTIVES:

During initial assessment of trauma patients, vital signs do not identify all patients with life-threatening hemorrhage. We hypothesized that a novel vital sign, muscle oxygen saturation (SmO2 ), could provide independent diagnostic information beyond routine vital signs for identification of hemorrhaging patients who require packed red blood cell (RBC) transfusion.

METHODS:

This was an observational study of adult trauma patients treated at a Level I trauma center. Study staff placed the CareGuide 1100 tissue oximeter (Reflectance Medical Inc., Westborough, MA), and we analyzed average values of SmO2 , systolic blood pressure (sBP), pulse pressure (PP), and heart rate (HR) during 10 minutes of early emergency department evaluation. We excluded subjects without a full set of vital signs during the observation interval. The study outcome was hemorrhagic injury and RBC transfusion ≥ 3 units in 24 hours (24-hr RBC ≥ 3). To test the hypothesis that SmO2 added independent information beyond routine vital signs, we developed one logistic regression model with HR, sBP, and PP and one with SmO2 in addition to HR, sBP, and PP and compared their areas under receiver operating characteristic curves (ROC AUCs) using DeLong's test.

SmO2.jpg

RESULTS:

We enrolled 487 subjects; 23 received 24-hr RBC ≥ 3. Compared to the model without SmO2 , the regression model with SmO2 had a significantly increased ROC AUC for the prediction of ≥ 3 units of 24-hr RBC volume, 0.85 (95% confidence interval [CI], 0.75-0.91) versus 0.77 (95% CI, 0.66-0.86; p < 0.05 per DeLong's test). Results were similar for ROC AUCs predicting patients (n = 11) receiving 24-hr RBC ≥ 9.

CONCLUSIONS:

SmO2 significantly improved the diagnostic association between initial vital signs and hemorrhagic injury with blood transfusion. This parameter may enhance the early identification of patients who require blood products for life-threatening hemorrhage.

01/09/2016

Médecine de catastrophe en France

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Une publication qui fait le point sur la médecine de catastrophe et ses différents enjeux à la lumière de la menace terroriste actuelle. A lire avec attention ++++

 

 

27/08/2016

Interventions salvatrices: Bien sûr mais lesquelles ?

Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident

Vassallo J. et Al. Injury, Int. J. Care Injured 47 (2016) 1898–190

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Plus le contexte d'intervention est difficile soit du fait de l'environnement soit du fait du danger tactique et plus le choix des nterventions médicales doit être réflechi et restreint et mis en oeuvre par uintervenant pas forcément médecin mas formé spécifiquement à la pratique d'une action nécessaire à la survie. Ce travail identiife ainsi une trentaine de conduites essentielles à un réseau de traumatisés graves. Lire aussi cet article

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Introduction: Triage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident.

Methods: We conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%.

Results: 24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus.

Conclusions: This study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool.

 
  Results of the Delphi Process – Life-Saving Interventions.
   
   
1 Intubation for actual airway obstruction
2 Intubation for impending airway obstruction
3 Surgical airway for airway obstruction
4 Surgical airway for impending airway obstruction
5 Needle thoracocentesis
6 Finger thoracostomy
7 Tube thoracostomy
8 Application of a chest seal (commercial/improvised)
9 Positive Pressure Ventilation for ventilatory inadequacy
10 Application of a tourniquet for haemorrhage control
11 Use of haemostatic agents for haemorrhage control
12 Insertion of an intra-osseous device for resuscitation purposes
13 Receiving uncross-matched blood
14 Receiving≥4 units of blood/blood products
15 Administration of tranexamic acid
16 Laparotomy for trauma
17 Thoracotomy for trauma
18 Pericardial window for trauma
19 Surgery to gain proximal vascular control
20 Interventional radiology for haemorrhage control
21 Application of a pelvic binder
22 ALS/ACLS protocols for a patient in a peri-arrest situation
23 ALS/ACLS protocols for a patient in cardiac arrest
24 Neurosurgery for the evacuation of an intra-cranial haematoma
25 Craniotomy
26 Burr Hole Insertion
27 Spinal nursing for a C1-3 fracture
28 Administration of a seizure-terminating medication
29 Active rewarming for initial core temp<32° celcius
30 Passive rewarming for initial core temp<32° celcius
31 Correction of low blood glucose
32 Administration of chemical antidotes

| Tags : triage

11/08/2016

Transfusion, Thrombosis and Bleeding Management

Special Issue: Transfusion, Thrombosis and Bleeding Management

January 2015 - Volume 70, Issue Supplement s1 - Pages 1–e41

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Blood – the most important humour? (pages 1–e1)

C. R. Bailey, A. A. Klein and B. J. Hunt

Version of Record online: 1 DEC 2014 | DOI: 10.1111/anae.12930

PDF(52K)

 

Review Articles

Modern banking, collection, compatibility testing and storage of blood and blood components (pages 3–e2)

L. Green, S. Allard and R. Cardigan

☛ CPD available at http://www.learnataagbi.org

Corrected by:

Corrigendum: Modern banking, collection, compatibility testing and storage of blood and blood components

Vol. 70, Issue 3, 373, Version of Record online: 11 FEB 2015

PDF(121K)

 

Evidence and triggers for the transfusion of blood and blood products (pages 10–e3)

A. Shah, S. J. Stanworth and S. McKechnie

PDF(135K)

 

Pre-operative anaemia (pages 20–e8)

B. Clevenger and T. Richards

PDF(241K)

 

The pathophysiology and consequences of red blood cell storage (pages 29–e12)

D. Orlov and K. Karkouti

PDF(445K)

 

Red cell transfusion and the immune system (pages 38–e16)

S. Hart, C. M. Cserti-Gazdewich and S. A. McCluskey

PDF(133K)

 

The current place of aprotinin in the management of bleeding (pages 46–e17)

D. Royston

PDF(69K)

 

The current place of tranexamic acid in the management of bleeding (pages 50–e18)

B. J. Hunt

PDF(69K)

 

Practical management of major blood loss (pages 54–e20)

R. Gill

PDF(79K)

 

Management of peri-operative anti-thrombotic therapy (pages 58–e23)

J. J. van Veen and M. Makris

PDF(262K)

 

Laboratory monitoring of haemostasis (pages 68–e24)

A. Fowler and D. J. Perry

PDF(67K)

 

Point-of-care monitoring of haemostasis (pages 73–e26)

S. V. Mallett and M. Armstrong

PDF(85K)

 

Haemostatic management of obstetric haemorrhage (pages 78–e28)

R. E. Collis and P. W. Collins

PDF(281K)

 

Haemostatic management of cardiac surgical haemorrhage (pages 87–e31)

M. W. Besser, E. Ortmann and A. A. Klein

PDF(129K)

 

The pathogenesis of traumatic coagulopathy (pages 96–e34)

A. Cap and B. J. Hunt

PDF(105K)

 

Management of traumatic haemorrhage – the European perspective (pages 102–e37)

H. Schöchl, W. Voelckel and C. J. Schlimp

PDF(1142K)

 

Management of traumatic haemorrhage – the US perspective (pages 108–e38)

R. P. Dutton

PDF(61K)

 

Surgery in patients with inherited bleeding disorders (pages 112–e40)

P. K. Mensah and R. Gooding

PDF(180K)

 

The management of abnormal haemostasis in the ICU (pages 121–e41)

A. Retter and N. A. Barrett

PDF(727K)

31/07/2016

Revue du CIMM/ICMM

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29/06/2016

Afghanistan et le bilan hollandais

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27/06/2016

The Trauma Manual: Trauma and Acute Care Surgery

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Trauma anesthesia

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14/06/2016

Combat Trauma. Lessons Learned from Military Operations

 

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13/06/2016

Can J Surg: Numéro spécial 2015

Foreword

Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S80. doi: 10.1503/cjs.006615

Avant-Propos

Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S81. French. DOI : 10.1503/cjs.006715

Introduction

BGen Jean-Robert Bernier
Can J Surg. 2015 Jun; 58(3 Suppl 3): S82. doi: 10.1503/cjs.015614
Bgén Jean-Robert Bernier
Can J Surg. 2015 Jun; 58(3 Suppl 3): S83. French. DOI : 10.1503/cjs.006815

Commentaries

 
Maj Andrew W. Kirkpatrick, Douglas Hamilton, Maj Andrew Beckett, Anthony LaPorta, Susan Brien, Col Elon Glassberg, Chad G. Ball, Derek J. Roberts, Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S85–S87. doi: 10.1503/cjs.013914
Maj Andrew W. Kirkpatrick, Anthony LaPorta, Susan Brien, Tim Leslie, Col Elon Glassberg, Jessica McKee, Chad G. Ball, Heather E. Wright Beatty, Jocelyn Keillor, Derek J. Roberts, Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S88–S90. doi: 10.1503/cjs.014214

Review

Col Homer Tien, Maj Andrew Beckett, LCol Naisan Garraway, LCol Max Talbot, Capt Dylan Pannell, Thamer Alabbasi
Can J Surg. 2015 Jun; 58(3 Suppl 3): S91–S97. doi: 10.1503/cjs.001815

Research

Maj Andrew Beckett, Robert Fowler, Neil Adhikari, Laura Hawryluck, Tarek Razek, Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S98–S103. doi: 10.1503/cjs.012214
Joseph Taddeo, Maj Melissa Devine, LCol Vivian C. McAlister
Can J Surg. 2015 Jun; 58(3 Suppl 3): S104–S107. doi: 10.1503/cjs.013114
 
Thamer Alabbasi, Avery B. Nathens, Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S108–S117. doi: 10.1503/cjs.015814
LTC Jacob Chen, Capt Roy Nadler, Maj Dagan Schwartz, Col Homer Tien, LTC Andrew P. Cap, Col Elon Glassberg
Can J Surg. 2015 Jun; 58(3 Suppl 3): S118–S124. doi: 10.1503/cjs.012914
Luis Teodoro da Luz, Bartolomeu Nascimento, Col Homer Tien, Michael J. Kim, Avery B. Nathens, Savvas Vlachos, Col Elon Glassberg
Can J Surg. 2015 Jun; 58(3 Suppl 3): S125–S134. doi: 10.1503/cjs.014114
Capt Dylan Pannell, Avery B. Nathens, Col Jacques Ricard, LCol Erin Savage, Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S135–S140. doi: 10.1503/cjs.013414
Capt Dylan Pannell, Jeffery Poynter, Paul W. Wales, Col Homer Tien, Avery B. Nathens, David Shellington
Can J Surg. 2015 Jun; 58(3 Suppl 3): S141–S145. doi: 10.1503/cjs.017414
LCol Erin Savage, Maj Michael D. Christian, Maj Stephanie Smith, Capt Dylan Pannell
Can J Surg. 2015 Jun; 58(3 Suppl 3): S146–S152. doi: 10.1503/cjs.013514

Discussions in Surgery

Maj Andrew Beckett, Jeannie Callum, Luis Teodoro da Luz, Joanne Schmid, Christopher Funk, Col Elon Glassberg, Col Homer Tien
Can J Surg. 2015 Jun; 58(3 Suppl 3): S153–S156. doi: 10.1503/cjs.012614

09/02/2016

Peau et maintien de la paix

A Review of Skin Conditions in Modern Warfare and Peacekeeping Operations

Gelman AB et Al. Mil Med. 2015 Jan;180(1):32-7

Skin is the most exposed organ of the body, and military personnel face many external skin threats. As a result, skin disease is an important source of morbidity among military personnel deployed on combat or peacekeeping operations. This article reviews the most common conditions seen by deployed military dermatologists. A PubMed search was used to identify articles in English, written between 1965 and 2014, using medical subject headings “military medicine” AND “skin disease” or “military personnel” AND “skin disease.” The five most common reasons for physician consultation for skin conditions in wartime since the Vietnam War were warts (10.7%), fungal infections (10.4%), acne (9.0%), nonspecific eczematous conditions (7.1%), and sexually transmitted diseases (6.1%). There was a significant difference in the skin conditions seen in the hot and humid climates of Vietnam and East Timor, where bacterial and fungal infections were more common reasons for consultation, and the dry climates of Bosnia and Iraq, where eczematous conditions made up a larger part of the dermatologic caseload.

09/01/2016

Le consensus d'hartford

Les événements récents ont mis en évidence l'importance de l'organisation des soins en cas d'attentats multisites notamment par armes de guerre. Le consensus d'Hartford est une démarche majeure conduite par nos alliés américains sur la survenue de telles situations. Très globalement il s'agit d'une chaîne de survie à mettre en place, ou bien sûr les professionnels de  santé ont leur place mais aussi et surtout le citoyen et les forces de l'ordre. L'acronyme THREAT réssume la démarche: pour Threat Suppression, pour Hemorrage Control, RE pour Rapid Extrication to safety, A pour Assessment by medical provider, T pour transport to definitive care.

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19/12/2015

Military medicine in the 21st

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23/11/2015

Médecine militaire et civile

Apports de la médecine de l’avant militaire en situation préhospitalière civile

Derkenne C. et Al. Ann. Fr. Med. Urgence (2015) 5:245-251

L’évolution récente des matériels issus de la médecine de guerre pourrait profiter à la médecine préhospitalièrecivile. Des dispositifs comme les garrots ou les pansements hémostatiques sont encore très peu diffusés en pratique civile, malgré des recommandations fortes et assez anciennes de sociétés savantes civiles. Les dispositifs de lutte contre l’hypothermie en préhospitalier sont, en pratique civile, limités, là où les praticiens militaires disposent de couvertures perfectionnées et beaucoup plus efficaces. Enfin, un modèle de kit de drain thoracique, ergonomique, léger et autorisant l’autotransfusion nous paraît pouvoir avantageusement remplacer les différents moyens disponibles en Smur. Selon des données scientifiques issues essentiellement de la médecine militaire, l’utilisation de ces matériels en médecine préhospitalière civile pourrait être particulièrement utile lors de la prise en charge de traumatisés sévères.

 

| Tags : matériel

12/11/2015

ABC of PHEM

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11/10/2015

Les blessés français en afghanistan

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15/08/2015

Quel médecin en role 1 ?

Perceptions of Frontline Providers on the Appropriate Qualifi cations for Battalion Level Care in United States Army Ground Maneuver Forces

Malish RG et Al. Military Medicine, 176, 12:1369, 2011

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Il est habituel pour nous qu'un médecin déployé en role 1 soit un médecin généraliste. Ce n'est pas le cas dans d'autres armées notamment l'armée américaine où d'une part des spécialistes hospitaliers  et d'autre part des officiers de santé ("physician assistant, souvent ancien combat medic) peuvent être déployés en role 1. 

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Objectives:

The U.S. Army emplaces physician assistants (PAs) in its maneuver battalions. When contingencies arise, clinic-based physicians join them to augment capability. Because both entities operate similarly, the policy permits a comparison of perceptions of optimal skill sets for the battalion medical mission.
 
Methods:
 
We conducted a survey to discover associations in opinion regarding the best qualifi cations for battalion care. We asked deployed PAs and physicians to rate themselves and their counterparts in eight domains. We hypothesized that both entities would rate PAs as superior based on their permanent presence at battalion level and their familiarity with the disease and injury patterns of their population.
 
Results:
 
Among 26 respondents, PAs awarded themselves a score of 8.3 ± 0.3 out of 10 and a score of 6.5 ± 0.5 to physicians. Physicians awarded PAs a score of 8.4 ± 0.3 and themselves a score of 8.3 ± 0.3. 
 
Conclusion:
 
Participants support the PA as an appropriate capability for battalion care in prolonged combat environments.  

07/02/2015

Soutien médical aux engagements opérationnels

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17/11/2014

Doctrine du soutien médical aux engagements opérationnels

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| Tags : doctrine