15/09/2018
Aggressions collectives par arme de guerre
10/09/2018
Settings standard for CCC
08/09/2018
Le TCCC dans la vraie vie
Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict.
BACKGROUND:
Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization.
METHODS:
A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel.
RESULTS:
There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%).
CONCLUSION:
Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.
06/06/2018
March: Aussi chez les chinois
Expert consensus on the evaluation and diagnosis of combat injuries of the Chinese People’s Liberation Army
30/01/2018
Golden hour: Un concept + qu'une obligation
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Un titre accrocheur pour une revue historique et conceptuelle de la médecine tactique. Un plaidoyer pour la conservation d'un minimum d'agilité dans les démarches actuelles
20/01/2018
Queensland Clinical Practice Manual
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17/01/2018
Guide de médecine rurale AUS
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09/01/2018
A lire
Prolonged Field Care of a Casualty With Penetrating Chest Trauma Case Report
Barnhart G. et Al. J Spec Oper Med. Winter 2016;16(4):99-101
As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.
Histoire à lire
A Case of Prehospital Traumatic Arrest in a US Special Operations Soldier: Care From Point of Injury to Full Recovery
During an assault on an extremely remote target, a US Special Operations Soldier sustained multiple gunshot and fragmentation wounds to the thorax, resulting in a traumatic arrest and subsequent survival. His care, including care under fire, tactical field care, tactical evacuation care, and Role III, IV, and V care, is presented. The case is used to illustrate the complex dynamics of Special Operations care on the modern battlefield and the exceptional outcomes possible when evidence-based medicine is taken to the warfighter with effective,
13/11/2017
les "Brit" en Irak 2003
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A quoi sert un médecin ?
The Role Of The Physician In Modern Military Operations: 12 Months Experience In Southern Iraq
Grainge C et Al. J R Army Med Corps 2005 151: 101-1
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Vaste débat surtout pour nous français élevé à la sauce de l a médecine préhospitalière type SAMU. D'autres ont une vision bien différente qui, bien qu'elle évolue (1) avec le concept de "prolonged field care" - ie: une certaine médicalisation de l'avant -, n'est globalement pas remise en cause après les engagements US et UK en irak et en afghanistan. Dans ce travail il apparait que les problématiques d'hygiène et de médecine de prévention, le préhospitalier n'est pas mentionné, sont pour nos alliés anglais au coeur du rôle de leurs médecins. On rappelle juste qu'ils sont aussi les adeptes de MEDEVAC très performantes - les MERT-Enhanced (équipes composées d'un médecin anesthésiste ou urgentiste expérimenté en matière de trauma, d'un-e infirmier-ère, de deux paramedics et d'une équipe de protection oeuvrant dans un Chinook CH-47.
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Objectives To examine the profile of medical morbidity and the role of the physician in modern conflict.
Methods Retrospective survey of admission records at a British Military Field Hospital on operational duty in Southern Iraq.
Results 62.5% of 4870 admissions to the Field Hospital in Shaibah during the first 12 months of military operations in Iraq were under the care of physicians. Of these 1531 (31.4%) were due to diarrhoea and vomiting (D&V) and 764 (15.7%) due to heat illness. The incidence of heat illness rose with ambient temperature, but soldiers were more likely to be admitted with heat illness shortly after arrival in theatre than when fully acclimatised. There was also a steady flow of admissions with a broad spectrum of medical pathology requiring the clinical skills of a general physician.
Conclusions A general physician is a necessary part of the clinical team in modern conflict. The incidence of D&V and of heat illness on military operations remains high. Planners for any operation in tropical climates should take this into consideration and put preventative measures into place early.
12/11/2017
Lunettes de vision nocturne: Une aide ? A voir !
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Des résultats bien étonnants quand on connait les problèmes de profondeur de champ inhérents à l'emploi de dispositifs de vision nocturne, surtout monoculaires. Comme toujours maîtriser le geste en conditions normales, maîtriser l'outil de vision et s'entraîner dans ces conditions. Lire également 1, 2, 3
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BACKGROUND:
In the patients with multiple and serious trauma, early applications of life-saving procedures are related to improved survival. We tried to experimentally determine the feasibility of life-saving interventions that are performed with the aid of night vision goggles (NVG) in nighttime combat scenario.
METHODS:
Chest tube thoracostomy (CTT), emergency cricothyroidotomy (EC), and needle thoracostomy (NT) interventions were performed by 10 combatant medical staff. The success and duration of interventions were explored in the study. Procedures were performed on the formerly prepared manikins/models in a bright room and in a dark room with the aid of NVG. Operators graded the ease of interventions.
RESULTS:
All interventions were found successful. Operators stated that both CTT and EC interventions were more difficult in dark than in daytime (p<0.05). No significant difference was observed in the difficulty in the NT interventions. No significant difference was observed in terms of completion times of interventions between in daytime and in dark scenario.
CONCLUSION:
The operators who use NVGs have to be aware of that they can perform their tactic and medical activities without taking off the NVGs and without the requirement of an extra light source.
| Tags : vision nocturne
10/11/2017
Formation des personnels des FS: Réflexions OTAN
Un peu ancien
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11/10/2017
Numéro Spécial SSA
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06/09/2017
Wilderness medicine: Numéro spécial
05/05/2017
TCCC. Point sur la recherche US
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05/03/2017
Prolonged field care: Un retex
Prolonged Field Care (PFC): Lessons Learned
Keenan S et Al.
Un document à lire avec intérêt
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| Tags : prolonged field care
18/12/2016
Coagulopathie traumatique. Données actuelles
Acute traumatic coagulopathy: pathophysiology and resuscitation.
Acute Traumatic Coagulopathy occurs immediately after massive trauma when shock, hypoperfusion, and vascular damage are present. Mechanisms for this acute coagulopathy include activation of protein C, endothelial glycocalyx disruption, depletion of fibrinogen, and platelet dysfunction. Hypothermia and acidaemia amplify the endogenous coagulopathy and often accompany trauma. These multifactorial processes lead to decreased clot strength, autoheparinization, and hyperfibrinolysis. Furthermore, the effects of aggressive crystalloid administration, haemodilution from inappropriate blood product transfusion, and prolonged surgical times may worsen clinical outcomes. We review normal coagulation using the cell-based model of haemostasis and the pathophysiology of acute traumatic coagulopathy. Developed trauma systems reduce mortality, highlighting critical goals for the trauma patient in different phases of care. Once patients reach a trauma hospital, certain triggers reliably indicate when they require massive transfusion and specialized trauma care. These triggers include base deficit, international normalized radio (INR), systolic arterial pressure, haemoglobin concentration, and temperature. Early identification for massive transfusion is critically important, as exsanguination in the first few hours of trauma is a leading cause of death. To combat derangements caused by massive haemorrhage, damage control resuscitation is a technique that addresses each antagonist to normal haemostasis. Components of damage control resuscitation include damage control surgery, permissive hypotension, limited crystalloid administration, haemostatic resuscitation, and correction of hyperfibrinolysis.
11/12/2016
Suppression métabolique ?
Inducing metabolic suppression in severe hemorrhagic shock: Pilot study results from the Biochronicity Project.
BACKGROUND:
Suspended animation-like states have been achieved in small animal models, but not in larger species. Inducing metabolic suppression and temporary oxygen independence could enhance survivability of massive injury. Based on prior analyses of key pathways, we hypothesized that phosphoinositol-3-kinase inhibition would produce metabolic suppression without worsening organ injury or systemic physiology.
METHODS:
Twenty swine were studied using LY294002 (LY), a nonselective phosphoinositol-3-kinase inhibitor. Animals were assigned to trauma only (TO, n = 3); dimethyl sulfoxide only (DMSO, n = 4), LY drug only (LYO, n = 3), and drug + trauma (LY + T, n = 10) groups. Both trauma groups underwent laparotomy, 35% hemorrhage, severe ischemia/reperfusion injury, and protocolized resuscitation. Laboratory, physiologic, cytokine, and metabolic cart data were obtained. Histology of key end organs was also compared.
RESULTS:
Baseline values were similar among the groups. Compared with the TO group, the LYO group had reversible decreases in heart rate, mean arterial pressure, cardiac output, oxygen consumption, and carbon dioxide production. Compared with TO, LY + T showed sustained decreases in heart rate (113 vs. 76, p = 0.03), mean arterial pressure (40 vs. 31 mm Hg, p = 0.02), and cardiac output (3.8 vs. 1.9 L/min, p = 0.05) at 6 hours. Metabolic parameters showed profound suppression in the LY + T group. Oxygen consumption in LY + T was lower than both TO (119 vs. 229 mL/min, p = 0.012) and LYO (119 vs. 225 mL/min, p = 0.014) at 6 hours. Similarly, carbon dioxide production was decreased at 6 hours in LY + T when compared with TO (114 vs. 191 mL/min, p = 0.043) and LYO (114 vs. 195 mL/min, p = 0.034) groups. There was no worsening of acidosis (lactate 6.4 vs. 8.3 mmol/L, p = 0.4) or other endpoints. Interleukin 6 (IL-6) showed a significant increase in LY + T when compared with TO at 6 hours (60.5 vs. 2.47, p = 0.043). Tumor necrosis factor α and IL-1β were decreased, and IL-10 increased in TO and LY + T at 6 hours. Markers of liver and kidney injury were no different between TO and LY + T groups at 6 hours.
CONCLUSIONS:
Phosphoinositol-3-kinase inhibition produced metabolic suppression in healthy and injured swine without increasing end-organ injury or systemic physiologic markers and demonstrated prolonged efficacy in injured animals. Further study may lead to targeted therapies to prolong tolerance to hemorrhage and extend the "golden hour" for injured patients.
10/12/2016
Maintenir la pression: Hydroxocobalamine ou adré ?
A prospective, randomized trial of intravenous hydroxocobalamin versus whole blood transfusion compared to no treatment for Class III hemorrhagic shock resuscitation in a prehospital swine model.
OBJECTIVES:
The objective was to compare systolic blood pressure (sBP) over time in swine that have had 30% of their blood volume removed (Class III shock) and treated with intravenous (IV) whole blood or IV hydroxocobalamin, compared to nontreated controlanimals.
METHODS:
Thirty swine (45 to 55 kg) were anesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged a total of 20 mL/kg over a 20-minute period. Five minutes after hemorrhage, animals were randomly assigned to receive 150 mg/kg IV hydroxocobalamin solubilized in 180 mL of saline, 500 mL of whole blood, or no treatment. Animals were monitored for 60 minutes thereafter. A sample size of 10 animals per group was determined based on a power of 80% and an alpha of 0.05 to detect an effect size of at least a 0.25 difference (>1 standard deviation) in mean sBP between groups. sBP values were analyzed using repeated-measures analysis of variance (RANOVA). Secondary outcome data were analyzed using repeated-measures multivariate analysis of variance (RMANOVA).
RESULTS:
There were no significant differences between hemodynamic parameters of IV hydroxocobalamin versus whole blood versus control group at baseline (MANOVA; Wilks' lambda; p = 0.868) or immediately posthemorrhage (mean sBP = 47 mm Hg vs. 41 mm Hg vs. 37 mm Hg; mean arterial pressure = 39 mm Hg vs. 28 mm Hg vs. 34 mm Hg; mean serum lactate = 1.2 mmol/L vs. 1.4 mmol/L vs. 1.4 mmol/L; MANOVA; Wilks' lambda; p = 0.348). The outcome RANOVA model detected a significant difference by time between groups (p < 0.001). Specifically, 10 minutes after treatment, treated animals showed a significant increase in mean sBP compared to nontreated animals (mean sBP = 76.3 mm Hg vs. 85.7 mm Hg vs. 51.1 mm Hg; p < 0.001). RMANOVA modeling of the secondary data detected a significant difference in mean arterial pressure, heart rate, and serum lactate (p < 0.001). Similar to sBP, 10 minutes after treatment, treated animals showed a significant increase in mean arterial pressure compared to nontreated animals (mean arterial pressure = 67.7 mm Hg vs. 61.4 mm Hg vs. 40.5 mm Hg). By 10 minutes, mean heart rate was significantly slower in treated animals compared to nontreated animals (mean heart rate = 97.3 beats/min vs. 95.2 beats/min vs. 129.5 beats/min; p < 0.05). Serum lactate, an early predictor of shock, continued to rise in the control group, whereas it did not in treated animals. Thirty minutes after treatment, serum lactate values of treated animals were significantly lower compared to nontreated animals (p < 0.05). This trend continued throughout the 60-minute observation period such that 60-minute values for lactate were 1.4 mmol/L versus 1.1 mmol/L versus 3.8 mmol/L. IV hydroxocobalamin produced a statistically significant increase in systemic vascular resistance compared to control, but not whole blood, with a concomitant decrease in cardiac output.
CONCLUSIONS:
Intravenous hydroxocobalamin was more effective than no treatment and as effective as whole blood transfusion, in reversing hypotension and inhibiting rises in serum lactate in this prehospital, controlled, Class III swine hemorrhage model.
| Tags : choc