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30/11/2010

Embarquer dans un hélicoptère type CH 47 Chinook

 

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| Tags : tactique

Embarquer dans un hélicoptère type PUMA

 

 

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| Tags : tactique

Apporter de l'oxygène

 

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| Tags : oxygène

Contrôler une hémorragie

 

 

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Rédiger un 9 line

 

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| Tags : 9 line

Effectuer un triage

 

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| Tags : triage

29/11/2010

Réagir au feu de l'ennemi

 

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| Tags : tactique, feu

28/11/2010

Foxtrot litter

Vous disposez pour le brancardage des blessés outre les techniques "manuelles", du filet golanis, du brancard souple et du foxtrot litter.

Ce brancard est un brancard semi-rigide qui permet un poratge plus aisé que les brancards souples, permet de tracter le blessé. Il pèse environ 2 kg et représente un bon compromis entre le poids, le volume d'emport et les capacités de portage de blessé.

C'est un produit américain de la société Tacmed.

 

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Son emploi couvre un domaine plus large que celui du combat. Il est proposé dans le cadre du secours en montagne.

 

La mise en oeuvre est présentée dans cette vidéo

 

22/11/2010

Quikclot Combat Gauze: Application

 

Cette version du quikclot est maintenant en dotation. Le manuel d'emploi est ici

| Tags : pansement

Tourniquet improvisé: Pas avec n'importe quoi !

Tourniquets improvisés: Avec les bons moyens

TQ_Post Accident_2

 
Points essentiels:

    1. Il vaut mieux avoir recours à des garrots prévus pour arrêter les hémorragies artérielles
    2. Les garrots doivent être portés sur soi et pas dans le sac
    3. Apprener les principes, et vous pourrez alors avoir recours à un garrot improvisé

Dans ce cas, il s'agit d'un accident sur un pas de tir

    Dans ce cas, il s'agit d'un accident sur un pas de tir

    1. La ceinture n'est pas une bonne idée
    2. Le garrot posé à la RACINE DU MEMBRE est ce qu'il faut faire, dans la mesure où il est correcement serré. L'hémorrgaie est arrêtée ET les pouls distaux ne sont plus perçus. Sinon il faut poser un second garrot.
    3. Vous pouvez utiliser comme garrot de fortune un bandage triangulaire, votre pansement israélien, toute bande compressive dont vous seriez porteur.
    4. Il est habituel de devoir associer rembourrage de plaie, pansement hémostatique, pansement compressif et garrot.

Vous devez avoir tout cela dans votre équipement

 

21/11/2010

Pansements hémostatiques: Une vision US

Prehospital topical hemostatic agents – A review of the current literature

PHTLS Executive Council

Lance E. Stuke, M.D. MPH

Background: The 6th edition of the PHTLS textbook discusses three topical hemostatic agents which were approved by the U.S. Food and Drug Administration and available for prehospital use at the time: HemCon dressing, QuikClot, and TraumaDex. Data on these products was based primarily on anecdotal military reports and very little data was available on their use in the civilian prehospital setting. Several new products have arrived on the market after the release of the 6th edition of PHTLS and several important new studies have been published which will be reviewed here. The vast majority of these products have been researched and developed for use in the military setting in Iraq and Afghanistan although some limited civilian data is also available.

The perfect hemostatic dressing does not exist. Ideally, the dressing should be lightweight, easy to store, and able to be rapidly applied to a hemorrhaging wound. It should be conformable to the wound, allowing the hemostatic agent to reach areas of injury which are difficult to access with direct pressure (i.e. deep groin wounds). The dressing should cause minimal local tissue destruction, be easily removable from the wound, and not contain particles which can spread systemically. Finally, the dressing must not be washed away by rapid bleeding from high-flow blood vessels.

Manufacturers have tried various methods to deliver hemostatic agents into bleeding wounds. Some products are packaged into a granular form which can be poured directly into the wound. Others are incorporated into a dressing or mesh which allows the provider to apply direct pressure to the site of injury. This dressing can be formed either as a rigid bandage, a small bag, or a gauze which must be unrolled prior to application. Each method of preparation has distinct advantages and disadvantages depending on the location and type of injury being treated.

Literature and Product Review:

HemCon: HemCon dressing (Hemorrhage Control Technologies, Portland, OR), is composed of chitosan, a substance derived from arthropod skeletons. Chitosan dressings are thought to function by mechanically sealing the wound and adhering to surrounding tissue. HemCon is a dual-sided 4 x 4 inch rectangular bandage: a chitosan-containing active side which must be placed directly on the wound and a nonstick side which the provider uses to apply pressure. The efficacy of HemCon depends entirely on the bandage adhering well to the wound, which is difficult in wounds which aren’t flat and easily accessible. The bandage isn’t flexible and can break when forced into a wound. It is best applied to flat, superficial wounds which are easily accessible. HemCon has been studied in both the military and civilian settings. The military demonstrated a 97% success rate in controlling bleeding with HemCon.1,2 The civilian experience has been less optimistic, controlling bleeding in 27 of 34 cases studied (79%). Of the seven failures, six were felt to be due to user error, possibly due to less training by civilian EMS providers in the proper use of the product.3 An additional study using a complex groin injury model in swine noted an increase in the rate of rebleeding and mortality between those treated with HemCon versus QuikClot. The authors noted that application of HemCon was more difficult than other agents and all failures of HemCon were due to the bandage not adhering to the injured tissue to which it was applied.4

As previously noted, a disadvantage of the HemCon dressing is that it is relatively non-conformable and difficult to pack into deeper wounds. ChitoFlex is the latest development from HemCon Medical Technologies. It utilizes the same chitosan-based hemostatic agent but packages it into a gauze form. This allows the dressing to be packed into deep bleeding wounds for improved access to the site of hemorrhage. ChitoFlex is available in several sizes, including 1”x3”, 3”x9”, and as a 3”x28” roll. In one study, ChitoFlex was found to be equivalent, but not superior to QuikClot and Celox (a chitosan granule).5

WoundStat: WoundStat was an FDA-approved mineral-based agent consisting of granular smectite, a nonmetallic clay. When the granules were exposed to blood they absorbed water, swelled, and formed a clay paste with strong adhesiveness to the surrounding tissue. Initial studies were promising6,7,8 and it was used by the U.S. Army for a short time. However, later data demonstrated that the granules could cause injury to the blood vessels and make repair difficult. The granules were also shown to enter the circulatory system and cause thrombosis in distal organs.9 Because of these potentially serious side effects, the U.S. Army announced in April 2009 that WoundStat would no longer be used by their medical personnel.

QuikClot: QuikClot (Z-Medica, Wallingford, CT) is a granular product consisting of kaolin, which is a combination of inert minerals such as silicon, aluminum, magnesium, and sodium found in volcanic rock. When placed in a bleeding wound, it absorbs water thereby increasing the local concentration of clotting factors, platelets, and red blood cells to stimulate clot formation. A byproduct of its mechanism is a severe exothermic reaction, with heat generation of up to 70̊ C (158o F). This heat generation causes local tissue destruction and even burns. QuikClot has been studied in both the military and civilian sector, with up to 92% effectiveness in stopping hemorrhage.10 QuikClot was issued to U.S. soldiers in the Iraq and Afghanistan conflicts. Civilian use has been by a wide range of providers, including EMT/firefighters, paramedics, and police. Examples of civilian use include treatment of severe lacerations, gunshot wounds to the neck and even hemodialysis catheter dislodgement. Trauma surgeons have also used QuikClot for successful treatment of bleeding during surgery in the chest, abdomen, and pelvis. QuikClot was noted to have two significant weaknesses. Since it is a granular powder poured into a wound, it had limited usefulness in high-pressure bleeding (i.e. femoral artery bleed)as the granules were washed away by the bleeding before they were able to form a clot. Furthermore, the heat generated from its use was associated with several burns.

QuikClot production was stopped after development of several newer generation products. These newer generation products have minimal heat production and are packaged both as gauzes and in a bagged form. Currently Z-Medica sells QuikClot packaged in 2”x2” and 4”x4” gauze pads for use on superficial lacerations which don’t have severe bleeding. QuikClot has also developed a small kaolin-impregnated pad (QuikClot ACS+) and as a laparotomy pad (QuikClot Trauma Pad) for use by trauma surgeons in the operating room for cases of severe bleeding during surgery. This later product remains in the research phase and is not yet approved for widespread use.

QuikClot Combat GauzeTM is a 3”x4 yard long roll of nonwoven gauze impregnated with kaolin. Combat Gauze has all the advantages of normal gauze (easy application, flexible, large coverage area, and easily removable) with the additional advantage of hemostatic function from the kaolin. It is designed for packing into deep wounds which are actively bleeding (i.e. arterial injury in the groin). Prehospital personnel can also use combat gauze as they would any standard Kerlix gauze. Combat Gauze was recently compared to several newer generation products, including the HemCon RTS, and found to be superior and had no apparent side effects.11 Currently, QuikClot Combat Gauze is the only product endorsed by the Tactical Combat Casualty Care Committee and they recommend it as first line treatment for life-threatening hemorrhage on external wounds not amendable to direct pressure and tourniquet placement.

Summary:

- Numerous topical hemostatic products have been developed and released onto the market.

- Some of these products have since been discontinued, while others are widely used.

-Economic and medical considerations continue to make this a rapidly evolving and growing area of prehospital care. It is important for the EMS provider to remain cognizant of these products and their advantages, disadvantages, and complications as they continue to evolve.

PHTLS Recommendation: Topical hemostatic agents may be used to control hemorrhage occurring in sites not amenable to tourniquet placement and which cannot be controlled by direct pressure alone.

 

 

Bibliography

  1. Achneck HE, Sileshi B, Jamiolkowski RM, et al. A comprehensive review of topical hemostatic agents: Efficacy and recommendations for use. Annals of Surgery 2010; 251: 217-228.

  2. Mabry R and McManus JG. Prehospital advances in the management of severe penetrating trauma. Crit Care Med. 2008:36(7);S258-266.

  3. Brown MA, Daya MR, Worley JA. Experience with chitosan dressings in a civilian EMS system. J Emerg Med. 2009;62:239-243.

  4. Kozen BG, Kircher SJ, Henao J, et al. An alternative hemostatic dressing: comparison of CELOX, HemCon, and QuikClot.Acad Emerg Med. 2008; 15:74-81.

  5. Devlin JJ, Kircher S, Kozen BG, et al. Comparison of ChitoFlex, CELOX, and QuikClot in control of hemorrhage. J Emerg Med. 2009 Apr 1 (Epub ahead of print).

  6. Ward KR, Tiba MH, Holbert WH, et al. Comparison of a new hemostatic agent to current combat hemostatic agents in a swine model of lethal arterial hemorrhage. J Trauma. 2007;63:276-284.

  7. Kheirabadi BS, Edens JW, Terrazas IB, et al. Comparison of new hemostatic granules/powders with currently deployed hemostatic products in a lethal model of extremioty arterial hemorrhage in swine. J Trauma. 2009;66:316-328.

  8. Arnaud F, Parreno-Sadalan D, Tomori T, et al. Comparison of 10 hemostatic dressings in a groin transaction model in swine. J Trauma. 2009;67:848-855.

  9. Bheirabadi BS, Mace JE, Terrazas IB, et al. Safety evaluation of new hemostatic agents, smectite granules, and kaolin-coated gauze in a vascular injury wound model in swine. J Trauma. 2010;68:269-278.

  10. Rhee P, Brown C, Martin M, et al. QuikClot use in trauma for hemorrhage control: case series of 103 documented uses. J Trauma. 2008;64:1093-1099.

  11. Kheirabadi BS, Scherer MR, Estep JS, et al. Determination of efficacy of new hemostatic dressings in a model of extremity arterial hemorrhage in swine. J Trauma. 2009;67:450-460.

| Tags : pansement

19/11/2010

Le traitement de l'eau

MJAFI 2009; 65 : 260-263

Household Water Purification: Low-Cost Interventions

Col VK Agrawal (Retd)*, Brig R Bhalwar+

Abstract

Numerous studies have shown that improving the microbiological quality of household water by point-of-use treatment reduces diarrhoea and other waterborne diseases. The most promising and accessible of the technologies for household water treatment are filtration with ceramic filters, chlorination with storage in an improvised vessel, solar disinfection in clear bottles by  the combined action of UV radiation and heat, thermal disinfection (pasteurization) in opaque vessels with sunlight from solar cookers or reflectors and combination systems employing chemical coagulation-flocculation, sedimentation, filtration and chlorination. However each of these technologies have limitations and effectiveness can be increased by use of two or more treatment systems in succession for improved treatment and the creation of multiple barriers. In particular those treatments that provide no residual disinfectant, such as boiling, solar treatment, UV disinfection with lamps and filtration could be followed by chlorination to provide a multibarrier approach. Water purifiers based on multiple interventions such as filtration/ultra filtration/ activated carbon adsorption / UV rays disinfection are available in the market which can be used to purify the water at point of use. Water purifiers based on single interventions like candle filters, resins filters or ultraviolet lamp can be used in most places being supplied water after purification. Troops on operational move can purify water by fabric/resins filtration and chlorine disinfection or by flocculent-disinfectant.

 

Altitude et acclimatation: Pas si simple

Determinants of Acclimatisation in High Altitude

Col VS Syed*, Maj Gen S Sharma+, Col RP Singh#

Abstract

Background: A total of 31 cases of effects of high altitude were admitted to a field hospital from a particular sector during the year 2008.  This study was hence undertaken to see the efficacy of acclimatisation as well as outline the determinants of acclimatisation

Methods: The study monitored the transients in the acclimatisation period as well as laid down the guidelines to certify the fitness after the acclimatisation period.

Result: Almost 4.70% of transients were found unfit to proceed to higher altitudes even after acclimatisation. Tachycardia with oxygen saturation below 90% by digital pulse oximetry were the parameters found to be statistically significant as an indicator declare a person as not fully acclimatised or otherwise.

Conclusion: The administrative authorities must ensure that an individual is fully acclimatized, based on the fitness certificat

issued, before being dispatched to their units located in high altitude areas.

MJAFI 2010; 66 : 261-265

 

Masque laryngé: Êtes vous sûr ?

 

La place des dispositifs laryngés pour le contrôle des voies aériennes en condition de combat est très limitée. Ces dispositifs ne font pas partie des mesures recommandées par le TCCC et le BATLS, car ils ne ne répondent pas aux critères essentiels qui sont d'assurer l'ouverture des voies aériennes en cas de plaie maxillo-faciale, ils ne protègent pas des risques d'inhalation, ils ne dispensent pas de la réalisation d'une sédation, ils sont susceptibles de mobilisation, enfin ils ne représente pas la première ligne de traitement pour la prise en charge d'une détresse respiratoire en condition de combat.

L'article suivant expose un certain nombre de désagrément lié à l'emploi de l'un de ces dispositifs. 

Indian Journal of Anaesthesia 2009; 53 (4):414-424

Troubleshooting ProSeal LMA

Bimla Sharma, Jayashree Sood  , Chand Sahai , V P Kumra

Summary

Supraglottic devices have changed the face of the airway management. These devices have contributed in a bigway in airway management especially, in the difficult airway scenario significantly decreasing the pharyngolaryngeal morbidity. There is a plethora of these devices, which has been well matched by their wider acceptance in clinical practice. ProSeal laryngeal mask airway (PLMA) is one such frequently used device employed for spontaneous as well as controlled ventilation. However, the use of PLMA at times may be associated with certain problems. Some of the problems related with its use are unique while others are akin to the classic laryngeal mask airway (cLMA). However, expertise is needed for its safe and judicious use, correct placement, recognition and management of its various malpositions and complications. The present article describes the tests employed for proper confirmation of placement to assess the ventilatory and the drain tube functions of the mask, diagnosis of various malpositions and the management of these aspects. All these areas have been highlighted under the heading of troubleshooting PLMA. Many problems can be solved by proper patient and procedure selection, maintaining adequate depth of anaesthesia, diagnosis and management of malpositions. Proper fixation of the device and monitoring cuff pressure intraoperatively may bring down the incidence of airway morbidity.

 

07/11/2010

La mesure du CO2 expiré

La mesure du CO2 expiré, élément incontournable de la sécurité en anesthésie, est également recommandé pour le monitorage pré-hospitalier du traumatisé (Consensus SFMU). Parmi les dispositifs utilsables, il faut citer le capnomètre EMMA de la société PHASEIN.

Très simple d'emploi, il apparaît très adapté à nos conditions d'exercice (Voir ici). 

 

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Il sera bientôt en doatation, en attendant vous pouvez utiliser un détecteur chimique.

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Réchauffer ACTIVEMENT le blessé sédaté

 

Un article à lire

 

 

Body temperature of trauma patients on admission to hospital: a comparison of anaesthetised and non-anaesthetised patients.

Langhelle A et all. Emerg Med J. 2010 Oct 20. [Epub ahead of print]

Abstract

Background Hypothermia at hospital admission has been found to independently predict increased mortality in trauma patients. Objectives To establish if patients anaesthetised in the prehospital phase of care had a higher rate of hypothermia than non-anaesthetised patients on admission to hospital. Methods Retrospective review of admission body temperature in 1292 consecutive prehospital trauma patients attended by a physician-led prehospital trauma service admitted to The Royal London Hospital between 1 July 2005 and 31 December 2008. Results 38% had a temperature recorded on admission. There was a significant difference in body temperature between the anaesthetised group (N=207) and the non-anaesthetised group (N=287): mean (SD) 35.0 (2.1) vs 36.2 (1.0)°C, respectively (p<0.001). No significant seasonal body temperature variation was demonstrated. Conclusion This study confirmed that patients anaesthetised in the prehospital phase of care had a significantly lower admission body temperature. This has led to a change in the author's prehospital practice. Anaesthetised patients are now actively surface heated and have whole body insulation to prevent further heat loss in an attempt to conserve body temperature and improve outcome. This is an example of best in-hospital anaesthetic practice being carried out in the prehospital phase.

 En pratique

Le recours à l'association Ready Heat Blanket II, Blizzard Blanket et charlotte thermolite est impératif en cas de sédation préhospitalière (Voir ici). La prudence est de mise en cas d'hypothermie sévère sans frissons (voir ici). On rappelle simplement l'importance de prévenir l'installation de la triade hypoxie/coagulopathie/acidose lors de la prise en charge d'un blessé choqué hémorragique (Voir ici)

 

 

06/11/2010

Point sur les pansements hémostatiques

Un article récent fait le tour des pansements hémostatiques.

Review

Pre-hospital haemostatic dressings: A systematic review

J. Granville-Chapman, N. Jacobs and M.J. Midwinter

Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK

Accepted 28 September 2010. 
Available online 28 October 2010.

 

Abstract

Background

Uncontrolled haemorrhage is a leading cause of prehospital death after military and civilian trauma. Exsanguination from extremity wounds causes over half of preven military combat deaths and wounds to the anatomical junctional zones provide a particular challenge for first responders. Commercial products have been developed, which claim to outperform standard gauze bandages in establishing and maintaining non-surgical haemostasis. Since 2004, two advanced haemostatic dressing products, HemCon and QuikClot have been widely deployed in military operations. Newer products have since become available which aim to provide more efficient haemostasis than and thus supersede HemCon and QuikClot.

Aim

To conduct a systematic review of clinical and preclinical evidence to compare the relative efficacy and safety of available haemostatic products, which are of relevance to pre-hospital military and civilian emergency medical providers.

Method

An English language literature search was performed, using PubMed® and Web of Knowledge® Databases, with cross-referencing, focussed product searches and communication with product manufacturers. For studies employing animal models, the injury model was required to produce fatal haemorrhage. Products were categorised by primary mode of action as either factor concentrators, mucoadhesive agents or procoagulant supplementors.

Results

From 60 articles collated, 6 clinical papers and 37 preclinical animal trials were eligible for inclusion in this review. Products have been tested in three different types of haemorrhage model: low pressure, high volume venous bleeding, high pressure arterial bleeding and mixed arterial-venous bleeding. The efficacy of products varies with the model adopted. Criteria for the ‘ideal battlefield haemostatic dressing’ have previously been defined by Pusateri, but no product has yet attained such status. Since 2004, HemCon (a mucoadhesive agent) and QuikClot (a factor concentrator) have been widely deployed by United States and United Kingdom Armed Forces; retrospective clinical data supports their efficacy. However, in some recent animal models of lethal haemorrhage, WoundStat (mucoadhesive), Celox (mucoadhesive) and CombatGauze (procoagulant supplementor) have all outperformed both HemCon and QuikClot products.

Conclusion

HemCon and QuikClot have augmented the haemostatic capabilities of the military first aid responder, but newer products demonstrate potential to be more effective and should be considered as replacements for current in service systems. These products could have utility for civilian pre-hospital care.

Keywords: Dressing; Battlefield; Haemostatic; Combat; Prehospital; WoundStat; QuikClot; HemCon; Celox; Combat Gauze

 

 

 

 

| Tags : pansement