Tourniquet: Serrer fort et surtout vérifier l'efficacité

Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War

King DR et All. J Spec Oper Med. 2012 Winter;12(4):33-8.

Un article important qui doit faire réfléchir à la manière dont l'instruction sur le garrot est conduite aussi bien au niveau du SC1 que du SC 2. 

Dans ce document il est expliqué que 79 garrots sont posés sur 65 jambes garrotées de 54 combattants. Seules 17 jambes avaient des lésions artérielles. 14 d'entre elles étaient majueres mais seules 4 avait un garrot sérré correctement c'est à dire avec abolition du pouls distal. mais qu'aucune lésion artérielle n'a été prise en charge sans garrot sur la même période. Un rappel simple est fait sen outre sur l'importance de la largeur du garrot.

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Introduction: Battlefield tourniquet use can be lifesaving, but most reports are from hospitals with knowledge gaps remaining at the forward surgical team (FST). The quality of tourniquet applications in forward settings remain unknown. The purpose of this case series is to describe observations oftourniquet use at an FST in order to improve clinical performance.

Methods: War casualties with tourniquet use presenting to an FST in Afghanistan in 2011 were observed. We identified appliers by training, device effectiveness, injury pattern, and clinical opportunities for improvement. Feedback was given to treating medics. Results: Tourniquet applications (79) were performed by special operations combat medics (47, 59%), flight medics (17, 22%), combat medics (12, 15%), and general surgeons (3, 4%). Most tourniquets were Combat Application Tourniquets (71/79, 90%). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of all tourniquets, the use was venous in 83% and arterial in 17%. In total, there were 14 arterial injuries, but only 5 had effective arterial tourniquetsapplied.

Discussion: Tourniquets are liberally applied to extremity injuries on the battlefield. 17% were arterial and 83% were venous tourniquets. When ongoing bleeding or distal pulses were appreciated, medics tightened tourniquets under surgeon supervision until distal pulses stopped. Medics were generally surprised at how tight a tourniquet must be to stop arterial flow ? convert a venous tourniquet into an arterial tourniquet. Implications for sustainment training should be considered with regard to this life-saving skill.

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1. Les garrots doivent être serrés de manière conforme; arrêt du saignement et dès que possible contrôle de l'absence de pouls. 

2. Les garrots doivent être surveillés tout au long de la chaine de prise en charge

3. La fiche mémento sur le concept de garrot tactique est à lire et relire

La douleur: S'en occuper ACTIVEMENT

Pain Following Battlefield Injury and Evacuation: A Survey of 110 Casualties from the Wars in Iraq and Afghanistan

Buckenmaier III CC et All. Pain Med. 2009 Nov;10(8):1487-96.

Objective. Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. Painmanagement practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. An exploratory study was undertaken to examine pain and other outcomes during evacuation and at Landstuhl Regional Medical Center (LRMC), Germany. 

Design. A mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded U.S. soldiers evacuated from Iraq and Afghanistan to LRMC. Setting and Patients. A total of 110 wounded soldiers evacuated from Iraq and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0–10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann–Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation.

Results. Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05).

Average percent pain relief achieved was 45.2%  26.6% during transport and 64.5%  23.5% while at LRMC (P < 0.001).

Participants with CPNB catheters placed at LRMC reported significantlyy less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs

Conclusions. Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes

Colloids versus crystalloids for fluid resuscitation in critically ill patients

There is no evidence from randomised controlled trials that resuscitation using colloids compared with crystalloids reduces the risk of death in patients with trauma, burns or following surgery. The use of hydroxyethyl starch might even increase mortality. Since colloid use is not associated with improved survival and colloids are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.

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Point sur les problématiques actuelles du remplissage

Accéder au document de cours

Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients

 

We recommend not to use HES with molecular weight C200 kDa and/or degree of substitution[0.4 in patients with severe sepsis or risk of acute kidney injury and suggest not to use 6% HES130/0.4 or gelatin in these populations. We recommend not to use colloids in patients with head injury and not to administer gelatins and HES in organ donors. We suggest not to use hyperoncotic solutions for fluid resuscitation. We conclude and recommend that any new colloid should be introduced into clinical practice only after its patient-important safety parameters are established. 

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Management of bleeding and coagulopathy following major trauma: an updated European guideline

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Atlas de traumatologie

Sonde de foley: Au moins 2 et pas pour un sondage

Improved mortality from penetrating neck and maxillofacial trauma using Foley catheter balloon tamponade in combat

Weppner J. J Trauma Acute Care Surg. 2013;75: 00Y00

BACKGROUND:

The military medical community has promoted use of Foley catheter balloon tamponade in the initial management of vascular injury owing to neck or maxillofacial trauma. The aim of the study was to compare outcomes with Foley catheter tamponade with those obtained with traditional use of external pressure.

METHODS:

This retrospective cohort study evaluated all cases of persistent bleeding caused by penetrating neck or maxillofacial trauma received at one forward aid station between December 2009 and October 2011. Cohorts included those who were treated with Foley catheter tamponade and those managed with external pressure. Which treatment option was applied depended solely on the availability of Foley catheters at the time. The effectiveness of each technique in controlling initial and delayed hemorrhage is described, and the impact on mortality is analyzed using the Student’s t test and Fisher’s exact test.

RESULTS:

Seventy-seven subjects met the inclusion criteria with 42 subjects in the Foley group and 35 subjects in the external pressure group. A statistically significant difference was found between the groups regarding delayed failure, experienced by three patients (7%) in the Foley group and nine patients (26%) in the external pressure group ( p G 0.05). The difference in mortality, 5% (two patients) in the Foley tamponade group and 23% (eight patients) in the external pressure group, was statistically significant ( p G 0.05).

CONCLUSION:

For penetrating neck and maxillofacial injuries in a combat environment, Foley catheter balloon tamponade significantly reduced mortality when compared with direct pressure techniques through its effect on preventing delayed bleeding.

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The Foley catheter tamponade is relatively simple and very easy to perform rapidly. Before its insertion in the cases examined in this study, a hemorrhaging wound was identified in the neck ormaxillofacial area, and a hemostat was applied to the distal endof an 18 Fr Foley catheter (30 cm3). The catheter was then introduced with a finger into the wound and directed along the wound track to the estimated or palpated source of bleeding, after which the Foley balloon was inflated with sterile water until the bleeding stopped or moderate resistance felt. If this technique did not stop the hemorrhage and either a deep wound or large defect was present in the bleeding vessel, it was considered that the balloon may have only been able to provide distal control. In such cases, a second catheter was introduced into the wound and inflated to provide more proximal control.

When treating Zone I injuries of the supraclavicular fossa, the catheter was introduced as far as possible past the defect in the vessel, allowing the balloon to be inflated before being pulled back firmly and then held in place with a hemostat. Doing so compressed the injured vessel onto the first rib and clavicle, which was intended to tamponade bleeding into the chest. If external hemorrhage continued following insertion of the Foley catheter, a second catheter may have been inserted to control bleeding

Garrot: Une nouvelle ère ?

New Tourniquet Device Concepts for  Battlefield Hemorrhage Control 

Kragh JF et all.US Army Med Dep J. 2011 Apr-Jun:38-48.

Ground:

Given the recent success of emergency tourniquets, limb exsanguination is no longer the most common cause of preventable death on the battlefield; hemorrhage amenable to truncal tourniquets now is. The purpose of the present study is to discuss the gaps today in battlefield hemorrhage control and candidate solutions in order to stimulate the advancement of prehospital combat casualty care.

Methods:

A literature review, a market survey of candidate devices, a request for devices, and an analysis of the current situation regarding battlefield hemorrhage control were performed.

Results:

Hemorrhage control for wounds in the junction between the trunk and the limbs and neck is a care gap in the current war, and, of these, the pelvic (including buttock and groin proximal to the inguinal ligament) area is the most common. Historical and recent reports give background information indicating that truncal tourniquets are plausible devices for controlling junctional hemorrhage on the battlefield. A request for candidate devices yielded few prototypes, only one of which was approved by the US Food and Drug Administration.

Conclusions:

In order to solve the now most common cause of preventable death on the battlefield, junctional hemorrhage from the pelvic area, the planned approach is a systematic review of research, device and model development, and the fielding of a good device with appropriate training and doctrine.

Page 38 de la revue présentée dans le lien

Hémostase: L'émergence des nanoparticules ?

Nano hemostat solution: immediate hemostasis at the nanoscale

Ellis-Behnke RG et all. Nanomedicine: Nanotechnology, Biology, and Medicine 2 (2006) 207 – 215

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Hemostasis is a major problem in surgical procedures and after major trauma. There are few effective methods to stop bleeding without causing secondary damage. We used a self-assembling peptide that establishes a nanofiber barrier to achieve complete hemostasis immediately when applied directly to a wound in the brain, spinal cord, femoral artery, liver, or skin of mammals. This novel therapy stops bleeding without the use of pressure, cauterization, vasoconstriction, coagulation, or cross-linked adhesives. The self-assembling solution is nontoxic and nonimmunogenic, and the breakdown products are amino acids, which are tissue building blocks that can be used to repair the site of injury. Here we report the first use of nanotechnology to achieve complete hemostasis in less than 15 seconds, hich could fundamentally change how much blood is needed during surgery of the future.

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Dans ce modèle une hémostase obtenue en moins de 15 secondes par un mécanisme peu évident:

1. ["First, we know that the hemostasis is not explainable by clotting. Blood clots are produced after injury, but do not begin to form until 1 to 2 minutes have elapsed, depending upon the status and coagulation history of the patient"]

2. ["the electron micrographs show no evidence of platelet aggregation at the interface of the material and wound site"]

3. ["We believe this tight contact is crucial to the hemostatic action because of the size of the self-assembling peptide units."]

Pneumothorax: Dès 10 mmHg

Physiology and cardiovascular effect of severe tension pneumothorax in a porcine model

Nelson D et all. J Surg Res. 2013 Jun 5. pii: S0022-4804(13)00505-2

BACKGROUND:

Pneumothoraces are relatively common among trauma patients and can rapidly progress to tension physiology and death if not identified and treated. We sought to develop a reliable and reproducible large animal model of tension pneumothorax and to examine the cardiovascular effects during progression from simple pneumothorax to tension pneumothorax.

MATERIALS AND METHODS:

Ten swine were intubated, sedated, and placed on mechanical ventilation. After a midline celiotomy, a 10-mm balloon-tipped laparoscopic trocar was placed through the diaphragm, and a 28F chest tube was placed in the standard position and clamped. Thoracic insufflation was performed in 5-mm increments, and continuous cardiovascular measurements were obtained.

RESULTS:

Mean insufflation pressures of 10 mm Hg were associated with a 67% decrease in cardiac output (6.6 L/min versus 2.2 l/min; P = 0.04). An additional increase in the insufflation pressure (mean 15 mm Hg) was associated with an 82% decrease in cardiac output from baseline (6.8 versus 1.2 L/min; P < 0.01). Increasing insufflation pressures were associated with a corresponding increase in central venous pressure (from 7.6 mm Hg to 15.2 mm Hg; P < 0.01) and a simultaneous decrease in the pulmonary artery diastolic pressure (from 15 mm Hg to 12 mm Hg; P = 0.06), with the central venous pressure and pulmonary artery diastolic pressure approaching equalization immediately before the development of major hemodynamic decline. Pulseless electrical activity arrest was induced at an average of 20 mm Hg. Tension physiology was immediately reversible with adequate decompression, allowing for multiple repeated trials.

 

CONCLUSIONS:

 

A reliable and highly reproducible model was created for severe tension pneumothorax in a large animal. Major cardiovascular instability proceeding to pulseless electrical activity arrest with stepwise insufflation was noted. This model could be highly useful for studying new diagnostic and treatment modalities for tension pneumothorax.

 

Croc axillaire:En théorie, c'est possible

Technique of axillary use of a Combat Ready Clamp to stop junctional bleeding

 Kragh JF et All. http://dx.doi.org/10.1016/j.ajem.2013.02.027

Bien que le Croc ne soit validé que les plaies de l'aine, son emploi au membre supérieur est possible.

Enlever la cupule et appliquer la barre de compression parallèle à la clavicule. Le serrage compotre en moyenne 5 tours.