Watters J et all. J Trauma. 2011;70:1413–1419
Un travail intéressant qui s'interroge sur le vrai intérêt des pansements hémostatiques. Sans remettre en question ce dernier cet article remet en question le positionnement de ce type de matériel. Dans un travail expérimental sur un modèle animal, un packing de plaie avec de la gaze simple serait plus rapide et tout aussi efficace qu'un packing effectué avec le Combat gauze ou le celox gauze.
Results: All animals survived to study end. There were no differences in baseline physiologic or coagulation parameters or in dressing success rate (SG: 8/8, CG: 4/8, XG: 6/8) or blood loss between groups (SG: 260 mL, CG: 374 mL, XG: 204 mL; p > 0.3). SG (40 seconds ± 0.9 seconds) packed significantly faster than either the CG (52 ± 2.0) or XG (59 ± 1.9). At 120 minutes, all groups had a significantly shorter time to clot formation compared with baseline (p < 0.01). At 30 minutes, the XG animals had shorter time to clot compared with SG and CG animals (p < 0.05). All histology sections had mild intimal and medial edema. No inflammation, necrosis, or deposition of dressing particles in vessel walls was observed. No histologic or ultrastructural differences were found between the study dressings.
"There are reasons that standard woven gauze bandages have existed for millennia. They are lightweight, absorbent, highly conformable, stable in a variety of environmental conditions, and inexpensive. Multiple advanced hemostatic agents have resulted in superior homeostasis, improved outcomes, and likely saved lives compared with SG when applied according to manufacturers’ recommendations for compression time. However, in a care under fire scenario or in a situation of mass casualties, compression times of 2 minutes to 5 minutes are not feasible. During ongoing battle, only lifethreatening injuries should be addressed and often the wounded must self-apply a tourniquet or dressing. An individual rendering self or buddy aid will need to continue to engage in battle as the first priority. Major vascular injuries, which cannot be controlled through application of a tourniquet, must be addressed as quickly as possible before profound bleeding incapacitates the casualty. Similarly, when there are persons with multiple injuries or wounds to treat, dressings must be rapidly placed and effective without prolonged hold times"
Conclusion: Ce qui compte c'est la compression et le packing de plaie
Effect of Initial Projectile Speed on Contamination Distribution in a Lower Extremity Surrogate “Wound Track”
Le nettoyage précoce et la couverture des orifices d'entrée et de sortie sont donc théoriquement des maillons importants de la lutte contre l'infection des plaies de guerre.
Chemical Terrorism for the Intensivist
The use of chemical agents for terrorist attacks or military warfare is a major concern at the presenttime. Chemical agents can cause signiﬁcant morbidity, are relatively inexpensive, and are easy to store and use.Weaponization of chemical agents is only limited by the physicochemical properties of some agents. Recent incidentsinvolving toxic industrial chemicals and chemical terrorist attacks indicate that critical care services are frequentlyutilized. For obvious reasons, the critical care literature on chemical terrorism is scarce. This article reviews the clinicalaspects of diagnosing and treating victims of chemical terrorism while emphasizing the critical care management. Theintensivist needs to be familiar with the chemical agents that could be used in a terrorist attack. The military classiﬁcation divides agents into lung agents, blood agents, vesicants, and nerve agents. Supportive critical care is the cornerstoneof treatment for most casualties, and dramatic recovery can occur in many cases. Speciﬁc antidotes are available forsome agents, but even without the antidote, aggressive intensive care support can lead to favorable outcome in manycases. Critical care and emergency services can be overwhelmed by a terrorist attack as many exposed but not ill willseek care.
Death on the battlefield (2001-2011): Implications for the future of combat casualty care.
Une publication n'est pas récente mais qui a pour intérêt d'actualiser la question à l'aulne de la dizaine d'années de combats asymétriques en afghanistan et en irak.
BACKGROUND: Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the preYmedical treatment facility (pre-MTF) environment.
METHODS: The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment.bThe autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS)score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study.
RESULTS: For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratificationof mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7%(n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage.
CONCLUSION: Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention. Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force.
Using augmented reality as a clinical support tool to assist combat medics in the treatment of tension pneumothoraces.
Wilson KL et All. Mil Med 2013; 178(9):981-5
La réalité augmentée désigne les systèmes informatiques qui rendent possible la superposition d'un modèle virtuel 3D ou 2D à la perception que nous avons naturellement de la réalité et ceci en temps réel. La commercialisation récente des Google glass est le témoin d'une technologie qui devient mature. Dès lors il n'est pas étonnant qu'un tel dispositif soit utilisé dans les domaines de la formation voire en conditions réelles. Le travail présenté ci-après n'est qu'un exemple.
This study was to extrapolate potential roles of augmented reality goggles as a clinical support tool assisting in the reduction of preventable causes of death on the battlefield. Our pilot study was designed to improve medic performance in accurately placing a large bore catheter to release tension pneumothorax (prehospital setting) while using augmented reality goggles. Thirty-four preclinical medical students recruited from Morehouse School of Medicine performed needle decompressions on human cadaver models after hearing a brief training lecture on tension pneumothorax management. Clinical vignettes identifying cadavers as having life-threatening tension pneumothoraces as a consequence of improvised explosive device attacks were used. Study group (n = 13) performed needle decompression using augmented reality goggles whereas the control group (n = 21) relied solely on memory from the lecture. The two groups were compared according to their ability to accurately complete the steps required to decompress a tension pneumothorax. The medical students using augmented reality goggle support were able to treat the tension pneumothorax on the human cadaver models more accurately than the students relying on their memory (p < 0.008). Although the augmented reality group required more time to complete the needle decompression intervention (p = 0.0684), this did not reach statistical significance.
Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques
Background: Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge ofthe outcome ofthese techniques is currently based on limited information.
Methods: Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.
Results: Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was signiﬁcantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p = 0.01). Sheet wrapping was associated with a signiﬁcantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No signiﬁcant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.
Conclusions: The data suggest that emergency stabilization ofthe pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.
Blast-related fracture patterns: a forensic biomechanical approach
Dehors et dedans, ce n'est pas la même chose
Les lésions dépendent du type de blast
Outcomes of IED Foot and Ankle Blast Injuries
Background: Improvements in protection and medical treatments have resulted in increasing numbers of modernwarfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome.
Methods: U.K. service personnel who had sustained lower leg injuries following an under-vehicle explosion from January 2006 to December 2008 were identiﬁed with the use of a prospective trauma registry. Patient demographics, injury severity, the nature of the lower leg injury, and the type of clinical management were recorded. Clinical end points were determined by (1) the need for amputation and (2) ongoing clinical symptoms.
Results: Sixty-three U.K. service personnel (eighty-nine injured limbs) with lower leg injuries from an explosion were identiﬁed. Fifty-one percent of the casualties sustained multisegmental injuries to the foot and ankle. Twenty-six legs (29%) required amputation, with six of them amputated because of chronic pain eighteen months following injury. Regression analysis revealed that hindfoot injuries, open fractures, and vascular injuries were independent predictors ofamputation. At the time of ﬁnal follow-up, sixty-six (74%) of the injured limbs had persisting symptoms related to the injury,and only nine (14%) of the service members were ﬁt to return to their preinjury duties.
Conclusions: This study demonstrates that foot and ankle injuries from IEDs are associated with a high amputation rateand frequently with a poor clinical outcome. Although not life-threatening, they remain a source of long-term morbidity in an active population
On insiste beaucoup sur la gravité des lésions des membres inférieurs car elles sont sources d'hémorragies graves. Cette gravité est aussi fonctionnelle. Les auteurs de ce document insistent sur la fréquence de l'atteinte de la cheville et du pied (plus d'une fois sur 2), sur la gravité de l'atteinte de la cheville et de l'arrière pied et de la fréquence des amputations près d'une fois sur 3
Identifying future ‘unexpected’ survivors: a retrospective cohort study of fatal injury patterns in victims of improvised explosive devices
To identify potentially fatal injury patterns in explosive blast fatalities in order to focus research and mitigation strategies, to further improve survival rates from blast trauma.
Retrospective cohort study.
UK military personnel killed by improvised explosive device (IED) blasts in Afghanistan, November 2007-August 2010.
UK military deployment, through NATO, in support of the International Security Assistance Force (ISAF) mission in Afghanistan.
UK military postmortem CT records, UK Joint Theatre Trauma Registry and associated incident data.
MAIN OUTCOME MEASURES:
Potentially fatal injuries attributable to IEDs.
We identified 121 cases, 42 mounted (in-vehicle) and 79 dismounted (on foot), at a point of wounding. There were 354 potentially fatalinjuries in total. Leading causes of death were traumatic brain injury (50%, 62/124 fatal injuries), followed by intracavity haemorrhage (20.2%, 25/124) in the mounted group, and extremity haemorrhage (42.6%, 98/230 fatal injuries), junctional haemorrhage (22.2%, 51/230 fatal injuries) and traumatic brain injury (18.7%, 43/230 fatal injuries) in the dismounted group.
Head trauma severity in both mounted and dismounted IED fatalities indicated prevention and mitigation as the most effective strategies to decrease resultant mortality. Two-thirds of dismounted fatalities had haemorrhage implicated as a cause of death that may have been anatomically amenable to prehospital intervention. One-fifth of the mounted fatalities had haemorrhagic trauma which currently could only be addressed surgically. Maintaining the drive to improve all haemostatic techniques for blast casualties, from point of wounding to definitive surgical proximal vascular control, alongside the development and application of novel haemostatic interventions could yield a significant survival benefit. Prospective studies in this field are indicated.
Cette publication est très importante car elle insiste sur l'absolue nécessité de poursuivre les efforts en vue de prévenir le trauma aussi bien en matière de protection balistique, de réduction des délais de transports pour permettre la prise en charge d'hémorragie intra-cavitaires et l'aspect fondamental d'arrêter toutes les hémorragies sur le terrain notamment pas la mise en oeuvre d'une nouvelle catégorie de garrots pour les hémorragies jonctionnelles (voir 1, 2, 3, 4, 5, 6)
Les morts par IED sont plus sévèrement atteints dans un véhicule qu'à pied.
58% des Décès sont liés à plus de 2 causes potentiellement évitables
Les causes de décès ne sont pas les mêmes en combat à pied ou en véhicule
Fiches biotox de prise en charge thérapeutique
Ces fiches sont destinées aux professionnels de santé habilités à appliquer les instructions du plan BIOTOX.
- Introduction aux fiches biotox de prise en charge thérapeutique (24/10/2008)
- Fiche récapitulative (24/10/2008)
- Conduite à tenir en situation d'urgence avant identification de l'agent pathogène responsable (24/10/2008)
- Vademecum thérapeutique (24/10/2008)
- Indications et alternatives thérapeutiques aux fluoroquinolones (24/10/2008)
- Fiche 2 - Charbon (24/10/2008)
- Fiche 3 - Peste (24/10/2008)
- Fiche 4 -Tularémie (23/10/2008)
- Fiche 5 - Brucellose (24/10/2008)
- Fiche 6 - Agents des fièvres hémorragiques virales (24/10/2008)
- Fiche 7 - Variole (24/10/2008)
- Fiche 8 - Toxine botulique (24/10/2008)
- Fiche 9 - Fièvre Q (24/10/2008)
- Fiche 10 - Morve et mélioïdose (24/10/2008)
- Fiche 11 - Autres infections bactériennes (24/10/2008)
- Fiche 12 - Autres agents biologiques, pour lesquels aucun traitements spécifique ou prophylactique ne peut être recommandés (24/10/2008)