Pansements hémostatiques: Utilité non démontrée

Haemostatic dressings in prehospital care

Hewitt Smith A. et Al.  Emerg Med J 2013; 30:784–789

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Une revue de littérature qui confirme que le bien fondé de l'emploi des pansements hémostatiques n'est pas si solide que cela. Pansement compressif et packing de plaie sont des valeurs sûres.

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Massive haemorrhage still accounts for up to 40% of mortality after traumatic injury. The importance of limiting blood loss after injury in order to prevent its associated complications has led to rapid advances in the development of dressings for haemostatic control. Driven by recent military conflicts, there is increasing evidence to support their role in the civilian prehospital care environment. This review aims to summarise the key characteristics of the haemostatic dressings currently available on the market and provide an educational review of the published literature that supports their use. Medline and Embase were searched from start to January 2012. Other sources included both manufacturer and military publications. Agents not designed for use in prehospital care or that have been removed from the market due to significant safety concerns were excluded. The dressings reviewed have differing mechanisms of action. Mineral based dressings are potent activators of the intrinsic clotting cascade resulting in clot formation. Chitosan based dressings achieve haemostasis by adhering to damaged tissues and creating a physical barrier to further bleeding. Acetylated glucosamine dressings work via a combination of platelet and clotting cascade activation, agglutination of red blood cells and local vasoconstriction. Anecdotal reports strongly support the use of haemostatic dressings when bleeding cannot,be controlled using pressure dressings alone; however, current research focuses on studies conducted using animal models. There is a paucity of published clinical literature that provides an evidence base for the use of one type of haemostatic dressing over another in humans

 

Maîtrise de la coniotomie en environnement austère: Une nécessité.

Optimizing Emergent Surgical Cricothyrotomy for use in Austere Environments

HessertMJ et Al. Wilderness Environ Med. 2013 Mar;24(1):53-66

" Although cricothyrotomy is becoming less common as other alternative airway devices are introduced, such as the laryngeal mask airway, King LT-D (King Systems Corp, Noblesville, IN), and other supraglottic devices, there is, and likely always will be, a role for cricothy- rotomy in a subsection of patients with difficult airways, especially in environments in which such devices are unlikely to be available. A common emergency medicine aphorism is: “If you do one cricothyrotomy, you’re a hero; if you do two, work on your airway skills.” True perhaps in a hospital, but in an austere environment many factors besides failed ET intubation lead to early cricothyrotomy. Wilderness providers must be not only technically skilled, but also adequately trained to recognize the key indications and situational decision triggers for cricothyrotomy that differ from in-hospital practice."

International journal of burns and trauma

 

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Gelures: Une vision actualisée 2014

Frostbite: a practical approach to hospital management

Handford et al. Extreme Physiology & Medicine 2014, 3:7

 

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La prise en charge des gelures évolue notamment par l'apport de la perfusion d'iloprost dans les formes les plus graves et du positionnement en cours de la thrombolyse. Ce document fait une synthèse des données actuelles.

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Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/ freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost.

In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians

Manoeuvre de Sellick: Questions/Réponses

Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis

Ellis DY et Al. An Emerg Med. 2007 Dec;50(6):653-65

La manœuvre de Sellick est une technique de compression du cartilage cricoïde, décrite en 1961 par Sellick BA. Lors de la réalisation d'une intubation trachéale, elle est utilisée pour prévenir le risque de régurgitation du contenu gastrique et œsophagien vers le pharynx et son inhalation bronchique et alvéolaire lors de l'induction anesthésique qui entraîne une dépression des réflexes de protection des voies aériennes, chez un patient dont l’estomac est plein.

Elle consiste à appuyer fermement sur le cartilage cricoïde qui va alors comprimer l'extrémité supérieure de l'œsophage dont les parois sont souples, contre le corps vertébral de la vertèbre cervicale sous-jacente, rigide. L'intensité de la force à exercer doit être d'environ 20 newtons (N) si le patient est conscient et de 30 N s'il est inconscient2. Cette force est suffisante pour prévenir la régurgitation (inefficace si inférieure à 10 N), n'entraîne pas de sensation nauséeuses susceptibles d'augmenter l'inhalation du contenu gastrique et met à l'abri d'une rupture œsophagienne.

Le taux d'efficacité de la manœuvre de Sellick n'est pas bien établi, techniquement simple, elle est pourtant souvent mal réalisée.

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Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.

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Le travail présenté répond à un certain nombre d'interrogations et précise pourquoi la réalisation de cette manoeuvre est remise en question.

L'actusanté australien

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Lésions rachidiennes: Plus fréquentes qu'envisagé

Spinal Injuries in United States Military Personnel Deployed to Iraq and Afghanistan

An Epidemiological Investigation Involving 7877 Combat Casualties From 2005 to 2009

Schoenfeld AJ et All. Spine 2013;38:1770–1778

Les lésions du rachis sont plus fréquentes que ce qui était supposé. Ce travail rapporte qu'une atteinte du rachis est présente dans 11% des cas. Une des explications est que l'amélioration des conditions de prise en charge permet la survie de blessés plus graves qu'auparavant, qui autrefois ne survivait pas à leurs blessures.

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In the years 2005 to 2009, 872 (11.1%) casualties with spine injuries were identified among a total of 7877 combat wounded. The mean age of spine casualties was 26.6 years. Spine fractures were the most common injury morphology, comprising 83% of all spinal wounds. The incidence of combat-related spinal trauma was 4.4 per 10,000, whereas that of spine fractures was 4.0 per 10,000. Spinal cord injuries occurred at a rate of 4.0 per 100,000.

Spinal cord injuries were most likely to occur in Afghanistan (incident rate ratio: 1.96; 95% confi dence interval: 1.68–2.28), among Army personnel (incident rate ratio: 16.85; 95% confidence interval: 8.39–33.84), and in the year 2007 (incident rate ratio: 1.90; 95% confi dence interval: 1.55–2.32). Spinal injuries from gunshot were significantly more likely to occur in Iraq (17%) than in Afghanistan (10%, P = 0.02).

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Douleur du combattant blessé

La prise en charge de la douleur à l'avant fait appel à l'association de mesures passant par les immobilisations, le recours à la morphine sous cutanée, le paracétamol et dès que possible certaines techniques d' ALR. Les US viennent de proposer l'évolution de leur vision des choses.

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