Froid: Alaska Guide 2014

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Médecine d'altitude: Manuel sponsorisé par l'OTAN

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Coniotomie: Pas si simple à enseigner

 Cricothyroidotomy Bottom–Up Training Review: Battlefield Lessons Learned

Benett BL et Al. Military Medicine, 176, 11:1311, 2011 

Challenges with surgical cricothyroidotomy on the battlefi eld can be attributed to limited frequency of use, procedure unfamiliarity, and limited knowledge base of anatomical landmarks of which is further heighten in the tactical environment. The objective was to identify ways to enhance the cricothyroidotomy training to minimize potential preventable procedural errors. A training review was conducted to determine the gaps in the cricothyroidotomy training in a 4-day Tactical Combat Casualty Care course at the Naval Medical Center Portsmouth. An ad hoc Working Group team identified five specific gap areas in the cricothyroidotomy training: 1) limited gross airway anatomy review; 2) lack of “hands-on” human laryngeal anatomy; 3) nonstandardized step-by-step surgical incision skill procedure; 4) inferior standards for anatomically correct cricothyroid mannequins; 5) lack of standardized refresher training frequency. Specific training enhancements are recommended across each day in the classroom, simulation laboratory, and field exercise. 

OHB des gelures: Etudes des pratiques européennes ?

Place de l'oxygenotherapie hyperbare dans le traitement des gelures : Evaluations des pratiques europeennes

Thèse de médecine Kolakowska E.

À l’heure actuelle, l’oxygénothérapie hyperbare (OHB) ne fait pas partie des recommandations pour le traitement des gelures et pourtant elle est proposée par plusieurs spécialistes. La gelure est une lésion tissulaire survenant lors d’une exposition prolongée et directe à une température inférieure à 0 °C. L’OHB pourrait être utile par le biais de l’amélioration de l’oxygénation locale, la limitation de l’oedème, la lutte contre l’infection et la stimulation des processus de cicatrisation. L’équipe du centre hyperbare de l’Hôpital de Sainte-Marguerite à Marseille avait traité les victimes de gelures avec des résultats très encourageants, ce qui nous a motivé à évaluer les pratiques concernant l’utilisation de l’OHB dans la prise en charge des gelures dans différents centres hyperbares Européens et vérifier, s’il avait existé un bénéfice thérapeutique. Il s’agit d’une étude réalisée à l’aide d’un questionnaire auprès des médecins exerçant aux caissons hyperbares en Europe. Sur 134 messages envoyés, 21 médecins avaient rempli le questionnaire. 86 % des spécialistes estimaient que théoriquement l’OHB pourrait être indiquée dans la prise en charge de gelures. Parmi les 25 patients inclus, 84 % avaient été atteints de gelures profondes et seulement 44% avaient bénéficié d’une prise en charge dans les premières 72 heures. Malgré la gravité des lésions et le délai de la prise en charge, nous avons constaté, qu’à 3 mois d’évolution, 88 % des patients avaient présenté une amélioration sur le plan cutané par rapport à l’état initial. Bien que notre étude ne soit pas d’une grande valeur statistique, elle permet toutefois de s’apercevoir du bénéfice thérapeutique que l’OHB pourrait apporter dans cette pathologie, y compris tardivement. En effet, des études prospectives larges seront nécessaires et justifiées.

Rappel: Schéma physiopathologique de la gelure 

Pneumothorax en vol: Merci l'écho

In-flight thoracic ultrasound detection of pneumothorax in combat

Madill JJ J Emerg Med. 2010 Aug;39(2):194-7

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Ce cas clinique est intéressant car il démontre que le recours à l'échographie est dans ce cas non seulement possible mais indispensable compte tenu des difficultés d'auscultation en vol. Ceci étant dit il faut cependant être bien conscient du caractère opérateur dépendant de l'échographie qui peut être peu parlante et nécessiter donc une pratique réelle au delà d'une simple formation à la FAST échographie

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Background: Ultrasonography is the only portable imaging modality available in the helicopter medical evacuation environment where physical examination is limited, auscultation is impossible, long transport times may occur, and altitude variations are frequent. Although the use of ultrasonography by aviation medical personnel has been documented, minimal literature exists on the contribution of in-flight ultrasonography to patient management. Objectives: This case demonstrates an indication for the use of in-flight ultrasonography. It shows how it can affect in-flight management and direct lifesaving intervention. 

Case Report: A patient with blast injury developed hemodynamic instability of unclear etiology during transport in the combat aviation environment. To our knowledge, this is the first reported case where in-flight thoracic ultrasonography augmented physical examination and diagnosed an untreated pneumothorax when auscultation was impossible. It directed the decision to perform in-flight procedural intervention with tube thoracostomy. This rapidly improved the patient’s hemodynamic stability in a remote and hostile setting.

Conclusion: In-flight thoracic ultrasonography is a portable imaging tool that can be used by aviation medical personnel to detect pneumothorax in environments where physical examination is limited and auscultation is impossible

Military Trauma System: Pour le civil ?

Military trauma system in Afghanistan: lessons for civil systems?

Bailey JA et Al. Curr Opin Crit Care. 2013 Dec;19(6):569-77

 

PURPOSE OF REVIEW:

This review focuses on development and maturation of the tactical evacuation and en route care capabilities of the military trauma system in Afghanistan and discusses hard-learned lessons that may have enduring relevance to civilian trauma systems.

 RECENT FINDINGS: 

Implementation of an evidence-based, data-driven performance improvement programme in the tactical evacuation and en route care elements of the military trauma system in Afghanistan has delivered measured improvements in casualty care outcomes.

 

SUMMARY: 

Transfer of the lessons learned in the military trauma system operating in Afghanistan to civilian trauma systems with a comparable burden of prolonged evacuation times may be realized in improved patient outcomes in these systems.  

Un nouveau concept de triage ?

Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011

Clarke JE et Al. Mil Med. 2012 Nov;177(11):1261-6

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Un article de synthèse sur l'organisation de la chaîne de prise en charge des blessés par nos confrères anglais, avec notamment l'emploi d'une évolution majeure pour le un système anglo-saxon (lire ce document): le recours à des EVASAN médicalisées par des personnels ayant une pratique régulière de la prise en charge de patients en état critique. Cet article est intéressant car il insiste sur l'importance du triage et le rôe prééminent que peuvent jouer les role 2 notamment si les élongations sont importantes.

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Medical evacuation of combat casualties in Operation Enduring Freedom-Afghanistan is achieved primarily by helicopter, because of distances involved as well as ground-based threats. In Helmand Province, evacuation from the point of injury may occur on a variety of helicopter evacuation platforms with disparate levels of attendant medical expertise. Furthermore, triage to a medical treatment facility may involve varying echelons of care before definitive management. Consequently, considerable differences in medical care may be encountered between point of injury and definitive treatment. We discuss the role of helicopter-based medical evacuation in Helmand, Afghanistan, as well as triage and timelines to the most appropriate medical facilities. Based on our experience and available evidence, we have made recommendations to regional commanders which favor the utilization of prehospital critical care teams aboard helicopter-based evacuation platforms and direct triage to the highest echelon of care available when feasible

Médecin EXPERIMENTÉ: Pronostic amélioré

Determining the composition and benefit of the pre-hospital medical response team in the conflict setting

Davis PR et Al. J R Army Med Corps. 2007 Dec;153(4):269-73

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La composition des équipes d'evasan tactique fait débat. La présence d'un médecin serait associée à une meilleure survie des blessés les plus graves, surtout si les délais de prise en charge par une équipe chirurgicales sont longs. Encore faut il que ce médecin ait de réelles compétences en matière de traumatologie et d'exercice de la médecine préhospitalière en situation isolée.

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Aim: To determine the optimal composition of the pre-hospital medical response team (MERT) and the value of prehospitalvcritical care interventions in a military setting, and specifically to determine both the benefit of including a doctor in the pre-hospital response team and the relevance of the time and distance to definitive care.

Method: A comprehensive review of the literature incorporating a range of electronic search engines and hand searches of key journals.

Results: There was no level 1 evidence on which to base conclusions. The 15 most relevant articles were analysed in detail. There was one randomized controlled trial (level 2 evidence) that supports the inclusion of a doctor on MERT. Several cohort studies were identified that analysed the benefits of specific critical care interventions in the pre-hospital setting.

Conclusions: A doctor with critical care skills deployed on the MERT is associated with improved survival in victims of major trauma. Specific critical care interventions including emergency endotracheal intubation and ventilation, and intercostal drainage are associated with improved survival and functional recovery in certain patients.

Intubation: L'exemple des paramedic

The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation

Prekker ME et AL. Crit Care Med. 2014 Jun;42(6):1372-8

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En France les seuls infirmiers à intuber sont les IADE. Pourtant dans le reste du monde d'autres catégories de personnels de santé non médecins le pratiquent. Les EMT communément appelés paramedic sont formés et réalisent ce geste en préhopsitalier. Il existe maintenant suffisamment de littérature pour pouvoir dire que cette pratique est valide avec bien sûr la nécessité d'une formation adaptée. C'est que rapporte  ce document qui n'est pas le seul.

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OBJECTIVES:

Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics.

DESIGN:

Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database.

SETTING:

Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation).

PATIENTS:

A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523).

Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies.

CONCLUSIONS:

Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.

 

Intubation par les paramedic: Affaire de formation et de pratique

Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: a 12 month review of practice

Mc Queen C et Al. Emerg Med J. 2015 Jan;32(1):65-9.

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A l'évidence, cette analyse montre que ce n'est pas une question de statut mais de formation et d'entrainement. Mais il s'agit là d'une autre culture médicale

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INTRODUCTION:

In the West Midlands region of the UK, delivery of pre-hospital care has been remodelled through introduction of a 24 h Medical Emergency Response Incident Team (MERIT). Teams including physicians and critical care paramedics (CCP) are deployed to incidents on land-based and helicopter-based platforms. Clinical practice, including delivery of rapid sequence induction of anaesthesia (RSI), is underpinned by standard operating procedures (SOP). This study describes the first 12 months experience of prehospital RSI in the MERIT scheme in the West Midlands.

METHODS:

Retrospective review of the MERIT clinical database for the 12 months following the launch of the scheme. Data was collected relating to the number of RSIs performed; indication for RSI; number of intubation attempts; grade of view on laryngoscopy and the base speciality/grade of the operator performing intubation.

RESULTS:

MERIT teams were activated 1619 times, attending scene in 1029 cases. RSI was performed 142 times (13.80% of scene attendances). There was one recorded case of failure to intubate requiring insertion of a supraglottic airway device (0.70%). In over a third of RSI cases, CCPs performed laryngoscopy and intubation (n=53, 37.32%). Proficiency of obtaining Grade I view at laryngoscopy was similar for physicians (74.70%) and CCPs (77.36%). Intubation was successful at the first attempt in over 90% of cases.

CONCLUSIONS:

This study demonstrates that operation within a system that provides high levels of exposure, underpinned by comprehensive and robust training and governance frameworks, promotes levels of performance in successful prehospital RSI regardless of base speciality or profession.

 

Coniotomie sur le terrain: La vraie vie

An analysis of battlefield cricothyrotomy in Iraq and Afghanistan

J Spec Oper Med. 2012 Spring;12(1):17-23

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Pouvoir oxygéner est fondamental. Mais il existe de très nombreuses situations où l'oxygénation par masque ou ballon n'est pas possible ou insuffisante. Il faut alors contrôler les voies aériennes, en particulier la la réalisation d'une coniotomie (1). Ce travail est un des rares actuellement publiés qui fasse le point sur la réalisation de ce geste en conditions de combat (2,3,). Il met en avant la réalité de sa réalisation y compris par les medic, qui ont cependant un taux d'échec double de celui des médecins. Il suggère également tout l'intérêt des ateliers de formation et de séjours au bloc opératoire pour améliorer cet état de fait.

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OBJECTIVES:

Historical review of modern military conflicts suggests that airway compromise accounts for 1,2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting.

METHODS:

This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined successful if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patient's record were also noted in the review.

RESULTS:

Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PCs failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PCs (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement.

CONCLUSIONS:

The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.

Vidéolaryngoscopie: Oui au moins dans les hélico !

Evolution of Pararescue Medicine During Operation Enduring Freedom

Rush S et All. Mil Med. 2015 Mar;180(3 Suppl):68-73

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Les conditions d'intubations lors d'un transport hélico peuvent nécessiter une intubation face à face. Bien que discuté, dans de telles conditions l'apport d'un vidéolaryngoscope est utile. Les pararescue US font la même analyse.

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This article highlights recent advances made in U.S. Air Force Pararescue Medical Operations in relation to tactical evacuation procedures. Most of these changes have been adopted and adapted from civilian medicine practice, and some have come from shared experiences with partner nations. Patient assessment includes a more comprehensive evaluation for hemorrhage and indications for hemorrhagic control. Ketamine has replaced morphine and fentanyl as the primary sedative used during rapid sequence intubation and procedural sedation. There has been an increasing use of the bougie to clear an airway or nasal cavity that becomes packed with debris. Video laryngoscopy provides advantages over direct laryngoscopy, especially in situations where there are environmental constraints such as the back of a Pave Hawk helicopter. Intraosseous access has become popular to treat and control hemorrhagic shock when peripheral intravenous access is impractical or impossible. Revisions to patient treatment cards have improved the efficacy and compliance of documentation and have made patient handoff more efficient. These improvements have only been possible because of the concerted efforts of U.S. Air Force and partner platforms operating in Afghanistan.

Intubation difficile: La vision canadienne actualisée

Prise en charge des voies aériennes – 1re partie – Recommandations lorsque des difficultés sont constatées chez le patient inconscient/anesthésie

Can J Anesth/J Can Anesth (2013) 60:1089–1118

Un document à lire dans le détail car insistant beaucoup sur la notion de facteur humain et se positionnant volontairement en retrait sur les aspects matériels mis en avant ces dernières années;

Prise en charge des voies aériennes – 2e partie – Recommandations lorsque des difficultés sont prévues

Can J Anesth/J Can Anesth (2013) 60:1119–1138

 

Reco US Intubation difficile

 

Doctors on board, utile ?

Doctor on board? What is the optimal skill-mix in military pre-hospital care?

Calderbank P et Al. Emerg Med J. 2011 Oct;28(10):882-3

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Le recul des MERT-E anglaise dans un contexte bien particulier  où le temps de vol moyen est de 3/4 d'heure. La présence d'un médecin n'est pas déterminante. Ce n'est pas du tout la même chose si les temps de vol sont longs (1).  

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BACKGROUNDS:  In a military setting, pre-hospital times may be extended due to geographical or operational issues. Helicopter casevac enables patients to be transported expediently across all terrains. The skill-mix of the pre-hospital team can vary.

AIM: To quantify the doctors' contribution to the Medical Emergency Response Team-Enhanced (MERT-E).

METHODS: A prospective log of missions recorded urgency category, patient nationality, mechanism of injury, medical interventions and whether, in the crew's opinion, the presence of the doctor made a positive contribution.

RESULTS: Between July and November 2008, MERT-E flew 324 missions for 429 patients. 56% of patients carried were local nationals, 35% were UK forces. 22% of patients were T1, 52% were T2, 21.5% were T3 and 4% were dead. 48% patients had blast injuries, 25% had gunshot wounds, 6 patients had been exposed to blast and gunshot wounds. Median time from take-off to ED arrival was 44 min. A doctor flew on 88% of missions. It was thought that a doctor's presence was not clinically beneficial in 77% of missions. There were 62 recorded physician's

INTERVENTIONS: The most common intervention was rapid sequence induction (45%); other interventions included provision of analgesia, sedation or blood products (34%), chest drain or thoracostomy (5%), and pronouncing life extinct (6%).

CONCLUSION: MERT-E is a high value asset which makes an important contribution to patient care. A relatively small proportion of missions require interventions beyond the capability of well-trained military paramedics; the indirect benefits of a physician are more difficult to quantify.

Transfert de compétences: Oui si organisé !

Amélioration de l'offre des soins obstétricaux par la délégation des tâches en milieu africain Exemple de l'hôpital du district sanitaire de Bogodogo à Ouagadougou, Burkina Faso

Ouédraogo CM et Al. Médecine et Santé Tropicales 2015 ; 00 : 1-5

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La performance du sauvetage au combat tient à un transfert de compétences et savoir faire choisis et pour lesquels des personnels ont été spécifiquement formés. Ainsi la médicalisation de l'avant doit elle être comprise non pas la présence du médecin à l'avant mais la présence de savoir faire. Ce besoin déborde largement le contexte militaire et est bien connu dans les pays où l'infrastructure médicale n'est pas aussi développée qu'en métropole. Le document présenté exprime toute la puissance de ces transferts quand ils sont organisés et bien maîtrisés. 

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Objectif : délégation de la pratique des interventions obstétricales majeures à des infirmiers spécialisés en chirurgie à l’hôpital de district de Bogodogo, Burkina Faso.

Méthode: Etude descriptive, analytique et non expérimentale comparant les prestations de gynécologues-obstétriciens et des infirmiers spécialisés en chirurgie pour des interventions obstétricales majeures. La collecte des données a été réalisée de février à octobre 2013 dans le service de gynécologie obstétrique de l’hôpital du district de Bogodogo. Ont été incluses dans l’étude les femmes qui ont bénéficié d’une intervention obstétricale majeure (IOM) en urgence, par un gynécologue obstétricien ou par un infirmier spécialisé en chirurgie. La collecte des données a été réalisée de février à octobre 2013 dans le service de gynécologie obstétrique de l’hôpital de district de Bogodogo, à l’aide d’une fiche (questionnaire) individuelle. Les données ont été saisies grâce au logiciel EPIDATA, version 3.1, et analysées par SPSS, version 22. Le test de Khi2 a permis la comparaison des proportions et celui de Student la comparaison des moyennes. Le seuil de significativité retenu était de 5%.

Résultats : Au cours de la période d’étude, nous avons colligé 601 cas d’interventions obstétricales majeures dont 65,4% réalisés par les gynécologues obstétriciens. L’âge moyen des femmes était de 26,7 ans. La césarienne était l’intervention obstétricale majeure la plus pratiquée avec fréquence de 90% suivi de la laparotomie avec une fréquence de 7,7%. Dans les cas de césarienne, la technique de Misgav-Ladach a été utilisée respectivement dans 86,5% et 95,3% par les gynécologues obstétriciens et les infirmiers spécialisés en chirurgie.

Conclusion : La délégation de tâches en chirurgie obstétricale est effective à l’hôpital du district de Bogodogo et sans risque selon les résultats de cette étude. Son extension au niveau national permettrait de combler le déficit en ressources humaines hautement qualifiées pour réaliser les IOM dans les hôpitaux de district des régions rurales 

 

Faut il drainer avant de décoller: Non ?

Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight ?

Braude D et Al. Air Med J. 2014 Jul-Aug;33(4):152-6

Objective: It is conventionally thought that patients with pneumothorax (PTX) require tube thoracostomy (TT) before air medical transport (AMT), especially in unpressurized rotor-wing (RW) aircraft, to prevent deterioration from expansion of the PTX or development of tension PTX. We hypothesize that patients with PTX transported without TT tolerate RW AMT without serious deterioration, as defined by hypotension, hypoxemia, respiratory distress, intubation, bag valve mask ventilation, needle thoracostomy (NT), or cardiac arrest during transport.

Methods: We conducted a retrospective review of a case-series of trauma patients transported to a single Level 1 trauma center via RW with confirmed PTX and no TT. Using standardized abstraction forms, we reviewed charts for signs of deterioration. Those patients identified as having clinical deterioration were independently reviewed for the likelihood that the clinical deterioration was a direct consequence of PTX.

Results: During the study period, 66 patients with confirmed PTX underwent RW AMT with an average altitude gain of 1890 feet, an average barometric pressure 586-600 mmHg, and average flight duration of 28 minutes. All patients received oxygen therapy; 14/66 patients (21%) were supported with positive pressure ventilation. Eleven of 66 patients (17%) had NT placed before flight and 4/66 (6%) had NT placed during flight. Four of 66 patients (6% CI0.3-11.7) may have deteriorated during AMT as a result of PTX; all were successfully managed with NT.

Conclusions: In this series, 6% of patients with PTX deteriorated as result of AMT without TT, yet all patients were managed successfully with NT. Routine placement of TT in patients with PTX before RW AMT may not be necessary. Further prospective evaluation is warranted.

Kétalar/Célo et plus de 40°C ?

Drugs and drug administration in extreme environments

Kupper TE et AL. J Travel Med. 2006 Jan-Feb;13(1):35-47.

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La question de la stabilité thermique des médicaments se pose dès lors les conditions de stockage sont extrêmes. C'est le cas actuellement dans la BSS. Récemment l'incidence plus élevée d'accidents allergiques à la succinylcholine a été rapportée, avec pour corollaire des recommandations spécifiques émises par l'ANSM. Ces dernières découlent d'une analyse bénéfice/risque au cours d'un exercice métroplitain. Le document qui suit est une revue de l'effet des conditions de stockage sur les médicaments de l'urgence. Dans bien des cas un emploi reste possible, notamment pour la kétamine et la succynilcholine, au prix d'une adaptation posologique. La destruction des ces produits doit rester la règle au delà de 15 j. 

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Emergency medicine must often cope with harsh climates far below freezing point or high temperatures, and sometimes, an alternative to the normal route of drug administration is necessary. Most of this information is not yet published. Therefore, we summarized the information about these topics for most drugs used in medical emergencies by combining literature research with extensive personal communications with the heads of the drug safety departments of the companies producing these drugs. Most drugs can be used after temperature stress of limited duration. Nevertheless, we recommend replacing them at least once per year or after extreme heat. Knowledge about drugs used in extreme environments will be of increasing importance for medical personnel because in an increasingly mobile society, more and more people, and especially elderly — often with individual medical risks — travel to extreme regions such as tropical or arctic regions or to high altitude, and some of them need medical care during these activities. Because of this increasing need to use drugs in harsh climates (tourism, expeditions, peace corps, military, etc) the actual International Congress of Harmonization recommendations should be added with stability tests at +50°C, freezing and oscillating temperatures, and UV exposure to simulate the storage of the drugs at “ outdoor conditions. ” 

Prise en charge d'un blessé: Ce n'est pas le SAMU, ni la catastrophe

Tactical medicine: a joint forces field algorithm.

Waldman M et Al. Mil Med. 2014 Oct;179(10):1056-61

 

La mâchoire en avant: Mieux pour intuber !

Mandibular Advancement Improves the Laryngeal View during Direct Laryngoscopy Performed by Inexperienced Physicians

Tamura M et Al. Anesthesiology 2004; 100:598–601

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Améliorer la vue laryngée pet se faire avec des moyens simples comme la manoeuvre BURP. C'est encore mieux si on associe la protusion mandibulaire. 

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Background: When oral or nasal fiberoptic laryngoscopy is attempted, mandibular advancement has been reported to improve the laryngeal view. The authors hypothesized that mandibular advancement may also improve the laryngeal view during direct laryngoscopy.

Methods: Forty patients undergoing elective surgery under general anesthesia were included in this study. After establishment of an adequate level of anesthesia and muscle relaxation, direct laryngoscopy was performed by inexperienced physicians. Four different maneuvers—simple direct laryngoscopy without any assistance (C), simple direct laryngoscopy with mandibular advancement (M), simple direct laryngoscopy with the BURP maneuver (backward, upward, rightward pressure maneuver of the larynx; B), and simple direct laryngoscopy with both mandibular advancement and the BURP maneuver (BM)—were attempted in each subject, and the laryngeal aperture was videotaped with each procedure. An instructor in anesthesiology who was blinded to the procedure evaluated the visualization by reviewing videotape off-line, using the Cormack-Lehane classification system (grades I–IV) and a rating score within each subject (1
best view; 4
poorest view). The Friedman test followed by the Student-Newman-Keuls test was performed for statistical comparison. P < 0.05 was considered significant.

Results: The laryngeal view was improved with M and B when compared with C (P < 0.05 by both rating and Cormack-Lehane evaluation). BM was the most effective method to visualize the laryngeal aperture (P < 0.05, vs. B and M by rating evaluation), whereas B and M were the second and the third most effective methods, respectively. No statistical difference was observed between B and M with the Cormack-Lehane classification.

Conclusion: Mandibular advancement improves the laryngeal view during direct laryngoscopy performed by inexperienced physicians.